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Vazquez Deida AA, Bizune DJ, Kim C, Sahrmann JM, Sanchez GV, Hersh AL, Butler AM, Hicks LA, Kabbani S. Opportunities to Improve Antibiotic Prescribing for Adults With Acute Sinusitis, United States, 2016-2020. Open Forum Infect Dis 2024; 11:ofae420. [PMID: 39100530 PMCID: PMC11297501 DOI: 10.1093/ofid/ofae420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/19/2024] [Indexed: 08/06/2024] Open
Abstract
Background Better understanding differences associated with antibiotic prescribing for acute sinusitis can help inform antibiotic stewardship strategies. We characterized antibiotic prescribing patterns for acute sinusitis among commercially insured adults and explored differences by patient- and prescriber-level factors. Methods Outpatient encounters among adults aged 18 to 64 years diagnosed with sinusitis between 2016 and 2020 were identified by national administrative claims data. We classified antibiotic agents-first-line (amoxicillin-clavulanate or amoxicillin) and second-line (doxycycline, levofloxacin, or moxifloxacin)-and ≤7-day durations as guideline concordant based on clinical practice guidelines. Modified Poisson regression was used to examine the association between patient- and prescriber-level factors and guideline-concordant antibiotic prescribing. Results Among 4 689 850 sinusitis encounters, 53% resulted in a guideline-concordant agent, 30% in a guideline-discordant agent, and 17% in no antibiotic prescription. About 75% of first-line agents and 63% of second-line agents were prescribed for >7 days, exceeding the length of therapy recommended by clinical guidelines. Adults with sinusitis living in a rural area were less likely to receive a prescription with guideline-concordant antibiotic selection (adjusted risk ratio [aRR], 0.92; 95% CI, .92-.92) and duration (aRR, 0.77; 95% CI, .76-.77). When compared with encounters in an office setting, urgent care encounters were less likely to result in a prescription with a guideline-concordant duration (aRR, 0.76; 95% CI, .75-.76). Conclusions Opportunities still exist to optimize antibiotic agent selection and treatment duration for adults with acute sinusitis, especially in rural areas and urgent care settings. Recognizing specific patient- and prescriber-level factors associated with antibiotic prescribing can help inform antibiotic stewardship interventions.
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Affiliation(s)
- Axel A Vazquez Deida
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani J Bizune
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine Kim
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John M Sahrmann
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Guillermo V Sanchez
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Anne M Butler
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Attal H, Huang Z, Kuan WS, Weng Y, Tan HY, Seow E, Peng LL, Lim HC, Chow A. N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2024; 13:e50417. [PMID: 38381495 PMCID: PMC10918537 DOI: 10.2196/50417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50417.
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Affiliation(s)
- Hersh Attal
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Zhilian Huang
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yanyi Weng
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hann Yee Tan
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Li Lee Peng
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hoon Chin Lim
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Angela Chow
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses. Antibiotics (Basel) 2023; 12:antibiotics12020224. [PMID: 36830137 PMCID: PMC9952143 DOI: 10.3390/antibiotics12020224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.
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4
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Shapiro NI, Filbin MR, Hou PC, Kurz MC, Han JH, Aufderheide TP, Ward MA, Pulia MS, Birkhahn RH, Diaz JL, Hughes TL, Harsch MR, Bell A, Suarez-Cuervo C, Sambursky R. Diagnostic Accuracy of a Bacterial and Viral Biomarker Point-of-Care Test in the Outpatient Setting. JAMA Netw Open 2022; 5:e2234588. [PMID: 36255727 PMCID: PMC9579916 DOI: 10.1001/jamanetworkopen.2022.34588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/15/2022] [Indexed: 01/08/2023] Open
Abstract
Importance Acute respiratory infections (ARIs) account for most outpatient visits. Discriminating bacterial vs viral etiology is a diagnostic challenge with therapeutic implications. Objective To investigate whether FebriDx, a rapid, point-of-care immunoassay, can differentiate bacterial- from viral-associated host immune response in ARI through measurement of myxovirus resistance protein A (MxA) and C-reactive protein (CRP) from finger-stick blood. Design, Setting, and Participants This diagnostic study enrolled adults and children who were symptomatic for ARI and individuals in a control group who were asymptomatic between October 2019 and April 2021. Included participants were a convenience sample of patients in outpatient settings (ie, emergency department, urgent care, and primary care) who were symptomatic, aged 1 year or older, and had suspected ARI and fever within 72 hours. Individuals with immunocompromised state and recent vaccine, antibiotics, stroke, surgery, major burn, or myocardial infarction were excluded. Of 1685 individuals assessed for eligibility, 259 individuals declined participation, 718 individuals were excluded, and 708 individuals were enrolled (520 patients with ARI, 170 patients without ARI, and 18 individuals who dropped out). Exposures Bacterial and viral immunoassay testing was performed using finger-stick blood. Results were read at 10 minutes, and treating clinicians and adjudicators were blinded to results. Main Outcomes and Measures Bacterial- or viral-associated systemic host response to an ARI as determined by a predefined comparator algorithm with adjudication classified infection etiology. Results Among 520 participants with ARI (230 male patients [44.2%] and 290 female patients [55.8%]; mean [SD] age, 35.3 [17.7] years), 24 participants with missing laboratory information were classified as unknown (4.6%). Among 496 participants with a final diagnosis, 73 individuals (14.7%) were classified as having a bacterial-associated response, 296 individuals (59.7%) as having a viral-associated response, and 127 individuals (25.6%) as negative by the reference standard. The bacterial and viral test correctly classified 68 of 73 bacterial infections, demonstrating a sensitivity of 93.2% (95% CI, 84.9%-97.0%), specificity of 374 of 423 participants (88.4% [95% CI, 85.0%-91.1%]), positive predictive value (PPV) of 68 of 117 participants (58.1% [95% CI, 49.1%-66.7%), and negative predictive value (NPV) of 374 of 379 participants (98.7% [95% CI, 96.9%-99.4%]).The test correctly classified 208 of 296 viral infections, for a sensitivity of 70.3% (95% CI, 64.8%-75.2%), a specificity of 176 of 200 participants (88.0% [95% CI, 82.8%-91.8%]), a PPV of 208 of 232 participants (89.7% [95% CI, 85.1%-92.9%]), and an NPV of 176 of 264 participants (66.7% [95% CI, 60.8%-72.1%]). Conclusions and Relevance In this study, a rapid diagnostic test demonstrated diagnostic performance that may inform clinicians when assessing for bacterial or viral etiology of ARI symptoms.
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Affiliation(s)
- Nathan I. Shapiro
- Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael R. Filbin
- Emergency Medicine, Massachusetts General Hospital Institute for Patient Care, Boston, Massachusetts
| | - Peter C. Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael C. Kurz
- Emergency Medicine, University of Alabama School of Medicine, Birmingham
| | - Jin H. Han
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare Center, Nashville
| | - Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee
| | - Michael A. Ward
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Michael S. Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert H. Birkhahn
- Emergency Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Jorge L. Diaz
- Internal Medicine, Doral Medical Research, Miami, Florida
| | | | - Manya R. Harsch
- Statistical Analysis, Technomics Research, Long Lake, Minnesota
| | - Annie Bell
- Medical Affairs, Lumos Diagnostics, Sarasota, Florida
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Nguyen NV, Do NTT, Vu DTV, Greer RC, Dittrich S, Vandendorpe M, Pham TN, Ta NTD, Pham TQ, Khuong VT, Le TTB, Anh LT, Cao TH, Trinh TS, Nguyen HT, Ngo LN, Vu TT, van Doorn HR, Lubell Y, Lewycka SO. Outpatient antibiotic prescribing for acute respiratory infections in Vietnamese primary care settings by the WHO AWaRe (Access, Watch and Reserve) classification: An analysis using routinely collected electronic prescription data. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2022; 30:100611. [DOI: 10.1016/j.lanwpc.2022.100611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chandra Deb L, McGrath BM, Schlosser L, Hewitt A, Schweitzer C, Rotar J, Leedahl ND, Crosby R, Carson P. Antibiotic Prescribing Practices for Upper Respiratory Tract Infections Among Primary Care Providers: A Descriptive Study. Open Forum Infect Dis 2022; 9:ofac302. [PMID: 35891692 PMCID: PMC9307097 DOI: 10.1093/ofid/ofac302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Most antibiotics are prescribed in the ambulatory setting with estimates that up to 50% of use is inappropriate. Understanding factors associated with antibiotic misuse is essential to advancing better stewardship in this setting. We sought to assess the frequency of unnecessary antibiotic use for upper respiratory infections (URIs) among primary care providers and identify patient and provider characteristics associated with misuse. Methods Unnecessary antibiotic prescribing was assessed in a descriptive study by using adults ≥18 years seen for common URIs in a large, Upper Midwest, integrated health system, electronic medical records from June 2017 through May 2018. Individual provider rates of unnecessary prescribing were compared for primary care providers practicing in the departments of internal medicine, family medicine, or urgent care. Patient and provider characteristics associated with unnecessary prescribing were identified with a logistic regression model. Results A total of 49 463 patient encounters were included. Overall, antibiotics were prescribed unnecessarily for 42.2% (95% confidence interval [CI], 41.7–42.6) of the encounters. Patients with acute bronchitis received unnecessary antibiotics most frequently (74.2%; 95% CI, 73.4–75.0). Males and older patients were more likely to have an unnecessary antibiotic prescription. Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice, having more years in practice, and being in higher volume practices such as an urgent care setting. Fifteen percent of providers accounted for half of all unnecessary antibiotic prescriptions. Conclusions Although higher-volume practices, a rural setting, or longer time in practice were predictors, unnecessary prescribing was common among all providers.
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Affiliation(s)
- Liton Chandra Deb
- North Dakota State University , Fargo, ND 58102 , USA
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University , Raleigh, NC , USA
| | | | | | - Austin Hewitt
- University of North Dakota School of Medicine and Health Sciences , Grand Forks, ND 58201 , USA
| | - Connor Schweitzer
- University of North Dakota School of Medicine and Health Sciences , Grand Forks, ND 58201 , USA
| | - Jeff Rotar
- Sanford Health , 736 Broadway N, Fargo, ND 58102 , USA
| | | | - Ross Crosby
- Sanford Health , 736 Broadway N, Fargo, ND 58102 , USA
| | - Paul Carson
- North Dakota State University , Fargo, ND 58102 , USA
- University of North Dakota School of Medicine and Health Sciences , Grand Forks, ND 58201 , USA
- Sanford Health , 736 Broadway N, Fargo, ND 58102 , USA
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Sills J, Boccio E, Govindarajan P, Duanmu Y. Less is more: Recommendations for achieving best practices in antibiotic use for acute upper respiratory infections. J Am Coll Emerg Physicians Open 2022; 3:e12767. [PMID: 35765308 PMCID: PMC9206846 DOI: 10.1002/emp2.12767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joe Sills
- Department of Emergency Medicine UMass Chan Medical School – Baystate Springfield Massachusetts USA
| | - Eric Boccio
- Department of Emergency Medicine UMass Chan Medical School – Baystate Springfield Massachusetts USA
- Institute for Healthcare Delivery and Population Science UMass Chan Medical School ‐ Baystate Springfield Massachusetts USA
| | - Prasanthi Govindarajan
- Department of Emergency Medicine Stanford Health Care, Stanford Medicine Palo Alto California USA
| | - Youyou Duanmu
- Department of Emergency Medicine Stanford Health Care, Stanford Medicine Palo Alto California USA
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Turk K, Jacobson Vann J, Oppewal S. Antibiotic prescribing patterns and guideline-concordant management of acute respiratory tract infections in virtual urgent care settings. J Am Assoc Nurse Pract 2022; 34:813-824. [PMID: 35472013 DOI: 10.1097/jxx.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotic overprescribing for acute respiratory tract infections (ARTIs) commonly occurs and can lead to higher medical costs, antibiotic resistance, and health complications. Inappropriate prescribing of antibiotics for ARTIs has been shown to occur more frequently in urgent care than other outpatient settings. It is not clear whether antibiotic overprescribing varies between virtual and in-person urgent care. OBJECTIVES Summarize published primary scientific literature on antibiotic prescribing patterns for ARTIs among adults in virtual urgent care settings. DATA SOURCES We conducted a systematic review to compare antibiotic prescribing for ARTIs between virtual and in-person urgent care. Our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We assessed risk of bias using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool. We summarized study results from seven included retrospective cohort studies. CONCLUSIONS Antibiotic prescribing frequency may be similar between virtual urgent care and in-person care for adult patients treated for ARTIs. However, variability existed in intervention characteristics, settings, and outcome measures. Additional studies are needed to better understand the conditions in which virtual care may be most effective. IMPLICATIONS FOR PRACTICE Evidence suggests that giving providers direct access to evidence-based guidelines and electronic health records within the virtual visit may support diagnosis and management. Furthermore, practices that use telemedicine platforms for virtual urgent care visits should consider how to potentially improve diagnosis and management of conditions through the use of home-based point-of-care testing or accessory "e-tools."
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Exploration of Trends in Antimicrobial Use and Their Determinants Based on Dispensing Information Collected from Pharmacies throughout Japan: A First Report. Antibiotics (Basel) 2022; 11:antibiotics11050682. [PMID: 35625326 PMCID: PMC9138112 DOI: 10.3390/antibiotics11050682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to evaluate the defined daily doses (DDD)/1000 prescriptions/month (DPM) as a new indicator that can be used in pharmacies, and to describe antimicrobial use patterns in pharmacies nationwide in Japan. Dispensing volumes, number of prescriptions received, and facility information were obtained from 2638 pharmacies that participated in a survey. DPM was calculated based on the dispensing volume and number of prescriptions, which are routinely collected data that are simple to use. Use of third-generation cephalosporins, quinolones, and macrolides in pharmacies that received prescriptions primarily from hospitals or clinics decreased from January 2019 to January 2021. In particular, the antimicrobial use was higher in otorhinolaryngology departments than in other departments, despite a decrease in the antimicrobial use. In the linear multiple regression analysis, otorhinolaryngology department was independently associated with the third-generation cephalosporin, quinolone, and macrolide prescription in all periods. This study reveals for the first-time trends in antimicrobial use through a new indicator using the volume of drugs dispensed in pharmacies throughout Japan. Antimicrobial use differed by the medical department, suggesting the need to target interventions according to the department type.
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10
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Ousey K, Rippon M, Rogers A, Stephenson J. Antimicrobial stewardship in wound care implementation and measuring outcomes: results of an e-survey. J Wound Care 2022; 31:32-39. [PMID: 35077213 DOI: 10.12968/jowc.2022.31.1.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Antimicrobial resistance (AMR) occurs (as a result of misuse, such as over-prescribing) when certain pathogens fail to respond to treatment with antimicrobials. Consequently, patients can become severely ill and possibly die. A strategy referred to as antimicrobial stewardship (AMS) has been introduced which reduces the impact of this antimicrobial misuse. To explore health professionals' (working in wound care, treating both acute and hard-to-heal wounds) position in terms of the following: awareness of AMS; if they are aware of AMS, if they implement procedures to support its practice; and if they implement AMS, do they measure its impact by and compare pre- and post-implementation? METHOD An e-survey designed to explore health professionals' awareness of AMS and its implications for wound care. RESULTS There were 987 respondents to the survey. The majority were specialist wound care nurses, mainly based in the UK or the US and Canada. A high proportion of those surveyed were completely/partially aware (35.1/57.9%, respectively) of AMS, and almost all implemented strategies to reduce antimicrobial prescribing. Of those surveyed, 36% took steps to measure the impact of AMS, and as a result 35.2% reported positive impacts (for example, cost reductions, a reduction in the systemic use of antimicrobials, a reduction in the topical use of antimicrobials and a reduced level of antimicrobial-resistant microorganisms). Challenging aspects of AMS implementation were reported by 33.2% of respondents (for example, poorer clinical outcomes in terms of healing and increased costs). The data highlighted that 40.49% felt that AMS would be 'easy' or 'very easy' to implement while 21.73% felt that AMS would be 'difficult' or 'very difficult' to implement. CONCLUSION Education strategies need to be devised to raise awareness and support health professionals, including wound care practitioners, to understand and implement effective AMS programmes. Development of clear metrics is required to evaluate the effect of AMS programmes in clinical practice.
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Affiliation(s)
- Karen Ousey
- Professor of Skin Integrity, Director for the Institute of Skin Integrity and Infection Prevention, Department of Nursing and Midwifery, University of Huddersfield, UK.,Adjunct Professor, School of Nursing, Faculty of Health at the Queensland University of Technology, Australia.,Visiting Professor, Royal College of Surgeons in Ireland, Dublin, Ireland.,Chair, International Wound Infection Institute.,Regional Director, International Skin Tear Advisory Panel (Europe)
| | - Mark Rippon
- Visiting Clinical Research Fellow, Medical Consultant, Dane River Consultancy Ltd, UK
| | | | - John Stephenson
- Senior Lecturer in Biomedical Statistics, University of Huddersfield, UK
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11
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Jankauskaite L, Grechukha Y, Kjær KA, Mamenko M, Nakstad B, Romankevych I, Schnyder S, Selvakumar J, Trapani S, Daniliaviciene S, Valiulis A, Wyder C, Størdal K. Overuse of medical care in paediatrics: A survey from five countries in the European Academy of Pediatrics. Front Pediatr 2022; 10:945540. [PMID: 36177454 PMCID: PMC9513058 DOI: 10.3389/fped.2022.945540] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Studies and initiatives such as the "Choosing wisely" (CW) campaign emphasise evidence-based investigations and treatment to avoid overdiagnosis and overtreatment. The perception of the extent of medical overactivity among professionals and drivers behind are not well studied in the paediatric field. AIM We aimed to investigate the physicians' opinion and clarify the main drivers regarding medical overactivity in member countries of the European Academy of Paediatrics (EAP). METHODS In this study, paediatricians, paediatric residents, primary care paediatricians, and family doctors treating children were surveyed in Norway, Lithuania, Ukraine, Italy, and Switzerland. Over-investigation was defined as "diagnostic work-up or referral that is unlikely to provide information which is relevant for a patient" and overtreatment was defined as "treatment that does not benefit or can harm more than benefit the patient." The original questionnaire was developed in 2018 by a working group from the Norwegian Paediatric Association. RESULTS Overall, 1,416 medical doctors participated in the survey, ranging from 144 in Lithuania to 337 in Switzerland. 83% stated that they experienced over-investigation/overtreatment, and 81% perceived this as a problem. The majority (83%) perceived expectations from family and patients as the most important driver for overtreatment in their country. Other drivers for overuse were use of national guidelines/recommendations, worry for reactions, and reduction of uncertainty. CONCLUSION This is the first study investigating knowledge and attitude toward medical overactivity in European countries. Despite different cultural and economic environments, the patterns and drivers of increased investigations and medicalisation are similar.
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Affiliation(s)
- Lina Jankauskaite
- Department of Paediatrics, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania.,European Academy of Paediatrics, Brussels, Belgium
| | - Yevgenii Grechukha
- European Academy of Paediatrics, Brussels, Belgium.,Department of Paediatric Infectious Diseases and Paediatric Immunology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | | | - Marina Mamenko
- European Academy of Paediatrics, Brussels, Belgium.,Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine.,Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine
| | - Britt Nakstad
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Ivanna Romankevych
- European Academy of Paediatrics, Brussels, Belgium.,Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine.,Miller School of Medicine, Jackson Memorial Hospital, University of Miami, Coral Gables, FL, United States
| | - Sara Schnyder
- European Academy of Paediatrics, Brussels, Belgium.,Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joel Selvakumar
- Department of Paediatric and Adolescent Health, Akershus University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Sandra Trapani
- European Academy of Paediatrics, Brussels, Belgium.,Paediatric Unit, Department of Health Sciences, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Sandra Daniliaviciene
- Karoliniskiu Policlinic, Vilnius, Lithuania.,Clinic of Children's Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Arunas Valiulis
- European Academy of Paediatrics, Brussels, Belgium.,Clinic of Children's Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University, Vilnius, Lithuania.,Human Ecology Research Group, Department of Public Health, Institute of Health Sciences, Medical Faculty of Vilnius University, Vilnius, Lithuania
| | - Corinne Wyder
- European Academy of Paediatrics, Brussels, Belgium.,Paediatric Praxis Kurwerk, Burgdorf, Switzerland
| | - Ketil Størdal
- European Academy of Paediatrics, Brussels, Belgium.,Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Department of Paediatric Research, University of Oslo, Oslo, Norway
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12
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Hijano DR, Alvarez-Paggi D, Caballero MT. Editorial: Translational research in pediatric respiratory diseases: From bench to bedside. Front Pediatr 2022; 10:1114549. [PMID: 36683809 PMCID: PMC9853422 DOI: 10.3389/fped.2022.1114549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023] Open
Affiliation(s)
- Diego R Hijano
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, United States
| | - Damián Alvarez-Paggi
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.,Fundación INFANT, Buenos Aires, Argentina
| | - Mauricio T Caballero
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.,Fundación INFANT, Buenos Aires, Argentina
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13
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Thompson DK, Muradyan AG, Miller AS, Ahiawodzi PD. Antibiotic resistance of Escherichia coli urinary tract infections at a North Carolina community hospital: Comparison of rural and urban community type. Am J Infect Control 2022; 50:86-91. [PMID: 34499977 DOI: 10.1016/j.ajic.2021.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to identify differences in urinary E. coli resistance rates based on community type of patient residence (rural and urban). METHODS This cross-sectional study examined antibiotic resistance of E. coli isolates from 12,604 urine specimens at a North Carolina hospital between 2016 and 2018. Using multivariable logistic regression modeling, we investigated the association between resistance and community type, adjusting for patient age, gender, season, and setting of infection onset. Analyses were performed using SAS Version 9.3 (SAS Institute, Cary, NC) at alpha = 0.05. RESULTS Prevalence of resistance was highest for ampicillin (42.2%), ampicillin-sulbactam (24.7%), ciprofloxacin (21.8%), trimethoprim-sulfamethoxazole (SXT) (21.6%), and levofloxacin (21.4%). Rural compared to urban community type was significantly associated with resistance of E. coli urinary isolates to ciprofloxacin (adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] = 1.16-1.43, P < .0001), levofloxacin (aOR = 1.28, 95% CI = 1.15-1.42, P < .0001), SXT (aOR = 1.15, 95% CI = 1.04-1.27, P = .01), and nitrofurantoin (aOR = 1.57, 95% CI = 1.13-2.17, P = .01). CONCLUSIONS Rural community type may influence urinary E. coli resistance to fluoroquinolones, SXT, and nitrofurantoin, indicating the need for antimicrobial stewardship interventions in medically underserved populations.
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Singh V, Sinvani L, Hirsch B, Finuf K, Popplewell C, Qiu M, Pisano M, Kohn N, Pekmezaris R, Wolf-Klein G. Quality-of-Care Implications of Antimicrobial Prescription Patterns for Acute Respiratory Tract Infections. J Healthc Qual 2021; 43:340-346. [PMID: 34334779 DOI: 10.1097/jhq.0000000000000317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The Centers for Disease Control and Prevention estimates that half of the antibiotic prescriptions for acute respiratory tract infections (ARTIs) in ambulatory care settings are unnecessary. To better understand the quality-of-care implications of prescription patterns for ARTIs, we conducted a retrospective chart review of outpatient ARTI visits, across a large integrated health system, and examined the association of patient characteristics with receiving antimicrobials, as well as the association between receiving antimicrobials and healthcare utilization (outpatient and emergency department visits). We found that 55.4% of all ARTI outpatients were treated with antimicrobials. There was no association between patient demographics and antimicrobial prescriptions on either the first (p < .0771) or follow-up (p < .6316) visits. A lower comorbidity score was significantly associated with receiving antimicrobials (p < .0022). Patients who received antimicrobials at the first visit had significantly higher number of follow-up visits (p < .005) and more follow-up antimicrobial prescriptions (p < .0066) as compared with patients who did not receive antimicrobials at the first visit. Our results highlight the potential for clinicians to improve quality of care in ARTI management.
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15
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Dick K, Schneider J. Economic Evaluation of FebriDx®: A Novel Rapid, Point-of-Care Test for Differentiation of Viral versus Bacterial Acute Respiratory Infection in the United States. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:56-62. [PMID: 34703832 PMCID: PMC8483888 DOI: 10.36469/001c.27753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
Background: Acute respiratory infections (ARIs) are commonly treated with antibiotics in outpatient settings, but many infections are caused by viruses and antibiotic treatment is therefore inappropriate. FebriDx®, a rapid point-of-care test that can differentiate viral from bacterial infections, can inform antibiotic treatment decisions. Objectives: The primary aim of this study is to conduct a literature-based US economic evaluation of a novel rapid point-of-care test, FebriDx®, that simultaneously measures two key infection biomarkers, C-reactive protein (CRP) and Myxovirus resistance protein A (MxA), to accurately differentiate viral from bacterial infection. Methods: A budget impact model was developed based on a review of published literature on antibiotic prescribing for ARIs in the United States. The model considers the cost of antibiotic treatment, antibiotic resistant infections, antibiotic-related adverse events, and point-of-care testing. These costs were extrapolated to estimate savings on a national level. Results: The expected national cost to treat ARIs under standard of care was US $8.25 billion, whereas the expected national cost of FebriDx point-of-care-guided ARI treatment was US $5.74 billion. Therefore, the expected national savings associated with FebriDx® rapid point-of-care testing was US $2.51 billion annually. Conclusions: FebriDx, a point of care test that can reliably aid in the differentiation of viral and bacterial infections, can reduce antibiotic misuse and, therefore, antibiotic resistant infections. This results in significant cost savings, driven primarily by the reduction in antibiotic resistant infections.
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16
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Rural-urban differences in antibiotic prescribing for uncomplicated urinary tract infection. Infect Control Hosp Epidemiol 2021; 42:1437-1444. [PMID: 33622432 DOI: 10.1017/ice.2021.21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine rural-urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI). DESIGN Observational cohort study. METHODS Using the IBM MarketScan Commercial Database (2010-2015), we identified US commercially insured women aged 18-44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural-urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural-urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural-urban status. RESULTS Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10-1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural-urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty. CONCLUSIONS Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.
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17
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McGurn A, Watchmaker B, Adam K, Ni J, Babinski P, Friedman H, Boyd B, Dugas LR, Markossian T. Socioeconomic Status and Determinants of Pediatric Antibiotic Use. Clin Pediatr (Phila) 2021; 60:32-41. [PMID: 32748648 PMCID: PMC7983842 DOI: 10.1177/0009922820941629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction. Evidence suggests that early-life antibiotic use can alter gut microbiome, predisposing children to obesity. The obesity epidemic has a disproportionate effect on individuals from lower socioeconomic status (SES). Thus, this study aims to explore the link between SES and antibiotic use. Design. We performed a retrospective cohort study of all babies born at and receiving 2 or more outpatient visits at a large, suburban health system in Illinois (United States) between 2007 and 2017. We collected data on zip code as a proxy for SES and antibiotic use in the first year of life. We also obtained comorbid diagnosis codes, race/ethnicity, gender, and number of inpatient, outpatient, and emergency department visits. Results. A total of 7224 patients met our study criteria. Children from low-poverty areas received a lifetime average of 4.28 prescriptions, while those from high-poverty neighborhoods received an average of 3.31 prescriptions. This was statistically significant in our unadjusted analysis but not after adjusting for covariates. Children from high-poverty areas were significantly more likely to receive more antibiotics at 48 hours, 1 week, and 1 month of life in our unadjusted analysis, but not after adjusting for covariates. In our unadjusted and adjusted analyses, children from high-poverty areas were significantly more likely to have received antibiotics at 1 week of life. Conclusion. The relationship between SES and antibiotic use warrants further investigation to help elucidate possible causes of the disproportionate impact obesity has in low-income communities.
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Affiliation(s)
| | | | - Kaavya Adam
- Loyola University Health System, Maywood, IL, USA
| | - Jeff Ni
- University of Chicago Hospitals and Health System, Chicago, IL, USA
| | | | | | - Bridget Boyd
- Loyola University Medical Center, Maywood, IL, USA
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18
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Pu J, Donovan FM, Ellingson K, Leroy G, Stone J, Bedrick E, Galgiani JN. Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization. Clin Infect Dis 2020; 73:e1587-e1593. [PMID: 32511677 DOI: 10.1093/cid/ciaa739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/04/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored. METHODS We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis. RESULTS For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days. CONCLUSIONS Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective.
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Affiliation(s)
- Jie Pu
- Division of Data Analytics, Banner Health Corporation, Phoenix, Arizona, USA
| | - Fariba M Donovan
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - Kate Ellingson
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - Gondy Leroy
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Management Information Systems, University of Arizona Eller College of Business, Tucson, Arizona, USA
| | - Jeff Stone
- Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Arizona Cancer Center, University of Arizona-Tucson, Tucson, Arizona, USA
| | - Edward Bedrick
- Department of Epidemiology and Biostatistics, University of Arizona College of Public Health, Tucson, Arizona, USA
| | - John N Galgiani
- Valley Fever Center for Excellence, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Tucson, Tucson, Arizona, USA.,Department of Medicine, University Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
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Temporal trends in ambulatory antibiotic prescription rates in South Carolina: Impact of age, gender, and resident location. Infect Control Hosp Epidemiol 2020; 41:879-882. [PMID: 32498729 DOI: 10.1017/ice.2020.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To examine the temporal trends in ambulatory antibiotic prescription fill rates and to determine the influences of age, gender, and location. DESIGN Population-based cohort study. SETTING Ambulatory setting in South Carolina. PATIENTS Patients ≤64 years of age from January 2012 to December 2017. METHODS Aggregated pharmacy claims data for oral antibiotic prescriptions were utilized to estimate community antibiotic prescription rates. Poisson regression or Student t tests were used to examine overall temporal trend in antibiotic prescription rates, seasonal variation, and the trends across age group, gender, and rural versus urban location. RESULTS Overall antibiotic prescription rates decrease from 1,127 to 897 per 1,000 person years (P < .001). The decrease was more noticeable in persons aged <18 years (26%) and 18-39 years (20%) than in those aged 40-64 years (5%; P < .001 for all). Prescription rates were higher among females than males in all age groups, although this finding was the most pronounced in group aged 18-39 years (1,232 vs 585 per 1,000 person years; P < .0001). Annualized antibiotic prescription rates were higher during the winter months (December-March) than the rest of the year (1,145 vs 885 per 1,000 person years; P < .0001), and rates were higher in rural areas than in urban areas (1,032 vs 941 per 1,000 person years; P < .0001). CONCLUSIONS The decline in ambulatory antibiotic prescription rates is encouraging. Ongoing ambulatory antibiotic stewardship efforts across South Carolina should focus on older adults, rural areas, and during the winter season when antibiotic prescriptions peak.
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20
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Kianmehr H, Sabounchi NS, Sabounchi SS, Cosler LE. A system dynamics model of infection risk, expectations, and perceptions on antibiotic prescribing in the United States. J Eval Clin Pract 2020; 26:1054-1064. [PMID: 31206901 DOI: 10.1111/jep.13203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Inappropriate antibiotic prescribing is still a major concern that can lead to devastating outcomes including antibiotic resistance. This study aimed to simulate the antibiotic prescribing behaviour by providers for acute respiratory tract infections (ARTIs) and to evaluate the impact of patient expectation, provider's perception of patient's expectation to receive a prescription, and patient's risk for bacterial infection, on the decision to prescribe. METHODS We developed a unique system dynamics (SD) simulation model based on the significant factors that impact the interaction between provider and patient during visits for ARTIs and the decision to prescribe antibiotics. In order to validate the model for different age groups and regions in the United States, we used the sample of 53 000 ARTI patient visits made at outpatient settings between 1993 and 2015, based on the National Ambulatory Medical Care Survey (NAMCS). RESULTS Simulation results reveal that physician diagnosis for prescribing antibiotics is based on physician's experience from their prior prescribing behaviour, their perception of patient's infection risk, and patient's expectation to receive antibiotics. Also, there are some variations depending on patient's age and residential region. The simulation analysis also depicts the decreasing trend in patient's expectation over the past two decades for most age groups and regions. CONCLUSIONS Given the high number of unnecessary prescriptions for ARTI, we found that policies are needed to influence provider's prescribing behaviour through patient's expectation and provider's perception regarding those expectations. Our simulation framework can further be used by policymakers to design and evaluate interventions that may modify the interaction between health providers and patients to optimize antibiotic prescriptions among ARTI patients for different regions and age groups.
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Affiliation(s)
- Hamed Kianmehr
- Thomas J. Watson School of Engineering and Applied Science, Binghamton University, Binghamton, New York
| | - Nasim S Sabounchi
- Thomas J. Watson School of Engineering and Applied Science, Binghamton University, Binghamton, New York
| | | | - Leon E Cosler
- Founding Chair, Department of Health Outcomes and Administrative Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York
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21
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Antimicrobial stewardship in the outpatient setting: A review and proposed framework. Infect Control Hosp Epidemiol 2020; 41:833-840. [PMID: 32342826 DOI: 10.1017/ice.2020.94] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.
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22
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Li D, Conson M, Kim N, Yasuda M, Ivy D, Diec S, Godley P. Patient and provider characteristics and outcomes associated with outpatient antibiotic overuse in acute adult bronchitis. Proc AMIA Symp 2020; 33:183-187. [PMID: 32313457 PMCID: PMC7155999 DOI: 10.1080/08998280.2019.1708667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/29/2019] [Accepted: 12/12/2019] [Indexed: 01/21/2023] Open
Abstract
Nonbacterial acute bronchitis leads to many outpatient clinic visits in the US that result in an antibiotic prescription. Understanding antibiotic prescribing patterns and their clinical consequences will help improve antimicrobial stewardship efforts. A retrospective chart review was conducted to identify any correlations between patient and provider characteristics with antibiotic use in adult acute bronchitis (AAB) and to compare the clinical outcomes and rates of health care utilization between those who did and did not receive antibiotics. Study participants included adults with uncomplicated AAB seen by family medicine or internal medicine, specialty, and mid-level practitioners in a Baylor Scott & White Health outpatient facility. Phase 1 investigated whether prescribing rates varied by provider- or patient-level characteristics. Phase 2 compared clinical outcomes and health care utilization between patients who received an antibiotic versus those who did not receive an antibiotic for AAB. Among 35,383 visits for AAB, 81.4% resulted in a prescription for an antibiotic. Physicians >35 years of age and internal and family medicine physicians were more likely to prescribe antibiotics. Health care utilization rates did not differ between cohorts. The number of Clostridium difficile events was negligible.
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Affiliation(s)
- Diana Li
- Department of Outpatient Pharmacy, Baylor Health EnterprisesTempleTexas
| | - Maricar Conson
- Department of Outpatient Pharmacy, Baylor Health EnterprisesTempleTexas
| | - Nina Kim
- Department of Health Outcomes, The University of Texas College of PharmacyAustinTexas
| | - Marie Yasuda
- Department of Health Outcomes, The University of Texas College of PharmacyAustinTexas
| | - Delaney Ivy
- Department of Pharmacy Practice, Texas A&M University Irma Lerma Rangel College of PharmacyKingsvilleTexas
| | - Sandy Diec
- Department of Pharmacy Practice, Texas A&M University Irma Lerma Rangel College of PharmacyKingsvilleTexas
| | - Paul Godley
- Department of Outpatient Pharmacy, Baylor Health EnterprisesTempleTexas
- Department of Health Outcomes, The University of Texas College of PharmacyAustinTexas
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May L, Tatro G, Poltavskiy E, Mooso B, Hon S, Bang H, Polage C. Rapid Multiplex Testing for Upper Respiratory Pathogens in the Emergency Department: A Randomized Controlled Trial. Open Forum Infect Dis 2019; 6:ofz481. [PMID: 32128326 PMCID: PMC7043218 DOI: 10.1093/ofid/ofz481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
Background Acute upper respiratory tract infections are a common cause of emergency department (ED) visits and often result in unnecessary antibiotic treatment. Methods We conducted a randomized clinical trial to evaluate the impact of a rapid, multipathogen respiratory panel (RP) test vs usual care (control). Patients were eligible if they were ≥12 months old, had symptoms of upper respiratory infection or influenza-like illness, and were not on antibiotics. The primary outcome was antibiotic prescription; secondary outcomes included antiviral prescription, disposition, and length of stay (ClinicalTrials.gov# NCT02957136). Results Of 191 patients enrolled, 93 (49%) received RP testing; 98 (51%) received usual care. Fifty-three (57%) RP and 7 (7%) control patients had a virus detected and reported during the ED visit (P = .0001). Twenty (22%) RP patients and 33 (34%) usual care patients received antibiotics during the ED visit (–12%; 95% confidence interval, –25% to 0.4%; P = .06/0.08); 9 RP patients received antibiotics despite having a virus detected. The magnitude of antibiotic reduction was greater in children (–19%) vs adults (–9%, post hoc analysis). There was no difference in antiviral use, length of stay, or disposition. Conclusions Rapid RP testing was associated with a trend toward decreased antibiotic use, suggesting a potential benefit from more rapid viral tests in the ED. Future studies should determine if specific groups are more likely to benefit from testing and evaluate the relative cost and effectiveness of broad testing, focused testing, and a combined diagnostic and antimicrobial stewardship approach.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Grant Tatro
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Eduard Poltavskiy
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Simson Hon
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Christopher Polage
- Department of Pathology, University of California Davis, Sacramento, California, USA.,Department of Pathology, Duke University, Durham, North Carolina, USA
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Xie Z, Gonzalez LE, Ferreira CR, Vorsilak A, Frabutt D, Sobreira TJP, Pugia M, Cooks RG. Multiple Reaction Monitoring Profiling (MRM-Profiling) of Lipids To Distinguish Strain-Level Differences in Microbial Resistance in Escherichia coli. Anal Chem 2019; 91:11349-11354. [PMID: 31398004 DOI: 10.1021/acs.analchem.9b02465] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Zhuoer Xie
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - L. Edwin Gonzalez
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Christina R. Ferreira
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
- Bindley Bioscience Center, Purdue University, West Lafayette, Indiana 47907, United States
| | - Anna Vorsilak
- Indiana Biosciences Research Institute, Indianapolis, Indiana 46202, United States
| | - Dylan Frabutt
- Indiana Biosciences Research Institute, Indianapolis, Indiana 46202, United States
| | - Tiago J. P. Sobreira
- Bindley Bioscience Center, Purdue University, West Lafayette, Indiana 47907, United States
| | - Michael Pugia
- Indiana Biosciences Research Institute, Indianapolis, Indiana 46202, United States
| | - R. Graham Cooks
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
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25
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D'Annibali O, Bonaldo G, Donati M, Småbrekke L, Motola D, Vaccheri A. Antibacterial prescription in Italian preschool children: analysis of 7 years of data from the Emilia-Romagna region reimbursement database. J Antimicrob Chemother 2019; 74:2434-2439. [PMID: 30993338 DOI: 10.1093/jac/dkz153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/27/2019] [Accepted: 03/16/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe antibacterial prescribing patterns in outpatients aged 0-5 years from 2007 to 2013 in the Emilia-Romagna region, assessing sex- and age-specific consumption over time. METHODS All children aged 0-5 years resident in the Emilia-Romagna region who received at least one prescription of a systemic antibacterial in the period 2007-13 were enrolled. The prescriptions of systemic antibacterials to children were collected from the regional prescription database. Data were stratified by year, sex and age, and analysed in terms of periodic prevalence and of annual prescription rate per 1000 person-years. RESULTS The prevalence of children receiving at least one prescription per year varied from 68.0% in 2007 to 59.0% in 2013, while the average prevalence of children receiving five or more prescriptions per year was 6.96%. The annual prescription rate varied from 1621.26 in 2007 to 1372.27 in 2013. Penicillins + β-lactamase inhibitors accounted for 35.3% of total prescriptions, followed by extended-spectrum penicillins (28.6%), macrolides (17.0%) and third-generation cephalosporins (13.9%). CONCLUSIONS Despite recommendations, a significant overprescription of antibacterials to children still exists, showing no satisfactory improvements over the years. In contrast to Northern European countries, adherence to evidence-based guidelines was poor, with frequent prescribing of broad-spectrum agents for the treatment of mostly viral childhood infectious disease.
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Affiliation(s)
- Ottavio D'Annibali
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Giulia Bonaldo
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Monia Donati
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Domenico Motola
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
| | - Alberto Vaccheri
- Unit of Pharmacology, Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48, 40126, Bologna, Italy
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Kianmehr H, Sabounchi NS, Seyedzadeh Sabounchi S, Cosler LE. Patient expectation trends on receiving antibiotic prescriptions for respiratory tract infections: A systematic review and meta-regression analysis. Int J Clin Pract 2019; 73:e13360. [PMID: 31066959 DOI: 10.1111/ijcp.13360] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/17/2019] [Accepted: 05/04/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Despite a variety of programs developed to control inappropriate antibiotic prescribing for viral infections, antibiotics are still prescribed excessively for Respiratory Tract Infections (RTI). The patient's expectation to receive an antibiotic often influences the clinician's decision and can lead to inappropriate antibiotic prescriptions. Our objective was to investigate the changes in patient expectations over time when presenting with symptoms of a respiratory infection. METHODS We performed a systematic review of patient's expectation to receive antibiotics for RTIs. Two reviewers independently evaluated the collected studies based on inclusion and exclusion criteria. Our search initially identified 12 070 studies, of which 321 studies were eligible for full text review and 37 articles were selected for final evaluation. Meta-regression analysis was used to evaluate the association between patient expectations and different years. Heterogeneity was evaluated using the Q statistic. RESULTS Patient expectations (effect size) were pooled using a random effects model. The effect-equality test showed heterogeneity among studies (Q = 3304.23, df = 40, P < 0.0001, k = 40, τ2 = 0.63). Meta-regression results revealed that there is a significant linear negative relationship (B = -1.8374, P < 0.05) between patient expectation and year of data collection, at the global level. A similar finding is observed for the subset of studies conducted outside United States (U.S.) (B = -1.2411, P < 0.1). However, there is no discernible trend for patient expectation in the U.S. or among children and adult subgroups. Also, no significant differences are observed between the patient expectations when considering different age groups. CONCLUSION The trend of patient expectation for receiving antibiotics for RTIs is declining over time on a global level and also outside the U.S.
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Affiliation(s)
- Hamed Kianmehr
- Thomas J. Watson School of Engineering and Applied Science, Binghamton University, Binghamton, New York
| | - Nasim S Sabounchi
- Thomas J. Watson School of Engineering and Applied Science, Binghamton University, Binghamton, New York
| | | | - Leon E Cosler
- Department of Health Outcomes and Administrative Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York
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Abstract
INTRODUCTION Numerous initiatives over the past decade have targeted the problem of antibiotic overuse in the US; however, the cumulative impact of such initiatives upon recent patterns of use is not known. OBJECTIVES The aims of this study were to (1) describe general trends in outpatient antibiotic use among adults over the period 2006-2015; and (2) identify rapid shifts in use during this time period as potential indicators for key events. METHODS This was an observational study set in the ambulatory setting. Patients ≥ 18 years of age were selected from the Optum Clinformatics Datamart™, a commercial insurance claims database. The outcome measures of interest were prescriptions filled/1000 enrolled individuals, by year or quarter. We used linear regression to identify trends in use over multiple years, and change-point regression to identify rapid shifts in use within individual years. RESULTS From 2006 to 2015, antibiotic use declined significantly, decreasing by 12% for adults younger than 65 years of age (913-807 prescriptions/1000 individuals, p = 0.0001) and by 5% for adults ≥ 65 years of age (991-943 prescriptions/1000 individuals, p = 0.018). With change-point regression, we identified a number of rapid shifts in the use of specific antibiotic classes, such as downward shifts in the use of quinolones and macrolides during the second quarter of 2008 and 2013, respectively. CONCLUSIONS Over the period 2006-2015 outpatient use of antibiotics decreased substantially among adults. Rapid shifts in use occurring in 2008 and 2013 may reflect the presence of key drivers of change, such as abrupt changes in access to care or perceived antibiotic safety.
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Andreev K, Martynowycz MW, Gidalevitz D. Peptoid drug discovery and optimization via surface X-ray scattering. Biopolymers 2019; 110:e23274. [PMID: 30892696 PMCID: PMC6661014 DOI: 10.1002/bip.23274] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 12/31/2022]
Abstract
Synthetic polymers mimicking antimicrobial peptides have drawn considerable interest as potential therapeutics. N-substituted glycines, or peptoids, are recognized by their in vivo stability and ease of synthesis. Peptoids are thought to act primarily on the negatively charged lipids that are abundant in bacterial cell membranes. A mechanistic understanding of lipid-peptoid interaction at the molecular level will provide insights for rational design and optimization of peptoids. Here, we highlight recent studies that utilize synchrotron liquid surface X-ray scattering to characterize the underlying peptoid interactions with bacterial and eukaryotic membranes. Cellular membranes are highly complex, and difficult to characterize at the molecular level. Model systems including Langmuir monolayers, are used in these studies to reduce system complexity. The general workflow of these systems and the corresponding data analysis techniques are presented alongside recent findings. These studies investigate the role of peptoid physicochemical characteristics on membrane activity. Specifically, the roles of cationic charge, conformational constraint via macrocyclization, and hydrophobicity are shown to correlate their membrane interactions to biological activities in vitro. These structure-activity relationships have led to new insights into the mechanism of action by peptoid antimicrobials, and suggest optimization strategies for future therapeutics based on peptoids.
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Affiliation(s)
- Konstantin Andreev
- Howard Hughes Medical Institute, Northwestern University, Evanston, Illinois
| | | | - David Gidalevitz
- Center for the Molecular Study of Condensed Soft Matter and Department of Physics, Illinois Institute of Technology, Chicago, Illinois
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Hey J, Thompson-Leduc P, Kirson NY, Zimmer L, Wilkins D, Rice B, Iankova I, Krause A, Schonfeld SA, DeBrase CR, Bozzette S, Schuetz P. Procalcitonin guidance in patients with lower respiratory tract infections: a systematic review and meta-analysis. Clin Chem Lab Med 2019; 56:1200-1209. [PMID: 29715176 DOI: 10.1515/cclm-2018-0126] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/16/2018] [Indexed: 12/19/2022]
Abstract
Although effective for bacterial lower respiratory tract infections (LRTIs), antibiotic treatment is often incorrectly prescribed for non-bacterial LRTIs. Procalcitonin has emerged as a promising biomarker to diagnose bacterial infections and guide antibiotic treatment decisions. As part of a regulatory submission to the U.S. Food and Drug Administration, this systematic review and meta-analysis summarizes the effects of procalcitonin-guided antibiotic stewardship on antibiotic use and clinical outcomes in adult LRTI patients. PubMed and the Cochrane Database of Systematic Reviews were searched for English-language randomized controlled trials published between January 2004 and May 2016. Random and fixed effects meta-analyses were performed to study efficacy (initiation of antibiotics, antibiotic use) and safety (mortality, length of hospital stay). Eleven trials were retained, comprising 4090 patients. Procalcitonin-guided patients had lower odds of antibiotic initiation (odds ratio: 0.26; 95% confidence interval [CI]: 0.13-0.52) and shorter mean antibiotic use (weighted mean difference: -2.15 days; 95% CI: -3.30 to -0.99) compared to patients treated with standard care. Procalcitonin use had no adverse impact on mortality (relative risk: 0.94; 95% CI: 0.69-1.28) and length of hospital stay (weighted mean difference: -0.15 days; 95% CI: -0.60 to 0.30). Procalcitonin guidance reduces antibiotic initiation and use among adults with LRTIs with no apparent adverse impact on length of hospital stay or mortality.
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Affiliation(s)
| | | | - Noam Y Kirson
- Vice President, Analysis Group Inc., 111 Huntington Avenue, Fourteenth Floor, Boston, MA 02199-7668, USA
| | | | | | | | | | | | | | | | | | - Philipp Schuetz
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Haque M, Rahman NAA, McKimm J, Kibria GM, Azim Majumder MA, Haque SZ, Islam MZ, Binti Abdullah SL, Daher AM, Zulkifli Z, Rahman S, Kabir R, Lutfi SNNB, Aishah Binti Othman NS. Self-medication of antibiotics: investigating practice among university students at the Malaysian National Defence University. Infect Drug Resist 2019; 12:1333-1351. [PMID: 31190922 PMCID: PMC6529675 DOI: 10.2147/idr.s203364] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Self-medication of drugs to alleviate symptoms is a common global behavior, helping relieve burdens on health services, but many drugs eg, antibiotics are prescription-only. Self-medication of antibiotics (SMA) is an irrational use of drugs, contributing to microbial resistance increasing health care costs and higher mortality and morbidity. This study aimed to assess SMA among university students. Methods: This was a cross-sectional study conducted among medical and non-medical students of the National Defence University of Malaysia. A validated instrument was used to gather data. Ethics approval was obtained. Random and universal sampling was adopted, and SPSS 21 was used for data analysis. Results: A total of 649 students participated in the study: 48.5% male and 51.5% female, 39.3% reported self-medicating with antibiotics. Penicillin, doxycycline, clarithromycin were the antibiotics most used with the majority reporting no adverse drug reactions. Cost savings and convenience were the principal reasons for SMA which were mainly obtained from local retail pharmacies. Despite medical students (particularly the more senior) having better knowledge of antibiotic use than non-medical students, 89% of all research participants responded that practicing SMA was a good/acceptable practice. Conclusion: SMA is common amongst Malaysian students and, despite understanding why SMA is unwise, even medical students self-medicate.
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Affiliation(s)
- Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Nor Azlina A Rahman
- Department of Physical Rehabilitation Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan, 25200, Malaysia
| | - Judy McKimm
- Swansea University School of Medicine, Grove Building, Swansea University, Swansea, Wales, SA2 8PP, UK
| | - Golam Mohammad Kibria
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Md Anwarul Azim Majumder
- Department of Medical Education, Faculty of Medical Sciences, The University of the West Indies, Bridgetown, Barbados, West Indies
| | - Seraj Zohurul Haque
- Department of Orthopedic Surgery, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Scotland, UK
| | - Md Zakirul Islam
- Department of Pharmacology, Eastern Medical College, Burichang3520, Bangladesh
| | - Shahidah Leong Binti Abdullah
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Aqil Mohammad Daher
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Zainal Zulkifli
- Department of Surgery, Sultan Haji Ahmad Shah Hospital, Temerloh, Pahang, 28000, Malaysia
| | - Sayeeda Rahman
- Department of Pharmacology and Public Health, School of Medicine, American University of Integrative Sciences, Bridgetown, Barbados
| | - Russell Kabir
- School of Allied Health, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, Essex, UK
| | - Siti Nur Najihah Binti Lutfi
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Nur Syamirah Aishah Binti Othman
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
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Karakonstantis S, Kalemaki D. Antimicrobial overuse and misuse in the community in Greece and link to antimicrobial resistance using methicillin-resistant S. aureus as an example. J Infect Public Health 2019; 12:460-464. [PMID: 30981652 DOI: 10.1016/j.jiph.2019.03.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/19/2019] [Accepted: 03/24/2019] [Indexed: 10/27/2022] Open
Abstract
Both antimicrobial consumption and antimicrobial resistance are very high in Greece, ranking among the highest of Europe. The link between antimicrobial consumption and resistance is well-known. Here, we discuss the reasons of antimicrobial overuse in Greece in the community (such as self-medication, dispersion of antibiotics by pharmacies without prescription, over-prescription by physicians, patient expectations and liability pressure) and we explore the misuse of antibiotics for common community infections. Furthermore, we discuss how such overuse/misuse can drive antimicrobial resistance, using methicillin-resistance in Staphylococcus aureus as an example. S. aureus is one of the pathogens with high rates of resistance in Greece. Comparing the rate of antimicrobial susceptibility to non-beta lactams between methicillin-resistant and methicillin-sensitive S. aureus we highlight the antibiotics that have the potential to drive methicillin-resistance through co-selection. Based on the above we identify targets for intervention in order to reduce antimicrobial overuse/misuse in the community in Greece.
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Affiliation(s)
- Stamatis Karakonstantis
- Department of Internal Medicine, General Hospital of Heraklion "Venizeleio-Pananeio", Leoforos Knossou, Heraklion, 71409, Greece.
| | - Dimitra Kalemaki
- General Medicine, University Hospital of Heraklion, Heraklion, 71410, Greece
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Inappropriate Antibiotic Prescribing for Acute Bronchitis in Children and Impact on Subsequent Episodes of Care and Treatment. Pediatr Infect Dis J 2019; 38:271-274. [PMID: 29794648 PMCID: PMC7918285 DOI: 10.1097/inf.0000000000002117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND To examine whether inappropriate antibiotic treatment for an initial bout of acute bronchitis in childhood affects patterns of future healthcare utilization and antibiotic prescribing. METHODS We conducted a retrospective analysis of children with at least 1 acute bronchitis episode, defined as the 14-day period after an acute bronchitis visit, born in 2008 and followed through 2015 in a nationally representative commercial claims database. We predicted the likelihood of returning for a subsequent acute bronchitis episode, and being prescribed an antibiotic as part of that episode, as a function of whether or not the child was prescribed an antibiotic as part of the first acute bronchitis episode controlling for patient, provider and practice characteristics. RESULTS Children prescribed an antibiotic as part of their initial acute bronchitis episode were more likely both to have a subsequent acute bronchitis episode (hazard ratio = 1.23; 95% confidence interval: 1.17-1.30) and to be prescribed an antibiotic as part of that second episode (hazard ratio = 2.13; 95% confidence interval: 1.99-2.28) compared with children who were not prescribed as part of their first episode. Children diagnosed with asthma were more likely to experience a second visit for acute bronchitis, but less likely to receive an antibiotic as part of that second episode. CONCLUSIONS Inappropriate antibiotic prescribing for a child's initial acute bronchitis episode of care predicted likelihood of subsequent acute bronchitis episodes and antibiotic prescriptions. Providers should consider the downstream effect of inappropriate antibiotic prescribing for acute bronchitis in childhood.
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van Houten CB, Cohen A, Engelhard D, Hays JP, Karlsson R, Moore E, Fernández D, Kreisberg R, Collins LV, de Waal W, de Winter-de Groot KM, Wolfs TFW, Meijers P, Luijk B, Oosterheert JJ, Heijligenberg R, Sankatsing SUC, Bossink AWJ, Stubbs A, Stein M, Reisfeld S, Klein A, Rachmilevitch R, Ashkar J, Braverman I, Kartun V, Chistyakov I, Bamberger E, Srugo I, Odeh M, Schiff E, Dotan Y, Boico O, Navon R, Friedman T, Etshtein L, Paz M, Gottlieb TM, Pri-Or E, Kronenfeld G, Simon E, Oved K, Eden E, Bont LJ. Antibiotic misuse in respiratory tract infections in children and adults-a prospective, multicentre study (TAILORED Treatment). Eur J Clin Microbiol Infect Dis 2019; 38:505-514. [PMID: 30707378 PMCID: PMC6394715 DOI: 10.1007/s10096-018-03454-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022]
Abstract
Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages.
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Affiliation(s)
- Chantal B van Houten
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | | | - Dan Engelhard
- Division of Paediatric Infectious Disease Unit, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roger Karlsson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Edward Moore
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Wouter de Waal
- Department of Paediatrics, Diakonessenhuis, Utrecht, The Netherlands
| | - Karin M de Winter-de Groot
- Department of Paediatric Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom F W Wolfs
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | - Pieter Meijers
- Department of Paediatrics, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Bart Luijk
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rik Heijligenberg
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | | | - Aik W J Bossink
- Department of Respiratory Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Andrew Stubbs
- Department of Bioinformatics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Michal Stein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Sharon Reisfeld
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Adi Klein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | | | - Jalal Ashkar
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Itzhak Braverman
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Valery Kartun
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Irena Chistyakov
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Ellen Bamberger
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Isaac Srugo
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Majed Odeh
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Elad Schiff
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Yaniv Dotan
- Department of Internal Medicine, Bnai Zion Medical Centre, Haifa, Israel
| | | | | | | | | | | | | | | | | | | | | | | | - Louis J Bont
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands.
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Lambregts MMC, Bernards AT, van der Beek MT, Visser LG, de Boer MG. Time to positivity of blood cultures supports early re-evaluation of empiric broad-spectrum antimicrobial therapy. PLoS One 2019; 14:e0208819. [PMID: 30601829 PMCID: PMC6314566 DOI: 10.1371/journal.pone.0208819] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/25/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Blood cultures are considered the gold standard to distinguish bacteremia from non-bacteremic systemic inflammation. In current clinical practice, bacteraemia is considered unlikely if blood cultures have been negative for 48-72 hours. Modern BC systems have reduced this time-to-positivity (TTP), questioning whether the time frame of 48-72 hrs is still valid. This study investigates the distribution of TTP, the probability of blood culture positivity after 24 hours, and identifies clinical predictors of prolonged TTP. METHODS Adult patients with monomicrobial bacteremia in an academic hospital were included retrospectively over a three-year period. Clinical data were retrieved from the medical records. Predictors of TTP >24 hours were determined by uni- and multivariate analyses. The residual probability of bacteremia was estimated for the scenario of negative BCs at 24 hours after bedside collection. RESULTS The cohort consisted of 801 patients, accounting for 897 episodes of bacteremia. Mean age was 65 years (IQR 54-73), 534 (59.5%) patients were male. Median TTP was 15.7 (IQR 13.5-19.3) hours. TTP was ≤24 hours in 85.3% of episodes. Antibiotic pre-treatment (adjusted OR 1.77; 95%CI 1.14-2.74, p<0.01) was independently associated with prolonged TTP. The probability of bacteremia, if BC had remained negative for 24 hours, was 1.8% (95% CI 1.46-2.14). CONCLUSION With adequate hospital logistics, the probability of positive blood cultures after 24 hours of negative cultures was low. Combined with clinical reassessment, knowledge of this low probability may contribute to prioritization of the differential diagnosis and decisions on antimicrobial therapy. As a potential antibiotic stewardship tool, this strategy warrants further prospective investigation.
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Affiliation(s)
- Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra T. Bernards
- Department of Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Leo G. Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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Barlam TF, Soria-Saucedo R, Ameli O, Cabral HJ, Kaplan WA, Kazis LE. Retrospective analysis of long-term gastrointestinal symptoms after Clostridium difficile infection in a nonelderly cohort. PLoS One 2018; 13:e0209152. [PMID: 30557401 PMCID: PMC6296708 DOI: 10.1371/journal.pone.0209152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 12/02/2018] [Indexed: 12/27/2022] Open
Abstract
Elderly patients and those with comorbid conditions are at high risk for poor outcomes after Clostridium difficile infection (CDI) but outcomes in a healthier, nonelderly population are not well described. We sought to investigate gastrointestinal diagnoses and CDI during hospitalizations in the 24 to 36 months after an initial episode of CDI in nonelderly patients in a cohort with an overall low prevalence of comorbid conditions. We performed a retrospective analysis of hospital admissions from 2010–2013 using the Truven MarketScan database of employment-based private insurance claims. Subjects <65 years of age and their adult dependents (> = 18 years old); a CDI diagnosis in 2011 (index date); at least 12 months of pre-index continuous enrollment; and 24–36 months of continuous post-index enrollment were included. The 12 months of each subject’s enrollment prior to the index date for a CDI served as the reference period for the analyses of that subject’s post-CDI time periods. Hospital claims during the follow-up period were evaluated for gastrointestinal diagnoses and/or CDI ICD-9 codes. The risk of gastrointestinal diagnoses was assessed using Cox proportional hazards models adjusted for a pre-specified set of baseline demographic and clinical factors. During 2011, 5,632 subjects with CDI met the inclusion criteria for our study. The risk of gastrointestinal diagnoses in patients with a CDI diagnostic code for the same admission was almost 8-fold higher 3 months post-CDI (hazard ratio (HR) = 7.56; 95% confidence interval (CI): 2.97–19.19) than for subjects without CDI and remained statistically significant until month 24 (HR = 1.47; 95% CI = 1.04–2.08). After CDI, patients remained at risk for gastrointestinal symptoms with CDI for up to two years. There is an important, long-term healthcare burden after CDI in this population.
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Affiliation(s)
- Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
- * E-mail:
| | - Rene Soria-Saucedo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy at the University of Florida, Gainesville, Florida, United States of America
| | - Omid Ameli
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Warren A. Kaplan
- Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Lewis E. Kazis
- Health Outcomes Unit, Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
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North F, Crane SJ, Ebbert JO, Tulledge-Scheitel SM. Do primary care providers who prescribe more opioids have higher patient panel satisfaction scores? SAGE Open Med 2018; 6:2050312118782547. [PMID: 29977551 PMCID: PMC6024493 DOI: 10.1177/2050312118782547] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/21/2018] [Indexed: 11/15/2022] Open
Abstract
Objectives: Opioid prescribing in the United States has tripled since 1999. At the same time, there has been increasing attention to patient satisfaction. It has been suggested that providers concerned about patient satisfaction may be more likely to treat pain with opioids. We examined primary care providers’ opioid prescribing practices to determine if higher provider opioid prescribing was associated with higher patient satisfaction. Methods: For 77 primary care providers, we compared each provider’s opioid prescription count and amount prescribed to each provider’s patient panel satisfaction measures. Satisfaction measures were obtained from surveys following office visits and consisted of Likert-type scale answers concerning satisfaction for pain management and other provider satisfaction domains. Satisfaction surveys were generated independent of patient complaint of pain and had the aim of overall assessment of patient satisfaction with the provider and the healthcare system. We assessed the correlation between opioid prescribing and patient panel pain management satisfaction using linear regression models with and without adjustment for patient complexity. Results: We observed no statistically significant correlation between patient panel satisfaction with their provider and the quantity of opioids that the provider prescribed (R2 = 0.006; p = 0.52). There was also no correlation between patient panel satisfaction and the number of opioid prescriptions written by their provider (R2 = 0.005; p = 0.54). Additional multivariate analysis after adjusting for patient complexity also demonstrated no correlation of pain management satisfaction with opioids prescribed. Although the quantity of opioid prescriptions was not correlated with pain management satisfaction, several other patient satisfaction measures correlated significantly with pain management satisfaction. Conclusion: Primary care providers with a greater rate of opioid prescribing did not have higher patient panel satisfaction scores for pain management. In primary care, providers who want to improve patient satisfaction should focus on other components of patient care besides opioid-based pain management.
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Affiliation(s)
- Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah J Crane
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis. Antimicrob Resist Infect Control 2018; 7:74. [PMID: 29946449 PMCID: PMC6000953 DOI: 10.1186/s13756-018-0364-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation. Methods This was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression. Results Among 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use. Conclusions Antibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.
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Efficacy and Safety of Procalcitonin Guidance in Patients With Suspected or Confirmed Sepsis. Crit Care Med 2018; 46:691-698. [DOI: 10.1097/ccm.0000000000002928] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Multicenter Evaluation of the ePlex Respiratory Pathogen Panel for the Detection of Viral and Bacterial Respiratory Tract Pathogens in Nasopharyngeal Swabs. J Clin Microbiol 2018; 56:JCM.01658-17. [PMID: 29212701 PMCID: PMC5786739 DOI: 10.1128/jcm.01658-17] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/20/2017] [Indexed: 12/20/2022] Open
Abstract
The performance of the new ePlex Respiratory Pathogen (RP) panel (GenMark Diagnostics) for the simultaneous detection of 19 viruses (influenza A virus; influenza A H1 virus; influenza A 2009 H1 virus; influenza A H3 virus; influenza B virus; adenovirus; coronaviruses [HKU1, OC43, NL63, and 229E]; human rhinovirus/enterovirus; human metapneumovirus; parainfluenza viruses 1, 2, 3, and 4; and respiratory syncytial virus [RSV] [RSV subtype A and RSV subtype B]) and 2 bacteria (Mycoplasma pneumoniae and Chlamydia pneumoniae) was evaluated. Prospectively and retrospectively collected nasopharyngeal swab (NPS) specimens (n = 2,908) were evaluated by using the ePlex RP panel, with the bioMérieux/BioFire FilmArray Respiratory Panel (BioFire RP) as the comparator method. Discordance analysis was performed by using target-specific PCRs and bidirectional sequencing. The reproducibility of the assay was evaluated by using reproducibility panels comprised of 6 pathogens. The overall agreement between the ePlex RP and BioFire RP results was >95% for all targets. Positive percent agreement with the BioFire RP result for viruses ranged from 85.1% (95% confidence interval [CI], 80.2% to 88.9%) to 95.1% (95% CI, 89.0% to 97.9%), while negative percent agreement values ranged from 99.5% (95% CI, 99.1% to 99.7%) to 99.8% (95% CI, 99.5% to 99.9%). Additional testing of discordant targets (12%; 349/2,908) confirmed the results of ePlex RP for 38% (131/349) of samples tested. Reproducibility was 100% for all targets tested, with the exception of adenovirus, for which reproducibilities were 91.6% at low virus concentrations and 100% at moderate virus concentrations. The ePlex RP panel offers a new, rapid, and sensitive “sample-to-answer” multiplex panel for the detection of the most common viral and bacterial respiratory pathogens.
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Butt AA, Navasero CS, Thomas B, Marri SA, Katheeri HA, Thani AA, Khal AA, Khan T, Abou-Samra AB. Antibiotic prescription patterns for upper respiratory tract infections in the outpatient Qatari population in the private sector. Int J Infect Dis 2017; 55:20-23. [DOI: 10.1016/j.ijid.2016.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/17/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022] Open
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Zatorski C, Zocchi M, Cosgrove SE, Rand C, Brooks G, May L. A single center observational study on emergency department clinician non-adherence to clinical practice guidelines for treatment of uncomplicated urinary tract infections. BMC Infect Dis 2016; 16:638. [PMID: 27814677 PMCID: PMC5097367 DOI: 10.1186/s12879-016-1972-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022] Open
Abstract
Background The Emergency Department (ED) is a frequent site of antibiotic use; poor adherence with evidence-based guidelines and broad-spectrum antibiotic overuse is common. Our objective was to determine rates and predictors of inappropriate antimicrobial use in patients with uncomplicated urinary tract infections (UTI) compared to the 2010 International Clinical Practice Guidelines (ICPG). Methods A single center, prospective, observational study of patients with uncomplicated UTI presenting to an urban ED between September 2012 and February 2014 that examined ED physician adherence to ICPG when treating uncomplicated UTIs. Clinician-directed antibiotic treatment was compared to the ICPG using a standardized case definition for non-adherence. Binomial confidence intervals and student’s t-tests were performed to evaluate differences in demographic characteristics and management between patients with pyelonephritis versus cystitis. Regression models were used to analyze the significance of various predictors to non-adherent treatment. Results 103 cases met the inclusion and exclusion criteria, with 63.1 % receiving non-adherent treatment, most commonly use of a fluoroquinolone (FQ) in cases with cystitis (97.6 %). In cases with pyelonephritis, inappropriate antibiotic choice (39.1 %) and no initial IV antibiotic for pyelonephritis (39.1 %) where recommended were the most common characterizations of non-adherence. Overall, cases of cystitis were no more/less likely to receive non-adherent treatment than cases of pyelonephritis (OR 0.9, 95 % confidence interval 0.4–2.2, P = 0.90). In multivariable analysis, patients more likely to receive non-adherent treatment included those without a recent history of a UTI (OR 3.8, 95 % CI 1.3–11.4, P = 0.02) and cystitis cases with back or abdominal pain only (OR 11.4, 95 % CI 2.1–63.0, P = 0.01). Conclusions Patients with cystitis with back or abdominal pain only were most likely to receive non-adherent treatment, potentially suggesting diagnostic inaccuracy. Physician education on evidence-based guidelines regarding the treatment of uncomplicated UTI will decrease broad-spectrum use and drug resistance in uropathogens.
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Affiliation(s)
- Catherine Zatorski
- Department of Emergency Medicine, The George Washington University, 2120 L Street, NW Suite 4-450, Washington, DC, 20037, USA
| | - Mark Zocchi
- Center for Healthcare Innovation & Policy Research, The George Washington University, 2100 Pennsylvania Avenue Suite 300, Washington, DC, 20037, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins Medical Institutions, Osler 425, 600 N. Wolfe St., Baltimore, MD, 21287, USA
| | - Cynthia Rand
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins Institutions, 5501 Hopkins Bayview Circle, Baltimore, MD, 21224, USA
| | - Gillian Brooks
- Department of Emergency Medicine, The George Washington University, 2120 L Street, NW Suite 4-450, Washington, DC, 20037, USA
| | - Larissa May
- Department of Emergency Medicine, UC Davis Medical Center, 4150 V Street, Suite 2100, Sacramento, CA, 95817, USA.
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