The Use of Antibiotics for Viral Upper Respiratory Tract Infections: An Analysis of Nurse Practitioner and Physician Prescribing Practices in Ambulatory Care, 1997-2001

Antibiotic action and resistance: updated review of mechanisms, spread, influencing factors, and alternative approaches for combating resistance

Antibiotics represent a frequently employed therapeutic modality for the management of bacterial infections across diverse domains, including human health, agriculture, livestock breeding, and fish farming. The efficacy of antibiotics relies on four distinct mechanisms of action, which are discussed in detail in this review, along with accompanying diagrammatic illustrations. Despite their effectiveness, antibiotic resistance has emerged as a significant challenge to treating bacterial infections. Bacteria have developed defense mechanisms against antibiotics, rendering them ineffective. This review delves into the specific mechanisms that bacteria have developed to resist antibiotics, with the help of diagrammatic illustrations. Antibiotic resistance can spread among bacteria through various routes, resulting in previously susceptible bacteria becoming antibiotic-resistant. Multiple factors contribute to the worsening crisis of antibiotic resistance, including human misuse of antibiotics. This review also emphasizes alternative solutions proposed to mitigate the exacerbation of antibiotic resistance.

Antimicrobial stewardship for nurse practitioners and physician assistants: enhancing patient safety through education

Background

As nurse practitioners and physician assistants (APPs) become more prevalent in delivering pediatric care, their involvement in antimicrobial stewardship efforts increases in importance. This project aimed to create and assess the efficacy of a problem-based learning (PBL) approach to teaching APPs antimicrobial stewardship principles.

Methods

A PBL education initiative was developed after communication with local APP leadership and focus group feedback. It was offered to all APPs associated with Lurie Children's Hospital of Chicago. Participants completed a survey which assessed opinions on antimicrobial stewardship and included knowledge-based questions focused on antimicrobial stewardship. Prescriptions for skin and soft tissue infections associated with APPs were recorded via chart review before and after the education campaign.

Results

Eighty APPs participated in the initial survey and teaching initiative with 44 filling out the 2-week follow-up and 29 filling out the 6-month follow-up. Subjective opinions of antimicrobial stewardship and comfort with basic principles of AS increased from pre-intervention. Correct responses to knowledge-based assessments increased from baseline after 2-week follow-up (p < 0.01) and were maintained at the 6-month follow-up (p = 0.03). Simple skin and soft tissue infection prescriptions for clindamycin went from 44.4% pre-intervention to 26.5% (p = 0.2) post-intervention.

Conclusions

A PBL approach for APP education on antimicrobial stewardship can be effective in increasing knowledge and comfort with principles of antimicrobial stewardship. These changes are maintained in long-term follow-up. Changes in prescribing habits showed a strong trend towards recommended empiric therapy choice. Institutions should develop similar education campaigns for APPs.

One size does not fit all: advanced practice provider considerations for the antimicrobial steward

Advanced practice providers are a diverse and established group of antimicrobial prescribers in both ambulatory and inpatient settings. We outline important considerations for antimicrobial stewardship programs and stewards to consider when engaging this important group of providers.

Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis

Background

Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics.

Objective

To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics.

Design

A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology.

Participants

A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice.

Methods

In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol.

Results

Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up).

Conclusion

The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.

Antibiotic prescription for HIV-positive patients in primary health care in Mozambique: A cross-sectional study

Background

Antibiotic overuse is a major public health challenge worldwide and it can result in the emergence and spread of drug resistance. In Mozambique, there are limited data related to primary care physicians’ antibiotic prescription patterns. The aim of this study was to assess the antibiotic prescription patterns for HIV- positive patients in primary health care.

Methods

A prospective cross-sectional quantitative study was conducted in eight primary health care units in Southern Mozambique. The study was based on recording outpatient prescriptions using a structured questionnaire. Three hundred and sixty-nine prescriptions and clinical records of HIV-positive patients from 31 prescribers were assessed. A total of eight general practitioners, 13 medical technicians and 10 nurses participated.

Results

Antibiotics were used in 65.9% of prescriptions, with an average of 0.9 antibiotics per prescription. Of a total of 334 prescribed antibiotics, 69.8% were for the treatment of infections and 30.2% for prophylaxis. Penicillin (29.2%), sulphonamides (19.7%), and quinolones (16.3%) were the most prescribed classes of antibiotics for treatment. For prophylaxis, only sulphonamides (93.1%) and macrolides (6.9%) were prescribed. The diagnosis was the only variable that had a significant association with antibiotic prescription (p < 0.001). Most of penicillins (68.0%) and sulphonamides (21.4%) were prescribed to treat infections related to the respiratory tract.

Conclusion

The prescription of antibiotics was high and influenced by patient clinical conditions. Antibiotics were prescribed either for treatment or prophylaxis of infections, mostly to treat respiratory tract infections. Prescribers should be encouraged to adopt a rational use of antibiotics to reduce unnecessary prescriptions.

Influences on antibiotic prescribing by non-medical prescribers for respiratory tract infections: a systematic review using the theoretical domains framework

BACKGROUND

The need to conserve antibiotic efficacy, through the management of respiratory tract infections (RTIs) without recourse to antibiotics, is a global priority. A key target for interventions is the antibiotic prescribing behaviour of healthcare professionals including non-medical prescribers (NMPs: nurses, pharmacists, paramedics, physiotherapists) who manage these infections.

OBJECTIVES

To identify what evidence exists regarding the influences on NMPs' antimicrobial prescribing behaviour and analyse the operationalization of the identified drivers of behaviour using the Theoretical Domains Framework (TDF).

METHODS

The search strategy was applied across six electronic bibliographic databases (eligibility criteria included: original studies; written in English and published before July 2019; non-medical prescribers as participants; and looked at influences on prescribing patterns of antibiotics for RTIs). Study characteristics, influences on appropriate antibiotic prescribing and intervention content to enhance appropriate antibiotic prescribing were independently extracted and mapped to the TDF.

RESULTS

The search retrieved 490 original articles. Eight papers met the review criteria. Key issues centred around strategies for managing challenges experienced during consultations, managing patient concerns, peer support and wider public awareness of antimicrobial resistance. The two most common TDF domains highlighted as influences on prescribing behaviour, represented in all studies, were social influences and beliefs about consequences.

CONCLUSIONS

The core domains highlighted as influential to appropriate antibiotic prescribing should be considered when developing future interventions. Focus should be given to overcoming social influences (patients, other clinicians) and reassurance in relation to beliefs about negative consequences (missing something that could lead to a negative outcome).

Care received by patients from nurse practitioners and physicians in U.S. primary care settings

OBJECTIVE

Nurse practitioners (NPs) and physicians serve in both usual source of care (USC) and supplement roles to each other in the provision of primary care to patients. Yet little is known about the care that patients receive from providers in these roles. This study examined the care individuals received when NPs and physicians served in USC and supplemental roles.

DATA SOURCES

Pooled data from the Household Component of the Medical Expenditure Panel Survey 2002-2013.

STUDY DESIGN

Cross-sectional, secondary data analysis using propensity score matching and multinomial logistic regression.

DATA COLLECTION

Data were collected from a national subsample of households.

PRINCIPAL FINDINGS

Regardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians. Patients reported having similar diagnoses when seen by NPs and physicians serving in USC roles, but different diagnoses when NPs and physicians served in supplemental roles.

CONCLUSIONS

NPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians.

Parental knowledge and practice on antibiotic use for upper respiratory tract infections in children, in Aksum town health institutions, Northern Ethiopia: a cross-sectional study

Introduction

worldwide, antibiotics are the most commonly prescribed and abused drugs for upper respiratory tract infections. Acute upper respiratory infections are common in children who attend childcare and preventing transmission of disease in health setting depends on actions by parents and staff. Therefore the objective of this study is to assess the parental knowledge and practice on antibiotic use for upper respiratory tract infections in children, in Aksum town health institutions, northern Ethiopia, 2018.

Methods

a facility-based cross-sectional study design was adopted involving 384 parents of children visited governmental health facilities in Aksum town from February to March, 2018. Respondents were selected based on the proportion of nurses in the health facilities. SPSS version 22 was applied for data entry and analysis.

Results

the total number of questionnaires was 384 resulting in a 100% response rate. Almost half of the parents had poor knowledge of the use of antibiotics in children for URTIs 183(47.7%), followed by 156(40.6%) moderate knowledge and 45(11.7%) good knowledge. Practices regarding antibiotic use in children with URTI varied. Only 12.8% of the parents did not always follow the doctors´ advice regarding antibiotic use. In this study has reported many areas in which parental awareness on antibiotic use for acute URTI is considered inadequate, consequently inappropriate knowledge and practices.

Conclusion

nearly half of the parents attending the physicians for their children with URTI expected to get antibiotics.

Influencing factors of knowledge, attitude, and practice regarding antibiotic use in children with upper respiratory tract infections in Dubai

INTRODUCTION

The main leading cause of the upper respiratory tract infections (URTIs) is viral infection. However, parental attitudes often lead to inappropriate prescription of antibiotics contributing to development of antibiotic resistance. The aim of this study is to assess parental knowledge, attitude, and practice (KAP) towards the use of antibiotics in Dubai and to reveal the associated factors.

METHOD

Questionnaires were distributed to 500 parents of children who were visiting Al Jalila Children's Specialty Hospital in Dubai.

RESULT

A total of 467 subjects agreed to participate in the study. Family income, educational level, nationality, age of the respondents, and numbers of children were identified as factors that significantly associated with inadequate knowledge, negative attitude, or malpractice.

CONCLUSION

The study has identified key factors associated with misuse of URTI antibiotics and highlights the importance of targeting those groups with intervention programs and campaigns to increase awareness and decrease misconception of antibiotic use.

Knowledge, Perception, and Educational Status of Antimicrobial Resistance Among Chinese Medical Students

Aims: Antimicrobial resistance (AMR) has become a serious global health issue, which is exacerbated globally by the overuse and misuse of antimicrobial drugs. Improving awareness and understanding AMR through effective communication, education, and training is recommended by the World Health Organization as one of five key strategies of tackling AMR. This study explores the knowledge and perception of AMR, its educational status, and any potential associations among Chinese medical students. Results: A total of 2,616 students from four medical schools across China were enrolled in this study. Data reveal a general lack of knowledge about both antibiotic use and AMR that is related to school type, major, and clinical experience. Students' AMR knowledge was associated with their perception of issues in this area as well as their educational status. Results of a linear regression model show that learning about AMR in class (OR: 1.85, 95% CI: 1.47-2.23) and the hours spent learning about these issues (OR: 0.11, 95% CI: 0.07-0.15) were both positively associated with enhanced knowledge. Conclusions: A significant lack of knowledge about AMR is found among Chinese medical students, associated with their perception of these issues. The status of AMR education in medical schools nationally is therefore less than satisfactory and positively correlated with general knowledge of this issue.

A survey of nurse practitioner controlled drugs and substances prescribing in three Canadian provinces

AIMS AND OBJECTIVES

In Canada, nurse practitioners (NP) were legally authorised to prescribe controlled drugs and substances (CDS) in 2012. The objective of this study was to understand current NP-CDS prescribing in Alberta, Manitoba and Saskatchewan, Canada. This study is a component of a larger three-phase survey of NP practice patterns in these same provinces.

BACKGROUND

Nurse practitioners are nurses with a graduate degree who have the legal authority to perform expanded functions in health systems, including prescribing CDS. Given the novelty of CDS prescribing for NPs in Canada, little is known about this component of their role.

DESIGN

A secondary analysis of survey data collected between March 2016 and May 2017 was used to examine NP-CDS-prescribing patterns and identify potential associated factors.

METHODS

Nurse practitioners in Alberta, Manitoba and Saskatchewan were invited to complete a professional practice pattern survey. The survey was administered through a secure electronic data collection software application (redcap). In the practice pattern survey, 42 variables from 15 distinct conceptual questions were analysed in this study as potential predictors of NP-CDS prescribing within a purposeful selection ordinal logistic regression model. This scientific submission has been assessed for accuracy and completeness using the Equator STROBE guideline criteria (see Appendix S1).

RESULTS/FINDINGS

Five variables were found to be associated with an increased odds of more frequent NP-CDS prescribing in addition to three confounders/clinically relevant variables. Factors commonly associated with an increased frequency of NP-CDS prescribing relate to location of practice, area of practice, previous nursing experience, team environments and common diagnoses.

CONCLUSION

Little is known about NP-CDS prescribing. Understanding this important component of the NPs emerging legal scope of professional practice can contribute to the continued refinement of this role as well as support ongoing enquiry into the causes of, and potential interventions to prevent, the present opioid overdose deaths occurring while under an active prescription.

RELEVANCE TO CLINICAL PRACTICE

Understanding factors that influence NP-CDS prescribing has relevance to the current drug-related prescription fatalities crisis in all countries.

Methicillin-Resistant Staphylococcus aureus in Diabetic Foot Infection in India: A Growing Menace

Diabetic foot infection (DFI) is a serious and common complication of diabetes mellitus. These infections are potentially disastrous and rapidly progress to deeper spaces and tissues. If not treated promptly and appropriately, DFI can be incurable or even lead to septic gangrene, which may require foot amputation. Mostly, these infections are polymicrobial, where Gram-positive pathogens mainly Staphylococcus aureus play a dominant causative role. Methicillin-resistant Staphylococcus aureus (MRSA) is present in 10% to 32% of diabetic infections and is associated with a higher rate of treatment failure, morbidity, and hospitalization cost in patients with DFIs. The increasing resistance of bacteria and the adverse effects pertaining to the safety and tolerability towards currently available anti-MRSA agents have limited the available treatment options for patients with DFI. Infection control, antimicrobial stewardship, and rapid diagnostics based on the microbiological culture and the antimicrobial susceptibility testing results are important components in helping curb this disturbing trend. Emphasis to revisit a vigorous research effort in order to improve the therapeutic options for the increasingly resistant and highly adaptable MRSA is the need of hour. Through this review article, we have made an attempt to explore the ongoing therapeutic trends in the management of DFI and highlighted the challenges in treatment of DFI. We have also given a brief overview of a few novel drugs that are under development to treat MRSA infections.

Long-term outcomes of tonsillectomy for recurrent tonsillitis in adults

BACKGROUND

There is uncertainty regarding the effectiveness of tonsillectomy for recurrent tonsillitis in the adult population. Several studies have described a reduced number and severity of tonsillitis episodes; however, the impact of tonsillectomy on healthcare burden has yet to be studied. The aim of the present study was to evaluate the long-term outcomes of tonsillectomy in the adult population.

METHODS

A retrospective review of the central database of Clalit Health Services, Tel Aviv, Israel, between 2003 and 2009 was performed. The study included all adult patients (>18 years) who underwent tonsillectomy due to recurrent tonsillitis. Clinical and epidemiological data from 3 years before and after surgery were collected and analyzed.

RESULTS

A total of 3,701 patients were included in the study. Mean age was 37.4 years, and 42.9% were males. Following surgery, there was a significant decrease in the total number of tonsillitis episodes, otolaryngologist clinic visits, consumption of pertinent antibiotics, and respiratory complaints. Moreover, a reduced number of hospitalizations to the otolaryngology department and shorter hospitalization duration were also noted. Although the total number of hospitalizations was unaffected, there was an increase in the number of primary care office visits. Finally, a break-even time analysis revealed an average of 2.7 years following tonsillectomy.

CONCLUSION

Tonsillectomy for recurrent tonsillitis is effective in decreasing the number and severity of tonsillitis episodes and might also have an economic benefit. The impact of tonsillectomy on general health needs to be further evaluated; however, it appears that there is no increase in overall morbidity.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:328-331, 2020.

Variability of Antibiotic Prescribing in a Large Healthcare Network Despite Adjusting for Patient-Mix: Reconsidering Targets for Improved Prescribing

Background

In the outpatient setting, the majority of antibiotic prescriptions are for acute respiratory infections (ARIs), but most of these infections are viral and antibiotics are unnecessary. We analyzed provider-specific antibiotic prescribing in a group of outpatient clinics affiliated with an academic medical center to inform future interventions to minimize unnecessary antibiotic use.

Methods

We conducted a cross-sectional study of patients who presented with an ARI to any of 15 The Emory Clinic (TEC) primary care clinic sites between October 2015 and September 2017. We performed multivariable logistic regression analysis to examine the impact of patient, provider, and clinic characteristics on antibiotic prescribing. We also compared provider-specific prescribing rates within and between clinic sites.

Results

A total of 53.4% of the 9600 patient encounters with a diagnosis of ARI resulted in an antibiotic prescription. The odds of an encounter resulting in an antibiotic prescription were independently associated with patient characteristics of white race (adjusted odds ratio [aOR] = 1.59; 95% confidence interval [CI], 1.47–1.73), older age (aOR = 1.32, 95% CI = 1.20–1.46 for patients 51 to 64 years; aOR = 1.32, 95% CI = 1.20–1.46 for patients ≥65 years), and comorbid condition presence (aOR = 1.19; 95% CI, 1.09–1.30). Of the 109 providers, 13 (12%) had a rate significantly higher than predicted by modeling.

Conclusions

Antibiotic prescribing for ARIs within TEC outpatient settings is higher than expected based on prescribing guidelines, with substantial variation in prescribing rates by site and provider. These data lay the foundation for quality improvement interventions to reduce unnecessary antibiotic prescribing.

A case study of nurse practitioner care compared with general practitioner care for children with respiratory tract infections

AIM

To compare quality of care provided by nurse practitioners (NP) with care provided by general practitioners (GP) for children with respiratory tract infections (RTI) in the Netherlands.

BACKGROUND

Nurse practitioners increasingly manage acute conditions in general practice, with opportunities for more protocolled care. Studies on quality of NPs' care for children with RTIs are limited to the US healthcare system and do not take into account baseline differences in illness severity.

DESIGN

Retrospective observational cohort study.

METHODS

Data were extracted from electronic healthcare records of children 0-6 years presenting with RTI between January-December 2013. Primary outcomes were antibiotic prescriptions and early return visits. Generalized estimating equations were used to correct for potential confounders.

RESULTS

A total of 899 RTI consultations were assessed (168 seen by NP; 731 by GP). Baseline characteristics differed between these groups. Overall antibiotic prescription and early return visit rates were 21% and 24%, respectively. Adjusted odds ratio for antibiotic prescription after NP vs. GP delivered care was 1.40 (95% confidence interval 0.89-2.22) and for early return visits 1.53 (95% confidence interval 1.01-2.31). Important confounder for antibiotic prescription was illness severity. Presence of wheezing was a confounder for return visits. Complication and referral rates did not differ.

CONCLUSION

Antibiotic prescription, complication and referral rates for paediatric RTI consultations did not differ significantly between NP and GP consultations, after correction for potential confounders. General practitioners, however, see more severely ill children and have a lower return visit rate. A randomised controlled study is needed to determine whether NP care quality is truly noninferior.

Observation of a Pharmacist-Conducted Group A Streptococcal Pharyngitis Point-of-Care Test: A Time and Motion Study

BACKGROUND

Acute pharyngitis is among the most common infectious diseases encountered in the United States, resulting in 13 million patient visits annually, with group A streptococcus (GAS) being a common causative pathogen. It is estimated that annual expenditures for the treatment of adult pharyngitis will exceed US$1.2 billion annually. This substantial projection reinforces the need to evaluate diagnosis and treatment of adult pharyngitis in nontraditional settings.

OBJECTIVE

The objective of this research is to quantify the amount of pharmacist time required to complete a point-of-care (POC) test for a patient presenting with pharyngitis symptoms.

METHODS

A standardized patient with pharyngitis symptoms visited 11 pharmacies for POC testing services for a total of 33 patient encounters. An observer was present at each encounter and recorded the total encounter time, divided into 9 categories. Pharmacists conducted POC testing in 1 of 2 ways: sequence 1-pharmacists performed all service-related tasks; sequence 2-both pharmacists and pharmacist interns performed service-related tasks.

RESULTS

The average time for completion of a POC test for GAS pharyngitis was 25.3 ± 4.8 minutes. The average pharmacist participation time per encounter was 12.7 ± 3.0 minutes (sequence 1), which decreased to 2.6 ± 1.1 minutes when pharmacist interns were involved in the testing (sequence 2).

CONCLUSION

Although additional studies are required to further assess service feasibility, this study indicates that a GAS POC testing service could be implemented in a community pharmacy with limited disruption or change to workflow and staff.

Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010

OBJECTIVES

Although antibiotic prescriptions are decreasing in the United States, broad-spectrum prescribing is increasing. It is unknown if decreases observed in national antibiotic prescribing differ by provider group. Understanding prescribing trends over time by provider group can be helpful for customizing antimicrobial stewardship efforts. Therefore, the purposes of this study were to describe outpatient antibiotic prescribing by provider group overall and adjusted for population and number of providers. In addition, trends in prescribing by class and seasonal variation are described by provider group over 6 years.

DESIGN

Cross-sectional observation of outpatient antibiotic prescriptions.

SETTING AND PARTICIPANTS

A population-level analysis of U.S. prescribing from 2005 to 2010 with the use of the IMS Health Xponent dataset.

MAIN OUTCOME MEASURES

Number and rates of prescriptions dispensed overall and by provider group.

RESULTS

The majority (81.0%) of antibiotics were prescribed by physicians, followed by dentists (10.4%), nurse practitioners (NPs; 4.5%), and physician assistants (PAs; 4.2%). The percentage of antibiotic prescriptions decreased for physicians, but increased significantly for NPs and PAs. Provider-based and population-based prescribing rates decreased for physicians and dentists and increased for NPs and PAs. Penicillins were prescribed most frequently by all provider groups, decreasing for physicians and dentists. Increased prescribing of broad-spectrum agents was observed for NPs and PAs. With the exception of dentists, antibiotic prescriptions were higher in winter than in summer, with the largest seasonal increase by NPs.

CONCLUSION

Over 6 years, antibiotic prescriptions overall and for broad-spectrum agents decreased for physicians and increased for NPs and PAs. Thus, increasing trends in the US of broad-spectrum antibiotic prescriptions can be attributed to midlevel providers. Interventions should be designed to reverse increasing prescribing trends, especially of broad-spectrum agents prescribed by NPs and PAs. Stewardship efforts should also be targeted towards dentists, since this group prescribes a higher proportion of antibiotics compared with midlevel providers.

Antibiotic Prescribing by Physicians Versus Nurse Practitioners for Pediatric Upper Respiratory Infections

Background:

This study investigates differences in antibiotic prescribing rates for pediatric upper respiratory infections (URIs) between physicians and nurse practitioners (NPs).

Methods:

Visits by children <18 years old diagnosed with URI to physicians or NPs between 2001 and 2010 were abstracted from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey. Logistic regression analyses examined variations in antibiotic prescribing rates.

Results:

Upper respiratory infections accounted for approximately 439 ± 21.5 million visits. Patients seen by NPs were more likely to have Medicaid, live in the lowest median household income quartile zip codes and micropolitan locations, and live in the South compared to patients seen by physicians. Nurse practitioners prescribed antibiotics 66.7% ± 4.2% of the time versus physicians at 52.8% ± 0.8% for URI visits (unadjusted P-value = .002). Adjusted by specialty, URI type, and chronic diseases, NPs had marginally significantly different odds of prescribing antibiotics (OR = 1.6, 95% CI, 1.0-2.6, P-value = .048), but the association with prescribing broad-spectrum antibiotics is not as strong (adjusted P-value = .063). Patient visits to a pediatric (OR = 0.54, 95% CI, 0.43-0.67) or ENT/surgery practice (OR = 0.11, 95% CI, 0.06-0.18) had lower odds of antibiotic prescribing compared to general/family medicine practices. Year (2001-2010) was not significantly associated with antibiotic or broad-spectrum antibiotic prescribing rates for physicians, but rates for NPs fell for otitis media ( P-value = .007) from 90.2% ± 8.2% (2001-2002) to 74.8% ± 6.8% (2009-2010) of visits.

Conclusions:

Nurse practitioners have higher rates of antibiotic prescribing compared to physicians for pediatric patients with URIs; however, this difference is less after adjusting for specialty. Examining comparative antibiotic prescribing is important to promote evidence-based practice and adoption of clinical guidelines.

Antibiotic prescribing and expenditures in outpatient adults in Greece, 2010 to 2013: evidence from real-world practice

We provide a representative analysis of antibiotic prescribing, identify factors associated with broad-spectrum antibiotic prescribing and assess the costs associated with antibiotic use in adult outpatients in Greece. Outpatient antibiotic prescriptions for patients older than 19 years between 2010 and 2013 in Greece were extracted from the IMS Health Xponent database. Prescribing rate and total cost for prescribed antibiotics were calculated. Multivariate logistic regression was used to identify factors related to broad-spectrum antibiotic prescribing. More than 20 million antibiotics were prescribed during the study period, an annual rate of 768 prescribed antibiotics per 1,000 adults. Overall, 33.5% of antibiotics were prescribed for acute respiratory tract infections (ARTIs) for which antibiotics are often not indicated. Macrolides (29.9%), cephalosporins (26.9%) and fluoroquinolones (21.0%) were the most commonly prescribed antibiotic classes. The majority (89.0%) of antibiotics were broad-spectrum. Antibiotic expenditures were approximately EUR 185 million during the study period. Factors associated with broad-spectrum prescribing included older patient age, specialty pulmonologists or otorhinolaryngologists, training in eastern Europe, diagnosis of ARTI, acute diagnosis, and first episode of disease. Broad-spectrum antibiotic prescribing for ARTIs is common in adult Greek outpatients and frequently inappropriate. These data indicate the need for initiatives aiming to control antibiotic prescribing.

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.

Community pharmacist-physician collaborative streptococcal pharyngitis management program

OBJECTIVES

To describe patient outcomes associated with a community pharmacy-based, collaborative physician-pharmacist group A Streptococcus (GAS) management program.

SETTING

Fifty-five chain and independent community pharmacies in Michigan, Minnesota, and Nebraska.

PRACTICE INNOVATION

Pharmacists screened clinically stable adult patients who presented with signs and symptoms consistent with GAS pharyngitis from October 1, 2013, to August 1, 2014, by means of Centor criteria, and performed a physical assessment followed by a rapid antigen detection test (RADT) for eligible patients. Patients were treated according to a collaborative practice agreement (CPA) with a licensed prescriber or a physician consult site model. Pharmacists followed up with patients 24-48 hours after the encounter to assess patient status and possible need for further intervention.

EVALUATION

Number of patients screened, tested, and treated, and health care utilization.

RESULTS

Of 316 patients screened, 43 (13.6%) were excluded and referred for care. Of 273 patients (86.4%) eligible for testing, 48 (17.6%) had positive test results and 46 (16.8%) received amoxicillin or azithromycin per the CPA. Of those tested, 43.2% had no primary provider and 43.9% visited the pharmacy outside of traditional clinic office hours.

CONCLUSION

Pharmacists demonstrated the ability and capacity to provide care for patients seeking treatment for pharyngitis. The number of patients without a primary care provider and seen at the pharmacy outside of normal office hours highlights the improved access that community pharmacy-based care offers.

Use of CLIA-waived point-of-care tests for infectious diseases in community pharmacies in the United States

Review of point-of-care (POC) testing in community pharmacies, availability and specifications of CLIA-waived infectious disease POC tests, and provide recommendations for future community pharmacy POC models in an effort to improve patient outcomes while reducing antibiotic resistance. PubMed and Medscape were searched for the following keywords: infectious disease, community pharmacy, rapid diagnostic tests, rapid assay, and POC tests. All studies utilizing POC tests in community pharmacies for infectious disease were included. Studies, articles, recommendations, and posters were reviewed and information categorized into general implementation of POC testing in community pharmacies, CLIA-waived tests available, Influenza, Group A Streptococcus pharyngitis, Helicobacter pylori, HIV and Hepatitis C. POC testing provides a unique opportunity for community pharmacists to implement collaborative disease management programmes for infectious diseases and reduce over-prescribing of antibiotics and improve patient outcomes through early detection, treatment and/or referral to a specialist.

Growth in nurse prescribing of antibiotics: the Scottish experience 2007-13

OBJECTIVES

The objective of this study was to retrospectively analyse patterns of primary care antibiotic prescribing by nurse prescribers in Scotland.

METHODS

Data on dispensed antibiotic prescriptions written by nurse prescribers in 2007-13 were obtained from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland.

RESULTS

Since 2007, there has been a steady increase in the volume of antibiotic prescribing in primary care undertaken by nurse prescribers. There was considerable variability in the frequency of antibiotic prescribing among nurses and across NHS regions. Since 2007, an increasing proportion of antibiotics prescribed by nurses are those recommended for first-line empirical treatment of infection, with a reduction in the proportion of broader-spectrum agents. Other measures of prescribing quality (duration of treatment of adult females with urinary tract infection and use of recommended doses) have improved since 2007.

CONCLUSIONS

This paper is the first, to our knowledge, to present an analysis of data on antibiotic prescribing in primary care by nurse prescribers. Inappropriate prescribing is a problem and, given the impact that antibiotic prescribing has on antimicrobial resistance, it is important that the prescribing behaviour of nurses is explored. This is especially significant as this is a growing body of prescribers who predominately work in the community, where the majority of antibiotics are prescribed. This analysis showed that practice varies across NHS regions and between prescribers and although more information is needed to establish whether nurse prescribers are prescribing appropriately, some quality indicators may suggest that they are following best practice.

Trends in nurse practitioners' prescribing to older adults in Ontario, 2000-2010: a retrospective cohort study

BACKGROUND

Nurse prescribing is a practice that has evolved and will continue to evolve in response to emerging trends, particularly in primary care. The goal of this study was to describe the trends and patterns in medication prescription to adults 65 years of age or older in Ontario by nurse practitioners over a 10-year period.

METHODS

We conducted a population-based descriptive retrospective cohort study. All nurse practitioners registered in the Corporate Provider Database between Jan. 1, 2000, and Dec. 31, 2010, were identified. We identified actively prescribing nurse practitioners through linkage of dispensed medications to people aged 65 years or older from the Ontario Drug Benefit database. For comparison, all prescription medications dispensed by family physicians to a similar group were identified. Geographic location was determined based on site of nurse practitioner practice.

RESULTS

The number and proportion of actively prescribing nurse practitioners prescribing to older adults increased during the study period, from 44/340 (12.9%) to 888/1423 (62.4%). The number and proportion of medications dispensed for chronic conditions by nurse practitioners increased: in 2010, 9 of the 10 top medications dispensed were for chronic conditions. There was substantial variation in the proportion of nurse practitioners dispensing medication to older adults across provincial Local Health Integration Networks.

INTERPRETATION

Prescribing by nurse practitioners to older adults, particularly of medications related to chronic conditions, increased between 2000 and 2010. The integration of nurse practitioners into primary care has not been consistent across the province and has not occurred in relation to population changes and perhaps population needs.

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Four structural subclasses of the antivirulence drug target disulfide oxidoreductase DsbA provide a platform for design of subclass-specific inhibitors

By catalyzing oxidative protein folding, the bacterial disulfide bond protein A (DsbA) plays an essential role in the assembly of many virulence factors. Predictably, DsbA disruption affects multiple downstream effector molecules, resulting in pleiotropic effects on the virulence of important human pathogens. These findings mark DsbA as a master regulator of virulence, and identify the enzyme as a target for a new class of antivirulence agents that disarm pathogenic bacteria rather than killing them. The purpose of this article is to discuss and expand upon recent findings on DsbA and to provide additional novel insights into the druggability of this important disulfide oxidoreductase by comparing the structures and properties of 13 well-characterized DsbA enzymes. Our structural analysis involved comparison of the overall fold, the surface properties, the conformations of three loops contributing to the binding surface and the sequence identity of residues contributing to these loops. Two distinct structural classes were identified, classes I and II, which are differentiated by their central β-sheet arrangements and which roughly separate the DsbAs produced by Gram-negative from Gram-positive organisms. The classes can be further subdivided into a total of four subclasses on the basis of surface features. Class Ia is equivalent to the Enterobacteriaceae class that has been defined previously. Bioinformatic analyses support the classification of DsbAs into 3 of the 4 subclasses, but did not pick up the 4th subclass which is only apparent from analysis of DsbA electrostatic surface properties. In the context of inhibitor development, the discrete structural subclasses provide a platform for developing DsbA inhibitory scaffolds with a subclass-wide spectrum of activity. We expect that more DsbA classes are likely to be identified, as enzymes from other pathogens are explored, and we highlight the issues associated with structure-based inhibitor development targeting this pivotal mediator of bacterial virulence. This article is part of a Special Issue entitled: Thiol-Based Redox Processes.

Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09

OBJECTIVES

To determine patterns of ambulatory antibiotic prescribing in US adults, including the use of broad-spectrum versus narrow-spectrum agents, to provide a description of the diagnoses for which antibiotics are prescribed and to identify patient and physician factors associated with broad-spectrum antibiotic prescribing.

METHODS

We used data for patients aged ≥ 18 years from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (2007-09). These are nationally representative surveys of patient visits to offices, hospital outpatient departments and emergency departments (EDs) in the USA, collectively referred to as ambulatory visits. We determined the types of antibiotics prescribed, including the use of broad-spectrum versus narrow-spectrum antibiotics, and examined prescribing patterns by diagnoses. We used multivariable logistic regression to identify factors associated with broad-spectrum antibiotic prescribing.

RESULTS

Antibiotics were prescribed during 101 million (95% CI: 91-111 million) ambulatory visits annually, representing 10% of all visits. Broad-spectrum agents were prescribed during 61% of visits in which antibiotics were prescribed. The most commonly prescribed antibiotics were quinolones (25% of antibiotics), macrolides (20%) and aminopenicillins (12%). Antibiotics were most commonly prescribed for respiratory conditions (41% of antibiotics), skin/mucosal conditions (18%) and urinary tract infections (9%). In multivariable analysis, among patients prescribed antibiotics, broad-spectrum agents were more likely to be prescribed than narrow-spectrum antibiotics for respiratory infections for which antibiotics are rarely indicated (e.g. bronchitis), during visits to EDs and for patients ≥ 60 years.

CONCLUSIONS

Broad-spectrum agents constitute the majority of antibiotics in ambulatory care. More than 25% of prescriptions are for conditions for which antibiotics are rarely indicated. Antibiotic stewardship interventions targeting respiratory and non-respiratory conditions are needed in ambulatory care.

Office-related antibiotic prescribing for Medicaid-enrolled children

BACKGROUND

Prudent antibiotic prescribing practices are essential to limiting antibiotic resistance.

OBJECTIVE

To assess the trend in percentage of office visits for acute respiratory infections (ARIs) linked with an antibiotic prescription.

METHODS

Retrospective analysis of Montana Medicaid billing claims data for each year, 1999 to 2010, was done. Participants included continuously enrolled children aged ≤14 years. Primary outcomes were ARI-related office visits and filled antibiotic prescriptions within 10 days of the office visit.

RESULTS

Of the 873 244 office visits identified, 116 962 (13%) had an ARI as the primary diagnosis. Among ARI-related office visits, 64 250 (55%) were linked with an antibiotic prescription. From 1999 to 2010, the odds of ARI-related visits being linked with an antibiotic prescription did not change (odds ratio = 1.00; 95% confidence interval = 0.995-1.002).

CONCLUSIONS

The percentage of ARI-related visits linked with an antibiotic prescription did not decrease from 1999 to 2010. Further efforts are needed to reduce antibiotic treatment for ARIs.

Rural parent behaviors and expectations when caring for children with acute respiratory infections

PURPOSE

To explore rural parents' behaviors and expectations regarding acute respiratory infections (ARIs) in children.

DATA SOURCES

A random digit dial telephone survey administered to 655 rural adults; 176 answered questions regarding care of their children.

CONCLUSIONS

Increasing fluid intake was the action most parents reported "always" taking when caring for a child with an ARI. Parents take their child to see a provider when they "just know" their child will not get better or when the child has discolored phlegm or discharge. Most reported reasons for not taking child to a provider were because the child got better on their own and they knew how to treat their child on their own. When seeing a provider for an ARI, parents considered it very important that the provider listen to the child's symptoms, examine their child for the cause of their symptoms, and provide symptom management advice. Parents expect providers to treat the ARI in one visit and allow for follow-up by phone or e-mail.

IMPLICATIONS FOR PRACTICE

Nurse practitioners (NPs) in rural communities should be aware of the behaviors and expectations of parents in their practice. Awareness of these potentially unique issues will allow NPs to work with rural patients more effectively.

Risk factors of antibiotic misuse for upper respiratory tract infections in children: results from a cross-sectional knowledge-attitude-practice study in Greece

Background. Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to identify possible risk factors associated with antibiotic misuse in Greece, a country with high levels of antibiotic use and antibiotic resistance. Methods. A knowledge-attitude-practice (KAP) questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. Results. The sample of the study contained 5312 parents from all geographic areas of Greece. The risk factors of being a father, having low education, having immigrant status, being a single parent, having low income, having <2 or >3 children, living in the islands, and being without experience in recurrent URTIs were significantly associated to inadequate knowledge, inappropriate attitudes, and wrong practices. Conclusions. This study has identified the main groups of parents that should be targeted in future intervention programs.

Resisting resistance: practical decision tools for choosing antimicrobials safely

PURPOSE

The purpose of this article is to provide, in a concise format, information about evidence-based decision-making strategies and support tools available for appropriate antimicrobial prescribing. A brief review of the current status of antimicrobial resistance, prescribing practices of nurse practitioners (NPs), and factors associated with inappropriate prescribing practices is included to further explicate the need for such support tools.

DATA SOURCES

Journal articles, Internet websites, reference texts.

CONCLUSIONS

Many microorganisms have developed resistance to previously standard treatments, and resistant strains continue to emerge. One factor associated with increasing resistance is inappropriate or overprescribing of antimicrobials sometimes related to lack of easy accessibility to clinical decision-making tools. Some practical evidence-based tools and decision-making strategies are presented here to foster making optimal antimicrobial choices in clinical practice.

IMPLICATIONS FOR PRACTICE

Evidence-based decision-making strategies and tools can be used at the point of care to maximize appropriate antimicrobial prescribing by NPs.

Challenges to nurse prescribers of a no-antibiotic prescribing strategy for managing self-limiting respiratory tract infections

AIMS

To report a qualitative study of the experiences of nurse prescribers in managing patients with self-limiting respiratory tract infections.

BACKGROUND

Patients frequently attend primary care with respiratory tract infections. Although a no-prescribing strategy is recommended for these consultations, general practitioners frequently prescribe antibiotics, citing non-clinical reasons such as patient pressure. Nurses increasingly manage people with respiratory tract infections, but research has not yet explored their experiences within such consultations.

DESIGN

Semi-structured interviews and focus groups.

METHODS

Fifteen semi-structured interviews and three focus groups (n=5, n=4, and n=12) with a purposive sample of nurse prescribers (n=34) and other non-medical prescribers (n=2) were conducted between November 2009-November 2010. A qualitative approach was used to develop conceptual categories from the dataset, and emerging themes were explored in subsequent interviews/focus groups.

FINDINGS

Although participants reported experiencing numerous challenges within these consultations, they believed that they possessed some of the communication skills to deal effectively with patients without prescribing antibiotics. Participants reported that protocols supported their decision-making and welcomed the benefits of peer support in dealing with 'demanding' patients. However, the newness of nurses and other non-medical prescribers to the prescribing role meant that some were cautious in dealing with patients with respiratory tract infections.

CONCLUSION

Training for nurses and other non-medical prescribers should focus on building their confidence and skills to manage people with respiratory tract infections without recourse to antibiotics. Further work should seek to explore which strategies are most effective in managing respiratory tract infections while maintaining patient satisfaction with care.

Nurse practitioners and physician assistants employed by general and subspecialty pediatricians

OBJECTIVE

There is little nationally representative information describing the current manner in which nurse practitioners (NPs) and physician assistants (PAs) work in pediatric practices and their professional activities. To understand better the current NP and PA workforce in pediatric primary and subspecialty care, we conducted a national survey of pediatricians.

METHODS

A survey study of a random national sample of 498 pediatric generalists and 1696 subspecialists in the United States was performed by using a structured questionnaire administered by mail. The survey focused on practice settings, employment, and scope of work of NPs and PAs.

RESULTS

Response rates were 72% for generalists and 77% for subspecialists. More than one-half (55%) of generalists reported that they do not currently work with NPs or PAs, compared with only one-third of subspecialists who do not. Many generalists and subspecialists intend to increase the number of NPs and PAs in their practices in the next 5 years. More generalist and subspecialty practices work with NPs than with PAs. There was great variability between generalists and subspecialists and among different subspecialties in the proportions that worked with NPs and PAs. The scope of work of NPs and PAs also varied between generalists and subspecialists.

CONCLUSIONS

Planned increases in the number of NPs hired and expansion of their scope of work might put subspecialists and general pediatricians in competition with regard to recruitment and hiring of a limited pool of new pediatric NPs. Similar issues might arise with PAs.

Administrative claims data analysis of nurse practitioner prescribing for older adults

AIM

This paper is a report of a study to identify the patterns of prescribing by primary health care nurse practitioners for a cohort of older adults.

BACKGROUND

The older adult population is known to receive complex pharmacotherapy. Monitoring prescribing to older adults can inform quality improvement initiatives. In comparison to other countries, research examining nurse practitioner prescribing in Canada is limited. Nurse practitioner prescribing for older adults is relatively unexplored in the international literature. Although commonly used to study physician prescribing, few studies have used claims data from drug insurance programmes to investigate nurse practitioner prescribing.

METHOD

Drug claims for prescriptions written by nurse practitioners from fiscal years 2004/05 to 2006/07 for beneficiaries of the Nova Scotia Seniors' Pharmacare programme were analysed. Data were retrieved and analysed in May 2008. Prescribing was described for each drug using the World Health Organization Anatomical Therapeutic Chemical code classification system by usage and costs for each fiscal year.

RESULTS

Antimicrobials and non-steroidal anti-inflammatory drugs consistently represented the top ranked groups for prescription volume and cost. Over the three fiscal years, antimicrobial prescription rates declined relative to rates of other groups of medications. Prescription volume per nurse doubled and cost per prescription increased by approximately 20%.

CONCLUSION

Prescription claims data can be used to characterize the prescribing trends of nurse practitioners. Research linking patient characteristics, including diagnoses, to prescriptions is needed to assess prescribing quality. Some potential areas of improvement were identified with antimicrobial and non-steroidal antiinflammatory selection.

Level of patient information on antibiotic use

Establishing an effective antimicrobial therapeutic requires choosing the appropriate antibiotic and ensuring compliance with times and doses prescribed. Problems concerning early abandonment and unfinished prescriptions due to lack of information, as well as more resistant microorganisms, have been identified as the major factors responsible for therapeutic failure in bacterial infections. This study aimed to determine the level of information among antibiotic users undergoing treatment with these drugs, and habits related to other therapies. A survey was applied to 403 users and identified great difficulties in understanding prescriptions, especially among users with no formal schooling who understood only 21 to 28% of the prescribed instructions. This same group reported having received the lowest amount of information during the consultation, with only 28.6% receiving verbal information from the prescriber on the length of course with the drug. Additionally, 21% of this group reported a tendency to use the antibiotic until symptoms resolved, without heeding the length of course prescribed. Guidance on antibiotics use should be an integral and fundamental part of effective therapy.

[Prescription patterns and antibiotic use in community-based infections]

INTRODUCTION

The aim of this study was to find out about the patterns of antibiotic use in the municipality of Sorocaba, through evaluating the reported diagnosis and the therapy used.

METHODS

An evaluation tool was applied among antibiotic users over a 12-month period. Sociodemographic data and information relating to health, diagnosis and therapeutics were gathered in relation to 403 users.

RESULTS

Great present use and the greatest previous use was found in the 0-10 year-old age group (p < 0.05). Infections with lung involvement were the ones most mentioned (p < 0.05) and penicillins were the drugs most used, present in 45.1% of the prescriptions. The mean duration of therapy for otitis (8.9 days) was below the recommendation. For sinusitis, 22% of the prescriptions did not give guidance regarding recommended use (10 days).

CONCLUSIONS

The lack and/or nonuse of therapeutic protocols resulted in great differences in prescription patterns, thereby leading to therapeutic failure and recurrence of infections, which were situations frequently found in this study.

A community health nursing approach to the problem of antibiotic over-prescribing

Antibiotic resistance due to over-prescribing is a critical problem for society. The purpose of this study was to examine the effect of a nurse-led quality-assurance-based program designed to decrease inappropriate antibiotic prescribing rates in patients suffering from viral upper respiratory tract infections. The study was based in a network of community health centers in the Southeastern United States. A quasi-experimental design based upon pre- and postintervention measurement via chart reviews was utilized in the study. Both the pre- and postintervention chart reviews revealed high levels of inappropriate prescribing. Following intervention, no gross decrease in prescribing rates was noted. Qualitative differences were noted postintervention that included increased rates of prescriptions for delayed antibiotic therapy and decreased rates of reflexive prescription writing for farmers. Additionally, the results reflected the decreased use of broad-spectrum antibiotics after the intervention. Although the study utilized a limited sample, it shows promise for the use of quality assurance approaches in moderating inappropriate prescribing practices.

Economic burden of adult pharyngitis: the payer's perspective

OBJECTIVES

Although not recommended by practice guidelines, physicians frequently prescribe an antibiotic for adults with viral pharyngitis. The financial burden of this practice, from the payer's perspective, has not been previously evaluated. The purpose of this study was to estimate those expenditures.

METHODS

A cost-of-illness study was performed to estimate annual expenditures of pharyngitis management from the payer's perspective. National Ambulatory Care Survey data were used to represent current patterns of ambulatory care visits and antibiotic prescriptions for adult pharyngitis. Direct and antibiotic resistance costs were summed to estimate total expenditures for pharyngitis management. Resistance costs were calculated using a model linking the effect of antibiotic consumption to the cost consequences of resistant Streptococcus pneumoniae infection. Sensitivity analyses compared cost outcomes of current practice, adherence to pharyngitis management guidelines from the Infectious Diseases Society of America (IDSA), and nonantibiotic treatment.

RESULTS

In the base-case analysis, reflecting current practice patterns, total expenditures were $1.2 billion with antibiotic resistance contributing 36% ($426 million). IDSA guideline adherence decreased costs to $559 million with resistance accounting for 6.8% ($37.9 million). Guideline adherence plus reducing office visits by 30% decreased costs to $372 million, with only 1.4% ($5.3 million) due to resistance. Additional cost-savings of $88 million were realized by using a nonantibiotic treatment strategy.

CONCLUSIONS

Current practice imposed a substantial economic burden on the payer, while guideline adherence resulted in cost reductions, especially in terms of resistance, emphasizing that antibiotic prescribing habits have broad economic consequences. Relevant stakeholders, payers, physicians, and other health-care providers should revisit efforts to encourage adherence to pharyngitis guidelines to reduce health-care costs.