Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study

Antibiotic Prescribing for Respiratory Tract Infections in Urgent Care: A Comparison of In-Person and Virtual Settings

BACKGROUND

Little is known about antibiotic prescribing for respiratory tract infections (RTIs) in virtual versus in-person urgent care.

METHODS

In this retrospective study, we used electronic health record data from Cleveland Clinic Health System. We identified RTI patients via International Classification of Diseases, Tenth Revision, Clinical Modification, codes and assessed whether the visit resulted in an antibiotic. We described differences in diagnoses and prescribing by setting (virtual versus in-person). We used mixed effects logistic regression to model the odds of antibiotic receipt by urgent care setting. We applied the model first to all physicians and second only to those who saw patients in both settings.

RESULTS

There were 69 189 in-person and 19 003 virtual visits. Fifty-eight percent of virtual visits resulted in an antibiotic compared with 43% of in-person visits. Sinusitis diagnoses were more than twice as common in virtual versus in-person care (36% vs 14%) and were associated with high rates of prescribing in both settings (95% in-person, 91% virtual). Compared with in-person care, virtual urgent care was positively associated with a prescription (odds ratio, 1.64; 95% confidence interval [CI]: 1.53-1.75). Among visits conducted by 39 physicians who saw patients in both settings, odds of antibiotic prescription in virtual care were 1.71 times higher than in in-person care (95% CI: 1.53-1.90).

CONCLUSIONS

Antibiotic prescriptions were more common in virtual versus in-person urgent care, including among physicians who provided care in both platforms. This appears to be related to the high rate of sinusitis diagnosis in virtual urgent care.

Doctors' perceptions of antimicrobial resistance in the Northern West Bank, Palestine: a qualitative study

Objectives

In the West Bank, antimicrobial resistance (AMR) is increasingly and alarmingly common. Efforts are being made to introduce antimicrobial stewardship programmes (ASPs). This study explores doctors' perceptions of AMR and context-specific barriers and facilitators to ASPs at a critical point in national ASP development.

Methods

Semi-structured interviews were conducted with 22 doctors working in primary healthcare, government and non-governmental hospitals in Nablus in 2019. Two researchers thematically analysed the data.

Results

Participants recognized antibiotic resistance as a major threat to health. Few felt that doctors were well informed about ASPs; many had not heard of them. However, there was willingness to expand and begin new education programmes. Barriers and facilitators to ASPs included: (i) doctors were perceived to 'misuse' antibiotics, lack awareness, favour short-term outcomes, and externalize blame; (ii) patients reportedly treat antibiotics 'like analgesia' with high expectations of doctors; (iii) resource limitations make ASPs and infection control difficult-a lack of drugs, laboratory services, infectious disease specialists, and research to develop local guidelines; and (iv) top-down policy is recommended to restrict access to antibiotics without a prescription, but should be coupled with support, collaboration and community action.

Conclusions

Doctors' appreciation of the severity of the issue, and willingness for the expansion of existing programmes targeted at their own prescribing practices, provides a strong foundation for successful ASPs. A top-down approach to prevent inappropriate antibiotic prescribing is welcomed by participating doctors. If financial and resource limitations could be addressed, a continued multifaceted approach may enable physician, pharmacist and patient behaviours to change.

Perspectives of paediatric providers on antibiotic stewardship in a high-prescribing rural region

PURPOSE

Understanding drivers of antibiotic use is key to limiting the development of antimicrobial resistance. Outpatient antibiotic prescribing rates vary substantially across and within states. Kentucky is one of the highest prescribing states, and the southeastern region has rates that are drastically higher than the national average and urban areas of the state. We sought to examine provider perceptions of antibiotic use in this rural area to more effectively guide future interventions and policy.

METHODS

This study utilized Medicaid prescription claims to identify providers who frequently prescribe antibiotics to children in southeastern Kentucky. Semistructured qualitative interviews were conducted to elicit provider perspectives on antibiotic overuse.

FINDINGS

Individual, in-person interviews were conducted with 25 providers from a variety of practices and training backgrounds (private, nonprofit, retail, physician, advanced practice registered nurses, etc.). The following themes emerged as issues that prescribers consider to contribute to antibiotic overuse: (1) caregiver pressure, especially from grandparents or families who desire a 'quick fix'; (2) business concerns and competition and (3) cultural factors related to poverty and rural locations. Interviewed providers were supportive of public education and had mixed views on the effectiveness of delayed fill or provider feedback initiatives.

CONCLUSIONS

This study highlights unique challenges associated with antibiotic prescribing in rural areas. Findings will guide future interventions through adaptation of existing strategies to better serve this vulnerable population.

Improving Antibiotic Use in Argentine Pediatric Hospitals: A Process Evaluation Using Normalization Process Theory

Introduction

In the pediatric setting, overprescribing of antibiotics contributes to the rise of multidrug-resistant organisms. Antimicrobial stewardship programs (ASPs) are recommended to optimize antibiotic use and combat resistance. However, the implementation of ASPs in low- and middle-income countries faces several challenges. This study aimed to evaluate the implementation process of a multifaceted ASP in 2 pediatric hospitals in Argentina.

Methods

A qualitative study was conducted in two large public children's hospitals in Argentina, using semistructured interviews with 32 healthcare providers at the beginning and end of the ASP implementation. The study was guided by the normalization process theory.

Results

The intervention faced challenges, including limited understanding of its objectives, confusion with existing practices, and insufficient commitment from senior staff. Although junior staff were more receptive, communication barriers with external staff and workload concerns hindered broader adoption. Infectious disease specialists primarily led implementation, with limited involvement of other staff, particularly in training activities. Despite these challenges, participants reported improvements, such as the development of standardized antibiotic guidelines, better interdisciplinary collaboration, and improved communication. However, organizational support and resistance to new practices remained barriers.

Conclusions

This study highlights the importance of organizational context and staff commitment in ASP implementation. Tailored strategies that address the specific challenges of low- and middle-income countries are needed to effectively implement ASPs.

National Survey of Factors Associated with Physician Antibiotic Prescribing Preferences

BACKGROUND

The development of new infectious disease therapies has become a public health priority given the suboptimal efficacy and adverse effects with current drugs for some patients. Understanding the factors associated with physician antibiotic prescribing preferences can help guide policymakers seeking to incentivize the development of interventions that improve patient outcomes for the treatment and prevention of infectious diseases.

OBJECTIVES

To determine the factors associated with physician decision-making when prescribing antibiotics for community-acquired pneumonia (CAP), uncomplicated urinary tract infection (UTI), and cellulitis.

DESIGN

A cross-sectional online survey in April 2023.

PARTICIPANTS

Physicians enrolled in an online panel who reported having prescribed antibiotics within the past year.

MAIN MEASURES

Respondents were asked to select 1 to 15 characteristics that they deemed most important. From their selected characteristics, for each type of infection, they were then asked to rank up to five on a scale with 5 points given to the top-scoring characteristic and 1 point to the bottom-scoring. The primary outcome was the mean score for each characteristic across the three types of infections weighted by the number of respondents in the sample, with higher scores indicating higher importance.

KEY RESULTS

Among the 130 physician participants, 106 (82%) completed the survey. Just under half (46%) were female; 89% of respondents were White, 3% Black, and 9% another race, while 15% reported Hispanic ethnicity. The highest-scored factors influencing antibiotic prescription preferences were the cure rate (treatment efficacy) (mean score: 2.87), severity of the infection (1.88), rare but major side effects (1.33), interactions with other drugs (1.33), previous experience and knowledge of the drug (1.19), and future risk of resistant infection to the patient (1.15). Out-of-pocket patient costs were prioritized lowest (mean score: 0.25).

CONCLUSIONS

In considering which antibiotic to prescribe, physicians prioritize clinical outcomes related to drug efficacy and safety over public health- or economics-focused factors.

Patient, Care Partner, and Physician Voices in Treatment Decision-Making for Multiple Myeloma

Introduction

Treatment decision-making for multiple myeloma (MM) is complex. Individuals involved in decision-making may value treatment attributes differently based on their role as a patient, care partner, or physician. This study describes those attributes, and what is most important by role.

Methods

We conducted a cross-sectional online survey with consenting adult patients with MM, MM care partners, and physicians treating MM. Respondents were recruited from US panels (Inspire and M3 Global Research) between September and December 2022. Survey items were informed by a targeted literature review, qualitative interviews, and a steering committee comprising clinical experts, a patient advocate, patient, and care partner. Descriptive statistics were generated and reported in aggregate.

Results

Email invitations were sent to 8071 Inspire members interested in or posting about MM. Of these, 4427 viewed the invitation, 941 responded, and 156 patients and care partners completed the survey (17% of respondents). For physicians, 5588 were invited via Email by M3 Global Research, with 761 viewing the invitation, 214 accessing the survey link, and 137 completing the survey (64% of respondents). Duration of response, side effects, and patients' quality-of-life (QoL) were the top three treatment attributes selected across the three cohorts; alignment of these attributes was consistent among patients regardless of disease severity. Separately, patients rated QoL and the amount of caregiving needed during/after treatment as the most important factors for future treatment decisions. If more effective MM treatments were offered, care partners were more willing to assume greater family burden (77%) compared to patients (49%), and patients were more accepting of potential serious side effects (50%) than were care partners (34%).

Conclusion

Patients with MM, care partners, and physicians consider and value various treatment decision-making factors. Recognizing and addressing these differences is critical to meeting patients' preferences, needs, and optimizing patient outcomes.

Antibiotic Overtreatment of Presumed Urinary Tract Infection Among Children with Spina Bifida

OBJECTIVE

To identify factors associated with overtreatment of presumed urinary tract infection (UTI) among children with spina bifida using such criteria.

STUDY DESIGN

A retrospective review of children with spina bifida (age <21 years) evaluated in the Emergency Department (ED) at a single institution was performed. Patients with a urinalysis (UA) performed who were reliant on assisted bladder emptying were included. The primary outcome was overtreatment, defined as receiving antibiotics for presumed UTI but ultimately not meeting spina bifida UTI criteria (≥2 urologic symptoms plus pyuria and urine culture growing >100k CFU/mL). The primary exposure was whether the components of the criteria available at the time of the ED visit (≥2 urologic symptoms plus pyuria) were met when antibiotics were initiated.

RESULTS

Among 236 ED encounters, overtreatment occurred in 80% of cases in which antibiotics were initiated (47% of the entire cohort). Pyuria with <2 urologic symptoms was the most important factor associated with overtreatment (OR 9.6). Non-Hispanic White race was associated with decreased odds of overtreatment (OR 0.3).

CONCLUSIONS

Overtreatment of presumed UTI among patients with spina bifida was common. Pyuria, which is not specific to UTI in this population, was the main driver of overtreatment. Symptoms are a cornerstone of UTI diagnosis among children with spina bifida, should be collected in a standardized manner, and considered in a decision to treat.

Prescribing antibiotics prudently-A survey of policy implementation drivers among physicians and veterinarians

Background

As the antimicrobial resistance (AMR) problem accelerates, humans and animals are suffering from the consequences of infections with diminishing antimicrobial treatment options. Within the One Medicine and One Health mandate, which denotes a collaborative, multisectoral, and transdisciplinary approach to improve medicine and health across human and animal sectors, we investigate how human and veterinary medical practitioners apply their medical and policy knowledge in prescribing antimicrobials. Different regions and locations establish different intermediary policies and programs to support clinicians in that pursuit. In Hong Kong, there are locally adapted programs at governance and clinical levels in the human medical field. However, there is no locally adapted veterinary antibiotic prescription guideline or stewardship program, and veterinarians adopt overseas or international professions' antimicrobial use guidelines. Such a policy environment creates a natural experiment to compare local policy implementation conditions and clinicians' knowledge, perception, and practice.

Method

We construct the investigative survey tool by adaptation of Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, and Motivation-Behavior (COM-B) models. We identify, compare and contrast factors that influence clinicians' antimicrobial prescription behavior. The factors are considered both intrinsically, such as personal attributes, and extrinsically, such as societal and professional norms.

Findings

The absence of locally adopted antimicrobial guidelines influences AMR stewardship program implementation in local Hong Kong veterinary community. As medical allies, physicians and veterinarians share similar demographic influence, organization considerations and perception of public awareness. Both cohorts prescribe more prudently with more years-in-practice, time available to communicate with patients or caretakers, and public awareness and support.

Antibiotic Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention in Primary Care

BACKGROUND

A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback.

METHODS

RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing.

RESULTS

We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3).

CONCLUSIONS

The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.

Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study

Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review

BACKGROUND

Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings.

METHODS

This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies.

RESULTS

Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability.

CONCLUSION

Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.

Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment

OBJECTIVE

To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits.

METHODS

In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility.

RESULTS

We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing.

CONCLUSION

This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.

Next Steps in Ambulatory Stewardship

Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.

A quality-improvement approach to urgent-care antibiotic stewardship for respiratory tract infections during the COVID-19 pandemic: Lessons learned

OBJECTIVE

We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews.

METHODS

We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression.

RESULTS

We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17-0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non-COVID-19 respiratory infections.

CONCLUSIONS

Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.

Perceptions of an automated benchmarking dashboard for antimicrobial stewardship programs among antimicrobial stewards within the veterans' health administration: a multicenter qualitative study

Objective

To evaluate the impact of a multicenter, try automated dashboard on ASP activities and its acceptance among ASP leaders.

Design

Frontline stewards were asked to participate in semi-structured interviews before and after implementation of a web-based ASP information dashboard providing risk-adjusted benchmarking, longitudinal trends, and analysis of antimicrobial usage patterns at each facility.

Setting

The study was performed at Iowa City VA Health Care System.

Participants

ASP team members from nine medical centers in the VA Midwest Health Care Network (VISN 23).

Methods

Semi-structured interviews were conducted pre- and post-implementation, with interview guides informed by clinical experiences and the Consolidated Framework for Implementation Research (CFIR). Participants evaluated the dashboard's ease of use, applicability to ongoing ASP activities, perceived validity and reliability, and relative advantage over other ASP monitoring systems.

Results

Compared to established stewardship data collection and reporting methods, participants found the dashboard more intuitive and accessible, allowing them to reduce dependence on other systems and staff to obtain and share data. Standardized and risk-adjusted rankings were largely accepted as a valuable benchmarking method; however, participants felt their facility's characteristics significantly influenced the rankings' validity. Participants recognized staffing, training, and uncertainty with using the dashboard as an intervention tool as barriers to consistent and comprehensive dashboard implementation.

Conclusions

Participants generally accepted the dashboard's risk-adjusted metrics and appreciated its usability. While creating automated tools to rigorously benchmark antimicrobial use across hospitals can be helpful, the displayed metrics require further validation, and the longitudinal utility of the dashboard warrants additional study.

Evaluation of antibiotic appropriateness at an outpatient oncology centre

Current evidence supporting antimicrobial stewardship programs focused largely in inpatient setting. With the shift in cancer management from inpatient to ambulatory setting, it is crucial to examine the prevalence and predictors of inappropriate antibiotics prescribing. This is a retrospective cross-sectional study conducted at the National Cancer Centre Singapore (NCCS). Patients at least 21 years, with an active or past cancer diagnosis and prescribed with at least one oral antibiotic by a NCCS physician from 1st July to 30th September 2019 were included. Antibiotic appropriateness was assessed using institutional antibiotic guidelines or published clinical practice guidelines. For cases where antibiotics appropriateness cannot be ascertained using these guidelines, an independent three-member expert panel was consulted. A total of 815 patients were screened; 411 (59.4% females) were included with mean age of 62.4 years. The top three cancer diagnoses were breast (26.5%), lung (15.6%) and head and neck (13.6%). More than half (58.6%) received appropriate antibiotic choice. Of which, 235 (97.5%), 238 (98.8%) and 194 (80.5%) received appropriate dose, frequency and duration respectively. The presence of non-oncologic immunosuppressive comorbidities (OR 4.890, 95% CI 1.556-15.369, p-value = 0.007), antibiotic allergy (OR 2.352, 95% CI 1.178-4.698, p-value = 0.015) and skin and soft tissue infections (OR 2.004, 95% CI 1.276-3.146, p-value = 0.003) were associated with a higher incidence of inappropriate antibiotic choice. This study highlighted that inappropriate antibiotic prescribing is prevalent in the ambulatory oncology setting. Predicators identified can aid in the design of targeted strategies to optimise antibiotic use in ambulatory oncology patients.

Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections

BACKGROUND

Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections.

METHODS

We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type.

RESULTS

Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections.

CONCLUSIONS

Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.

Community pharmacists as antimicrobial guardians and gatekeepers - A qualitative study of the perspectives of pharmacy sector stakeholders

Background

Community pharmacists, as primary care providers, are an underutilised resource in antimicrobial stewardship (AMS). Primary care plays an important role in tackling antimicrobial resistance (AMR) as the principle of balancing access to antimicrobials while ensuring optimal use is agnostic to health setting. Understanding the sector's perceptions and practices towards AMS involvement is a continuing focus area of research. However, there is an opportunity to understand the sociological factors which influence the profession's contribution to stewardship practice, particularly across a broader spectrum of sector stakeholders at the individual, practice, system, and policy levels.

Objective

To explore stakeholders' perceptions of the Australian community pharmacy sector's AMS involvement.

Methods

Semi-structured interviews were conducted with fifteen key informants from the Australian community pharmacy sector. Participants' insights were invited across three broad areas: (1) understanding of AMR and AMS; and the (2) current and (3) future state of community pharmacy's AMS involvement. Interviews were audio-recorded, transcribed verbatim and analyzed using a combined method of inductive (informed by the Theoretical Domains Framework) and deductive thematic analysis.

Results

Perceptions on promoting community pharmacists' AMS involvement within their existing role in promoting the quality use of medicines were heard. Adopting an antimicrobial guardian or gatekeeper role was perceived as influenced by the timing of their interaction with a patient either prior to, or post-consultation with a general practitioner (GP). Suggestions that the profession's potential and actual role in AMS could be challenged or even delimited due to lack of access to completeness of clinical information, and perceived consequences from a clinical and professional engagement perspective were also heard.

Conclusion

Collaborative partnerships between GPs and community pharmacists, framing stewardship within a quality use of medicines agenda, and highlighting connections between pharmacists' professional services such as minor ailments are key elements enabling community pharmacist's antimicrobial gatekeeper and guardian role.

How to design and implement an outpatient antimicrobial stewardship programme

Antimicrobial stewardship programmes in the outpatient setting have recently become an area of focus in an effort to improve antimicrobial prescribing. The Centers for Disease Control and Prevention and The Joint Commission have recently addressed this concern and provided a framework for the implementation of an outpatient stewardship programme. This manuscript offers detailed guidance on how to design and implement an outpatient antimicrobial stewardship programme and reviews the literature on current strategies. Challenges related to initiating and maintaining outpatient stewardship efforts are also discussed. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

"Antibiotics are for everyone, our past and our future generations, right? If antibiotics are dead, we will be in big trouble": Building on community values for public engagement on appropriate use of antibiotics in Singapore

Introduction

Shared decision-making (SDM) and trust building through continuity of care are known to play a pivotal role in improving appropriate antibiotic prescribing and use.

Problem

However, less is known about how to effectively leverage these factors when present-or overcome them when not-to address community needs and improve patient liaison.

Methods

We addressed this question using a convergent parallel mixed-methods design. Focus group discussions (N = 13; August 2018-September 2020), were analyzed alongside a nationally-representative cross-sectional survey (N = 2004; November 2020-January 2021), in Singapore. Descriptive quantitative analyses and multivariable logistic regression were undertaken to examine antibiotic knowledge and factors associated with preference for SDM. Qualitative applied thematic analysis was integrated with these data to further explain the findings.

Findings

Poor knowledge and misbeliefs on appropriate antibiotic use and antimicrobial resistance (AMR) were identified. For example, only 9% of the surveyed population understood that AMR occurs when the bacteria, not the human body, become resistant to antibiotics. Qualitative data corroborated the survey findings and suggested a shared value was placed on public education to avoid the fallout from resistant bacterial strains on current and future generations. This study also identified the opportunity to harness community trust in primary care doctors, who were described as highly valued educators for antibiotic use and AMR. Those who had trust in doctors were 75% more likely to prefer SDM (aOR 1.75, 95% CI 1.10-2.77, P = 0.017), especially adults aged ≥50 years who were receiving continued care with a regular doctor (aOR 1.83, 95% CI 1.18-2.86, P = 0.007). Continuity of care was observed to value-add SDM by building trusting relationships, though it was often absent in younger populations.

Conclusion

This study highlights the long-term value-add of building on cultural capital pertaining to appropriate antibiotic use and AMR, by leveraging on the role of trust in doctors, desire for SDM and anchoring these in continuity of care when possible.

Recommendations

Using focused messaging and exploring alternative channels of communications such as annual check-ins or tele-consultations with a regular doctor, and emphasizing continuity of care across all age groups would help bridge the identified gaps.

Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria

Importance

Antibiotic treatment for asymptomatic bacteriuria is not recommended in guidelines but is a major driver of inappropriate antibiotic use.

Objective

To evaluate whether clinician culture and personality traits are associated with a predisposition toward inappropriate prescribing.

Design, Setting, and Participants

This survey study involved secondary analysis of a previously completed survey. A total of 723 primary care clinicians in active practice in Texas, the Mid-Atlantic, and the Pacific Northwest, including physicians and advanced practice clinicians, were surveyed from June 1, 2018, to November 26, 2019, regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Clinician culture was represented by training background and region of practice. Attitudes and cognitive characteristics were represented using validated instruments to assess numeracy, risk-taking preferences, burnout, and tendency to maximize care. Data were analyzed from November 8, 2021, to March 29, 2022.

Interventions

The survey described a male patient with asymptomatic bacteriuria and changes in urine character. Clinicians were asked to indicate whether they would prescribe antibiotics.

Main Outcomes and Measures

The main outcome was self-reported willingness to prescribe antibiotics for asymptomatic bacteriuria. Willingness to prescribe antibiotics was hypothesized to be associated with clinician characteristics, background, and attitudes, including orientation on the Medical Maximizer-Minimizer Scale. Individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous.

Results

Of the 723 enrolled clinicians, 551 (median age, 32 years [IQR, 29-44 years]; 292 [53%] female; 296 [54%] White) completed the survey (76% response rate), including 288 resident physicians, 202 attending physicians, and 61 advanced practice clinicians. A total of 303 respondents (55%) were from the Mid-Atlantic, 136 (25%) were from Texas, and 112 (20%) were from the Pacific Northwest. A total of 392 clinicians (71% of respondents) indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% CI, 1.53-5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38-3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38-0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33-0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria.

Conclusions and Relevance

The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the US Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions.

Antibiotic Use in Children Before, During and After Hospitalization

Purpose

To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in‐hospital antibiotic exposure compared to children from the general population that had not received antibiotics in‐hospital.

Methods

Explorative data‐linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in‐Hospital (H+), and one group had not received antibiotics in‐hospital (H‐). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H‐ group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation.

Results

Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H‐ group, relative risk (RR) 2.88 (95% confidence interval 2.38–3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H‐ group, RR 2.77 (2.30–3.33). Comorbidity‐adjusted RR was 2.30 (1.84–2.86) before and 2.25 (1.81–2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99–3.26) in children 3 months‐2 years, 4.03 (2.84–5.71) in children 3–12 years and 2.07 (1.33–3.20) in children 13–17 years.

Conclusions

Children exposed to antibiotics in‐hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in‐hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.

Parental and physician's point-of-view towards antibiotic prescriptions and discharge conversations in the pediatric emergency department

BACKGROUND

Within Europe, the Netherlands has one of the lowest antibiotic consumption rates. We aimed to gain insight into attitudes of Dutch physicians and parents towards information provided during discharge conversations in the emergency department (ED) and towards antibiotic use in children, in order to obtain information on the assumptions and beliefs that underlie a practice of low prescription rates.

METHODS

Discharge conversations of 70 children presenting with an infectious disease at the ED were observed. After 7-10 days, 55 parents were called for a semi-structured interview. In addition, 29 pediatricians and pediatric residents completed a questionnaire on their prescription behaviour.

RESULTS

Concerns about (recognizing) the severity of their child's infection was parents' main motivation to seek help. Both pediatricians and parents reported a general reluctance towards antibiotic use. While pediatricians took appropriateness based on indication and the risk of antimicrobial resistance development into account when considering antibiotic treatment, a thorough medical assessment was deemed more important for Dutch parents than any type of therapeutic treatment, including antibiotics. The topic most often discussed during the discharge conversations was safety netting instructions (in 86%), which were discussed more often during discharge conversations with parents of children that did not receive antibiotic treatment (91% versus 69%).

CONCLUSION

Dutch pediatricians and parents are both reluctant to use antibiotics for uncomplicated infections in children, but for different reasons. The emphasis of discharge conversations was on safety netting instructions, which seems to be an alternative for (early) antibiotic use in our setting and may guide overuse prevention strategies in settings where antibiotic overuse is more common.

Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship

Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

PURPOSE

Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis.

METHODS

We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing.

FINDINGS

Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing.

IMPLICATIONS

To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.

Use of the Electronic Health Record to Optimize Antimicrobial Prescribing

PURPOSE

This review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified.

METHODS

A narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience.

FINDINGS

EHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions.

IMPLICATIONS

Prescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.

Comparing Hospital and Primary Care Physicians' Attitudes and Knowledge Regarding Antibiotic Prescribing: A Survey within the Centre Region of Portugal

BACKGROUND

Antibiotic resistance is a worldwide public health problem, leading to longer hospital stays, raising medical costs and mortality levels. As physicians' attitudes are key factors to antibiotic prescribing, this study sought to explore their differences between primary care and hospital settings.

METHODS

A survey was conducted between September 2011 and February 2012 in the center region of Portugal in the form of a questionnaire to compare hospital (n = 154) and primary care (n = 421) physicians' attitudes and knowledge regarding antibiotic prescribing.

RESULTS

More than 70% of the attitudes were statistically different (p < 0.05) between hospital physicians (HPs) and primary care physicians (PCPs). When compared to PCPs, HPs showed higher agreement with antibiotic resistances being a public health problem and ascribed more importance to microbiological tests and to the influence of prescription on the development of resistances. On the other hand, PCPs tended to agree more regarding the negative impact of self-medication with antibiotics dispensed without medical prescription and the need for rapid diagnostic tests. Seven out of nine sources of knowledge's usefulness were statistically different between both settings, with HPs considering most of the knowledge sources to be more useful than PCPs.

CONCLUSIONS

Besides the efforts made to improve both antibiotic prescribing and use, there are differences in the opinions between physicians working in different settings that might impact the quality of antibiotic prescribing. In the future, these differences must be considered to develop more appropriate interventions.

Barriers of Appropriate Antibiotic Prescription at PHCC in Qatar: Perspective of Physicians and Pharmacists

The Ministry of Public Health in Qatar developed the NAP (National Action Plan to combat Antimicrobial Resistance (AMR) in collaboration with WHO Regional Office for the Eastern Mediterranean (WHO/EMRO). Among the major factors shaping AMR is antimicrobial prescribing and use. Tailoring Antimicrobial Resistance Program is a behavior change methodology that is utilized to adapt behavior change in relation to antimicrobial use. This study explores barriers of appropriate antibiotic (AB) prescription from the physicians' and pharmacists' perspectives at primary healthcare centers in Qatar. Data were collected from 50 participants across two PHCCs: 30 physicians and 20 pharmacists. Two different interview guides were constructed: One for physicians and one for pharmacists. In-depth, face-to-face, five focus groups were conducted and transcribed verbatim. Inductive qualitative analysis, involving discovering the themes in the interviews, was followed. Data were analyzed using constant comparative techniques. The Major themes arose from the analysis revealed that patients, practitioners mainly physicians, and the organization itself, played a role in shaping these barriers in the two primary healthcare centers. The findings would help develop and pilot behavior change interventions among patients, physicians and pharmacists with the aim of optimizing appropriate antibiotic prescription and use, which would support the implementation of the antibiotic stewardship program. Effective behavior change interventions should consider multiple factors including individual and organizational factors to optimize appropriate antibiotic prescription.