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Lagarde M, Blaauw D. Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa. BMJ Glob Health 2023; 8:e012374. [PMID: 37524502 PMCID: PMC10391785 DOI: 10.1136/bmjgh-2023-012374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients' expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)-healthy individuals trained to portray a scripted clinical case to providers-presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers' engrained habits and incorrect beliefs.
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Affiliation(s)
- Mylene Lagarde
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Duane Blaauw
- Center for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
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Sahilu T, Kano Z. Antibiotics prescribing practice among patients with urinary tract infection at outpatient department, the case of Dilchora referral hospital, Eastern Ethiopia: an institutional retrospective cross-sectional study. J Pharm Policy Pract 2023; 16:23. [PMID: 36810136 PMCID: PMC9945606 DOI: 10.1186/s40545-023-00539-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Inappropriate prescription of antibiotics is a global public health challenge. Widespread use, misuse, or inappropriate prescribing has resulted in unnecessary expenditure on drugs, raised risk of adverse reactions, the development of antimicrobial resistance, and increment in health care costs. There is a limited practice in rational prescribing of antibiotics in the management of Urinary tract infection (UTI) in Ethiopia. OBJECTIVE To assess antibiotic prescribing practice in the treatment of patients with UTI at outpatient department (OPD), Dilchora referral hospital, Eastern Ethiopia. METHODS A retrospective cross-sectional study was conducted from January 7 to March 14, 2021. Data were collected from 600 prescription papers using systematic random sampling method. World Health Organization's standardized core prescribing indicators was used. RESULTS A total of 600 prescriptions containing antibiotics prescribed for patients with UTIs were observed during the study period. Of these, 415 (69.19%) were females and 210 (35%) were in the age group of 31-44 years. The number of generic drugs and antibiotics prescribed per encounter was 1.60 and 1.28, respectively. The percentage of antibiotics per prescription was found to be 27.83%. About 88.40% of antibiotics were prescribed by generic names. Fluoroquinolones were the most frequently prescribed class of drugs for the treatment of patients with UTIs. CONCLUSION The prescribing practice of antibiotics in patients with UTIs was found to be good as the drugs were prescribed in generic name.
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Affiliation(s)
- Tamiru Sahilu
- Department of Pharmacy, College of Health Science, Assosa University, Assosa, Ethiopia.
| | - Zenebe Kano
- grid.192267.90000 0001 0108 7468School of Pharmacy, College of Medical and Health Science, Haramaya University, Dire Dawa, Ethiopia
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Abuhammad S, Ababneh H. Nurses’ knowledge, motivation, behaviors, and information sources on antibiotic use and resistance in Jordan. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
<b>Aim:</b> This study aims to examine the nurse knowledge, motivation, and behavior about antibiotics and antibiotic resistance. A secondary objective was to study the preferred information sources used by Jordanian nurses, as well as their knowledge of the information available to promote rational prescription practices in the Jordanian health system.<b> </b><br />
<b>Method: </b>The study was cross-sectional in design and nurses (n=1,093) completed an online survey using Google Forms. Participation in the study was completely optional, and participants were free to drop out at any point. During the months of February-May 2022, nurses were asked to participate in a survey<br />
<b>Results:</b> The study found 48.2% of nurses given prescribed antibiotics to the patients daily or multiple times a day in the preceding week; 13.3% of nurses provided support on daily or more frequent antibacterial drugs use or infection management. The reason for not giving advice regarding antibiotics were no leaflet regarding the use of the antibiotics (42.3%) and the patients do not get attention for the information (30.4%).<br />
<b>Conclusion:</b> In conclusion, the findings of this study show that public health actions are needed (e.g., educational or communication campaigns). Nurses must be educated on the proper use of antibiotics and the emergence of antibiotic resistance. Antibiotic stewardship can benefit from the findings, which can be used to develop interventions aimed at improving antibiotic usage.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Faculty of Nursing, Jordan University of Science and Technology, Irbid, JORDAN
| | - Hamza Ababneh
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, JORDAN
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Smolinski NE, Antonelli PJ, Winterstein AG. Watchful Waiting for Acute Otitis Media. Pediatrics 2022; 150:188303. [PMID: 35726560 DOI: 10.1542/peds.2021-055613] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Updated guidelines continue to support watchful waiting as an option for uncomplicated acute otitis media (AOM) and provide explicit diagnostic criteria. To determine treatment prevalence and associated determinants of watchful waiting for AOM in commercially insured pediatric patients. METHODS This was a retrospective cohort study using IBM Marketscan Commercial Claims Databases (2005 to 2019) of patients 1 to 12 years old with AOM, without otitis-related complications within 6 months prior, with no tympanostomy tubes, and no other infections around index diagnosis of AOM. We examined monthly antibiotic treatment prevalence (defined as pharmacy dispensing within 3 days of AOM diagnosis) and used multivariable logistic regression models to examine determinants of watchful waiting. RESULTS Among 2 176 617 AOM episodes, 77.8% were treated within 3 days. Whereas some clinical characteristics were moderate determinants for watchful waiting, clinician antibiotic prescribing volume and specialty were strong determinants. Low-volume antibiotic prescribers (≥80% of AOM episodes managed with watchful waiting) had 11.61 (95% confidence interval 10.66-12.64) higher odds of using watchful waiting for the index AOM episode than high-volume antibiotic prescribers (≥80% treated). Otolaryngologists were more likely to adopt watchful waiting (odds ratio 5.45, 95% CI 5.21-5.70) than pediatricians, whereas other specialties deferred more commonly to antibiotics. CONCLUSIONS Adoption of watchful waiting for management of uncomplicated, nonrecurrent AOM was limited and stagnant across the study period and driven by clinician rather than patient factors. Future work should assess motivators for prescribing and evaluate patient outcomes among clinicians who generally prefer versus reject watchful waiting approaches to guide clinical decision-making.
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Affiliation(s)
- Nicole E Smolinski
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy.,Center for Drug Evaluation and Safety (CoDES)
| | - Patrick J Antonelli
- Center for Drug Evaluation and Safety (CoDES).,Department of Otolaryngology, College of Medicine
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy.,Center for Drug Evaluation and Safety (CoDES).,Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
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Bianco A, Licata F, Nobile CG, Napolitano F, Pavia M. Pattern and appropriateness of antibiotic prescriptions for upper respiratory tract infections in primary care paediatric patients. Int J Antimicrob Agents 2021; 59:106469. [PMID: 34757133 DOI: 10.1016/j.ijantimicag.2021.106469] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/12/2021] [Accepted: 10/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this cross-sectional study was to investigate the pattern of antibiotic prescriptions for upper respiratory tract infections (URTIs) in children seen by primary care paediatricians (PCPs). METHODS Data were collected from face-to-face interviews administered to a sample of parents of outpatient children aged 0-14 years in two regions in Southern Italy. To be eligible, children had to be diagnosed with sinusitis, pharyngotonsillitis, otitis media, bronchitis, influenza or a common cold. The presence of an indication of antibiotic therapy was evaluated according to national and international guidelines. RESULTS An antibiotic prescription was indicated in 57 (10.1%) of the sampled patients, of whom 33.3% did not receive an antibiotic prescription; among the 508 patients for whom an antibiotic prescription was not indicated, 27.4% received a prescription. Of all PCP consultations, 72% were appropriate (an antibiotic was prescribed when indicated and not prescribed when not indicated), whilst an antibiotic prescription not indicated by guidelines was given to 24.6% of the participants, and 3.4% of the sample did not receive an antibiotic prescription when indicated. The most frequently prescribed antibiotic was amoxicillin with clavulanic acid. A rapid microbiological examination was performed in two patients. CONCLUSIONS The study findings highlight a high rate of sub-optimal antibiotic therapeutic profile. Over-prescription of antibiotic therapy and the use of broad-spectrum molecules are widespread in children with URTIs. Antibiotic under-prescription, which may deprive paediatric patients of an effective treatment when indicated, also occurs.
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Affiliation(s)
- Aida Bianco
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Francesca Licata
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy
| | - Carmelo Ga Nobile
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Cosenza, Italy
| | - Francesco Napolitano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Pavia
- Department of Health Sciences, School of Medicine, University of Catanzaro "Magna Græcia", Catanzaro, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
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Karasneh RA, Al-Azzam SI, Ababneh MA, Basheti IA, Al-Azzeh O, Al Sharie S, Conway BR, Aldeyab MA. Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan. Antibiotics (Basel) 2021; 10:963. [PMID: 34439013 PMCID: PMC8389019 DOI: 10.3390/antibiotics10080963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians' preferred sources of information and evaluate physicians' awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers' views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.
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Affiliation(s)
- Reema A. Karasneh
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Sayer I. Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan; (S.I.A.-A.); (M.A.A.)
| | - Mera A. Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan; (S.I.A.-A.); (M.A.A.)
| | - Iman A. Basheti
- Faculty of Pharmacy, Applied Sciences Private University, Amman 11931, Jordan;
| | - Ola Al-Azzeh
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia;
| | - Sarah Al Sharie
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
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Al Hashmi AS, Al Shuhumi AS, Al Kindi RM. Parental Knowledge, Attitudes and Practices Regarding Antibiotic Use for Upper Respiratory Tract Infections in Children. Sultan Qaboos Univ Med J 2021; 21:e289-e296. [PMID: 34221478 PMCID: PMC8219313 DOI: 10.18295/squmj.2021.21.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 11/23/2022] Open
Abstract
Objectives This study aimed to assess parental knowledge, attitudes and practices regarding antibiotic use for children with upper respiratory tract infections (URTIs). Methods A multi-centre cross-sectional study was conducted from September 2018 to April 2019 at 15 randomly selected primary health centres in Muscat, Oman. A total of 384 parents with children under 12 years old were recruited. A validated questionnaire was utilised to determine knowledge, attitudes and practices regarding antibiotic use for children with URTIs. Results All 384 parents participated in the study (response rate: 100%). Almost half of the participants (n = 173; 45.1%) agreed that antibiotics were the first and best treatment for URTIs in children, with 184 parents (47.9%) reporting that influenza symptoms in children improved more rapidly after the administration of antibiotics and 203 (52.9%) believing that antibiotics prevented complications. The majority (n = 219; 57.0%) of parents never gave their children antibiotics without a prescription, and 291 (75.8%) never used leftover antibiotics. Most participants (n = 233; 60.7%) stated that it was the doctor’s decision to prescribe antibiotics, 192 (50.0%) had never asked a physician to prescribe antibiotics for their child and 256 (66.7%) had never changed doctors because they did not prescribe antibiotics. Conclusion This study found that parents had confidence in their healthcare providers; however, it also showed the extent of their lack of knowledge regarding the use of antibiotics for children with URTIs. There is a need for both public- and healthcare professional-oriented educational initiatives to promote rational antibiotic usage in Oman.
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Affiliation(s)
| | - Abir S Al Shuhumi
- Department of Family Medicine, Oman Medical Specialty Board, Muscat, Oman
| | - Rahma M Al Kindi
- Department of Family Medicine and Public Health, Sultan Qaboos University Hospital, Muscat, Oman
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8
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Ahmad A, Nor J, Abdullah AA, Tuan Kamauzaman TH, Yazid MB. Patient Factors in Inappropriate Antibiotic Prescribing for Upper Respiratory Tract Infection in the Emergency Department. Malays J Med Sci 2021; 28:72-83. [PMID: 33958962 PMCID: PMC8075589 DOI: 10.21315/mjms2021.28.2.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/07/2020] [Indexed: 10/29/2022] Open
Abstract
Background Emergency departments (EDs) are frequently misused for non-emergency cases such as upper respiratory tract infections (URTIs). Flooding of these cases may contribute to inappropriate antibiotic prescribing. The aim of this study was to determine the patient factors associated with inappropriate antibiotic prescribing for URTIs in the EDs. Methods This cross-sectional study involved patients over age 3 years old who presented with URTI to the green zone of the ED of a tertiary hospital on the east coast of Malaysia in 2018-2019. Convenient sampling was done. The patients were categorised into two groups according to their McIsaac scores: positive (≥ 2) or negative (< 2). Antibiotics given to the negative McIsaac group were considered inappropriate. Results A total of 261 cases were included - 127 with positive and 134 with negative McIsaac scores. The most common symptoms were fever and cough. About 29% had inappropriate antibiotic prescribing with a high rate for amoxycillin. Duration of symptoms of one day or less (OR 18.5; 95% CI: 1.65, 207.10; P = 0.018), presence of chills (OR 4.36; 95% CI: 1.13, 16.88; P = 0.033) and diagnosis of acute tonsillitis (OR 5.26; 95% CI: 1.76, 15.72; P = 0.003) were significantly associated with inappropriate antibiotic prescription. Conclusion Factors influencing inappropriate antibiotic prescribing should be pointed out to emergency doctors to reduce its incidence.
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Affiliation(s)
- Azmi Ahmad
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Junainah Nor
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ariff Arithra Abdullah
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | | | - Mohd Boniami Yazid
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Edwards G, Newbould L, Nesbitt C, Rogers M, Morris RL, Hay AD, Campbell SM, Hayward G. Predicting poor outcomes in children aged 1-12 with respiratory tract infections: A systematic review. PLoS One 2021; 16:e0249533. [PMID: 33872323 PMCID: PMC8055026 DOI: 10.1371/journal.pone.0249533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Demand for NHS services is high and rising. In children respiratory tract infections (RTI) are the most common reason for consultation with primary care. Understanding which features are associated with good and poor prognosis with RTI will help develop interventions to support parents manage illness. Aim To identify symptoms, signs, and investigation results associated with good and poor prognosis, and clinical decision making in children aged 1–12 years with RTI symptoms, at home and presenting to ambulatory care. Design and setting Systematic literature review. Methods We searched MEDLINE, EMBASE, Cinahl, Web of Science and the Cochrane database of systematic reviews for studies of children aged 1 to 12 years with a RTI or related condition reporting symptoms, signs and investigation results associated with prognostic outcomes. Quality was assessed using the QUIPS tool. Results We included 27 studies which included 34802 children and measured 192 factors. Nine studies explored future outcomes and the remainder explored clinical management from the initial consultation with the health services. None were conducted in a home setting. Respiratory signs, vomiting, fever, dehydration and tachycardia at the initial contact were associated with future hospitalisation. Little evidence was available for other outcomes. Conclusion Some evidence is available to clinicians to stratify risk of, future hospitalisation, but not of other prognostic outcomes. There is little evidence available to parents to identify children at risk of poor prognosis. Research is needed into whether poor prognosis can be predicted by parents in the home.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Louise Newbould
- Social Policy Research Unit, University of York, York, United Kingdom
| | - Charlotte Nesbitt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Miranda Rogers
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rebecca L. Morris
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Stephen M. Campbell
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Broniatowski DA, Klein EY, May L, Martinez EM, Ware C, Reyna VF. Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting. Med Decis Making 2019; 38:547-561. [PMID: 29847253 DOI: 10.1177/0272989x18770664] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.
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Affiliation(s)
- David A Broniatowski
- Department of Engineering Management and Systems Engineering, The George Washington University, Washington, DC, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.,Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA, USA
| | - Elena M Martinez
- Center for Disease Dynamics, Economics, & Policy, Washington, DC, USA
| | - Chelsea Ware
- Department of Medicine, The GW Medical Faculty Associates, Washington, DC, USA
| | - Valerie F Reyna
- Departments of Human Development and Psychology, Center for Behavioral Economics and Decision Research and Human Neuroscience Institute, Cornell University, Ithaca, NY, USA
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12
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Biezen R, Grando D, Mazza D, Brijnath B. Dissonant views - GPs' and parents' perspectives on antibiotic prescribing for young children with respiratory tract infections. BMC FAMILY PRACTICE 2019; 20:46. [PMID: 30922238 PMCID: PMC6437946 DOI: 10.1186/s12875-019-0936-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Antibiotics are not recommended for treating uncomplicated respiratory tract infections (RTIs), despite this, antibiotic prescribing for this is widespread. General practitioners (GPs) report parental pressure and fear of losing patients if they do not prescribe antibiotics, however, parental views on antibiotics for RTIs are unclear. Therefore, this study examined GPs' and parents' perceptions regarding antibiotic prescribing for RTIs in young children. METHODS We conducted semi-structured interviews with 20 GPs, and a survey and focus groups with 50 parents and carers of children under the age of five between June 2014 and July 2015 in Melbourne, Australia. Qualitative data were thematically analysed using NVivo and quantitative data were analysed using SPSS. RESULTS GPs believed that parents expect antibiotics for RTIs and were more likely to prescribe them if parents were insistent. They believed parents would go elsewhere if they did not prescribe antibiotics. GPs suggested that there would be less conflict if parents were better educated on appropriate antibiotics use. In contrast, parents demonstrated good knowledge of RTIs and appropriate antibiotic use. Their main expectation from GPs was to obtain a diagnosis, discuss management, and receive reassurance that the illness was not serious. Parental satisfaction with GPs was not dependent on receiving antibiotics (r = 0.658, p < 0.001), and they would not seek another GP if antibiotics were not prescribed (r = 0.655, p < 0.001). CONCLUSION GPs and parents have dissonant views on antibiotic prescribing for RTI in young children. GPs perceived parents wanting a diagnosis and reassurance that their child is not severely ill as pressure to prescribe antibiotic. To overcome these barriers, targeted training for both GPs and parents to improve communication and reassurance that satisfaction is not related to receiving antibiotics may reduce unnecessary antibiotic prescribing for RTI in young children.
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Affiliation(s)
- Ruby Biezen
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, VIC, 3168, Australia.
| | - Danilla Grando
- School of Science, RMIT University, Building 223, Level 1, Bundoora Campus, Plenty Road, Bundoora, VIC, 3083, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, VIC, 3168, Australia
| | - Bianca Brijnath
- National Ageing Research Institute LTD, 34-54 Poplar Road, Parkville, VIC, 3052, Australia
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13
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Hayes R, Merritt B, Lewis S, Shields J, Gerlach J, Gress TW, Evans J. Antibiotic Prescriptions for Upper Respiratory Infections in a Pediatric Office Versus an Urgent Care Center. Glob Pediatr Health 2019; 6:2333794X19835632. [PMID: 30906818 PMCID: PMC6421603 DOI: 10.1177/2333794x19835632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 12/14/2018] [Indexed: 12/04/2022] Open
Abstract
It is estimated that as many as 10 million unnecessary antibiotic prescriptions are written each year for children. Children are more likely to receive antibiotics for an upper respiratory infection in an urgent care center compared with the primary care office. However, no study has examined the antibiotic prescribing practices of the same physicians in these settings. This retrospective chart review evaluated pediatricians’ antibiotic prescribing practices for patients with symptoms of an upper respiratory tract infection in the office setting and an urgent care setting. There was no difference in the total antibiotic prescribing rate by pediatricians in their primary care office versus an urgent care setting. Pediatricians who were high antibiotic prescribers in the office setting were also high prescribers in the urgent care. The highest prescribing physicians prescribed the appropriate recommended antibiotics for a particular diagnosis the lowest percentage of the time. Efforts to promote antimicrobial stewardship should be directed toward the individual physician and not toward the location where the patients are being evaluated.
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14
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Poole NM, Shapiro DJ, Fleming-Dutra KE, Hicks LA, Hersh AL, Kronman MP. Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014. Pediatrics 2019; 143:peds.2018-1056. [PMID: 30622156 PMCID: PMC6581044 DOI: 10.1542/peds.2018-1056] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 01/21/2023] Open
Abstract
UNLABELLED : media-1vid110.1542/5972296744001PEDS-VA_2018-1056Video Abstract OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs). METHODS A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis. RESULTS In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001). CONCLUSIONS Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.
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Affiliation(s)
- Nicole M. Poole
- Pediatric Infectious Diseases, University of Washington,
Seattle, WA
| | | | | | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for
Disease Control and Prevention, Atlanta, GA
| | - Adam L. Hersh
- Pediatric Infectious Diseases, University of Utah, Salt
Lake City, UT
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15
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Messina F, Clavenna A, Cartabia M, Piovani D, Bortolotti A, Fortino I, Merlino L, Bonati M. Antibiotic prescription in the outpatient paediatric population attending emergency departments in Lombardy, Italy: a retrospective database review. BMJ Paediatr Open 2019; 3:e000546. [PMID: 31909220 PMCID: PMC6937000 DOI: 10.1136/bmjpo-2019-000546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study aimed to assess the appropriateness of antibiotic prescription in children seen in emergency departments (EDs) and to compare prescription profiles in ED and primary care. DESIGN This is a retrospective analysis of healthcare administrative databases. SETTING The study analysed data collected in emergency departments (EDs) and primary care practices (PCPs) in Lombardy, Italy. PARTICIPANTS Children and adolescents between 1 and 13 years old with an ED access and/or an antibiotic prescription in the first semester of 2012 participated in the study. Only those with an index event (ie, without ED access, hospital admissions or antibiotic prescriptions in the previous 60 days) were included. MAIN OUTCOME MEASURES The main outcomes are percentage of subjects receiving amoxicillin (first-choice antibiotic) and percentages receiving macrolides/cephalosporins (second-choice therapies). RESULTS During the observation period, 133 275 children had one ED access, and 26 087 (19.6%) received an antibiotic prescription. In all, 56.1% of children seen for upper respiratory tract infections (URTIs) received an antibiotic, with a prevalence of 67.8% for otitis media and 56.4% for pharyngotonsillitis; 22.3% of children were given amoxicillin after a visit for URTIs, with no differences among infections, and 19.6% received macrolides and cephalosporins. Few differences were found when comparing the index antibiotic prescriptions in ED and PCP settings. A higher prescription of second-choice antibiotics was observed among children cared for by PCPs compared with children attending EDs (31.3% vs 23.4%, χ2 M-H=720, p<0.001). The place of residence was the main determinant of the qualitative profile of prescriptions. CONCLUSIONS More must be done to improve rational use of antibiotics in the ED and PCP setting, and educational interventions including physicians in both setting are strongly needed.
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Affiliation(s)
- Francesco Messina
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Massimo Cartabia
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Daniele Piovani
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | - Ida Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Luca Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
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16
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van de Voort EMF, Mintegi S, Gervaix A, Moll HA, Oostenbrink R. Antibiotic Use in Febrile Children Presenting to the Emergency Department: A Systematic Review. Front Pediatr 2018; 6:260. [PMID: 30349814 PMCID: PMC6186802 DOI: 10.3389/fped.2018.00260] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/31/2018] [Indexed: 01/30/2023] Open
Abstract
Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.
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Affiliation(s)
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | - Alain Gervaix
- Division of Pediatric Emergency Medicine, Department of Child and Adolescent, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Henriette A. Moll
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rianne Oostenbrink
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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17
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Okubo Y, Michihata N, Morisaki N, Kinoshita N, Miyairi I, Urayama KY, Yasunaga H. Recent patterns in antibiotic use for children with group A streptococcal infections in Japan. J Glob Antimicrob Resist 2018; 13:55-59. [DOI: 10.1016/j.jgar.2017.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/06/2017] [Indexed: 11/29/2022] Open
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18
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Goyal MK, Johnson TJ, Chamberlain JM, Casper TC, Simmons T, Alessandrini EA, Bajaj L, Grundmeier RW, Gerber JS, Lorch SA, Alpern ER. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics 2017; 140:e20170203. [PMID: 28872046 PMCID: PMC5613999 DOI: 10.1542/peds.2017-0203] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED. METHODS This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site. RESULTS Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%-2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36-0.53), Hispanic (aOR 0.65; CI 0.53-0.81), and other NH (aOR 0.68; CI 0.52-0.87) children remained less likely to receive antibiotics for viral ARTIs. CONCLUSIONS Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.
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Affiliation(s)
- Monika K Goyal
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC;
| | - Tiffani J Johnson
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Timothy Simmons
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Evaline A Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Children's Hospital, Boulder, Colorado; and
| | - Robert W Grundmeier
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A Lorch
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R Alpern
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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19
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Gotta V, Baumann P, Ritz N, Fuchs A, Baer G, Bonhoeffer JM, Heininger U, Szinnai G, Bonhoeffer J. Drivers of antibiotic prescribing in children and adolescents with febrile lower respiratory tract infections. PLoS One 2017; 12:e0185197. [PMID: 28957358 PMCID: PMC5619731 DOI: 10.1371/journal.pone.0185197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 09/05/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Knowledge of key drivers for antibiotic prescribing in pediatric lower respiratory tract infection (LRTI) could support rational antibiotic use. Thus, we aimed to determine the impact of clinical and laboratory factors on antibiotic prescribing in children and adolescents with febrile LRTI. METHODS Pediatric patients from the standard care control group of a randomized controlled trial (ProPAED) investigating procalcitonin guided antibiotic treatment in febrile LRTI were included in a multivariate logistic regression analysis to evaluate the impact of laboratory and clinical factors on antibiotic prescribing. RESULTS The standard care control group of the ProPAED study comprised 165 LRTI patients (median age: 2.7 years, range: 0.1-16), out of which 88 (55%) received antibiotic treatment. Factors significantly associated with antibiotic prescribing in patients with complete clinical and laboratory documentation (n = 158) were C-reactive protein (OR 5.8 for a 10-fold increase, 95%CI 2.2-14.9), white blood count beyond age-dependent reference range (OR 3.9, 95%CI 1.4-11.4), body temperature (OR 1.7 for an increase by 1°C, 95%CI 1.02-2.68), and pleuritic pain (OR 2.8, 95%CI 1.1-7.6). Dyspnea (OR 0.3, 95%CI 0.1-0.7) and wheezing (OR 0.3, 95%CI 0.13-0.95) were inversely associated with antibiotic prescribing. CONCLUSION Laboratory markers were strong drivers of antibiotic prescribing in children with febrile lower respiratory tract infections, in spite of their known poor prediction of antibiotic need. Building on current guidelines for antibiotic treatment in children with febrile LRTI, a reliable decision algorithm for safe antibiotic withholding considering the laboratory and clinical factors evaluated in this study has the potential to further reduce antibiotic prescribing.
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Affiliation(s)
- Verena Gotta
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Philipp Baumann
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
- * E-mail:
| | - Nicole Ritz
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
| | - Aline Fuchs
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children’s Hospital, Basel, Switzerland
| | - Gurli Baer
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
| | | | - Ulrich Heininger
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
| | - Gabor Szinnai
- Department of Pediatric Endocrinology and Diabetology, University of Basel Children’s Hospital, Basel, Switzerland
| | - Jan Bonhoeffer
- Department of Pediatric Infectious Diseases and Vaccinology, University of Basel Children’s Hospital, Basel, Switzerland
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20
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Alrafiaah AS, Alqarny MH, Alkubedan HY, AlQueflie S, Omair A. Are the Saudi parents aware of antibiotic role in upper respiratory tract infections in children? J Infect Public Health 2017; 10:579-585. [PMID: 28283368 DOI: 10.1016/j.jiph.2017.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 11/18/2016] [Accepted: 01/07/2017] [Indexed: 10/20/2022] Open
Abstract
Upper respiratory tract infection (URTI) is considered to be the most common reason for children's visits to emergency departments or outpatient clinics. The misuse and overuse of antibiotics are currently major public health problems worldwide. This study aimed to assess Saudi parents' knowledge, attitude, and practice (KAP) regarding the use of antibiotics in URTIs in children. This cross-sectional study was conducted in Saudi Arabia using a previously validated questionnaire, which was distributed using Twitter. A total of 385 individuals completed the questionnaire. For the majority of the participants (77%), physicians were the primary source of information regarding the use of antibiotics. Forty-four percent of parents agreed that most URTIs are caused by viruses, and 81% were aware that inappropriate use of antibiotics leads to the development of antibiotic resistance. Fever was the primary symptom (27%) that led parents to ask for prescriptions for antibiotics. Although women had a higher attitude score (p=0.01), there was no difference between genders regarding knowledge and practice. Older participants (41 years or more) had a lower attitude score (p=0.02). Furthermore, participants with five children or more had lower attitude and practice scores (p=0.006, 0.04, respectively). Participants who lived in large cities had greater knowledge compared to the inhabitants of small cities (p=0.01). In conclusion, the findings of this study demonstrated that most of the participants were educated but lacked knowledge regarding antibiotic use in URTIs in children. This lack of knowledge led to inappropriate attitude and practice. Thus, launching public educational campaigns and encouraging physicians to educate parents regarding the proper use of antibiotics are recommended.
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Affiliation(s)
- Abdulaziz S Alrafiaah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Meaad H Alqarny
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Haneen Y Alkubedan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sulaiman AlQueflie
- Department of Pediatric, King Abdullah Specialist Children Hospital, Riyadh, Saudi Arabia
| | - Aamir Omair
- Department of Medical Education, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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21
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Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections. Antimicrob Agents Chemother 2016; 60:4106-18. [PMID: 27139474 DOI: 10.1128/aac.00209-16] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 04/20/2016] [Indexed: 01/21/2023] Open
Abstract
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.
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22
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Kim BN, Kim HB, Oh MD. Antibiotic Control Policies in South Korea, 2000-2013. Infect Chemother 2016; 48:151-159. [PMID: 27704729 PMCID: PMC5047995 DOI: 10.3947/ic.2016.48.3.151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Indexed: 01/06/2023] Open
Abstract
Antibiotic stewardship is a key strategy for limiting antibiotic resistance. Over the last decade the South Korean government has implemented a series of healthcare policies directed to this end, consisting of legislative separation of drug prescribing and dispensing, antibiotic utilization reviews, healthcare quality assessment, and public reporting. As a result, the proportion of antibiotic prescriptions for acute upper respiratory tract infections in primary healthcare facilities decreased from 72.9% in 2002 to 42.7% in 2013. However, no significant decrease in antibiotic resistance occurred over the same period in clinically important bacteria such as Streptococcus pneumoniae. These government-driven policies played a pivotal role in improving antibiotic use for outpatients and surgical patients in South Korea. However, to achieve long-lasting successful outcomes, coordinated efforts and communications among the stakeholders, including physicians and medical societies, are needed.
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Affiliation(s)
- Baek Nam Kim
- Department of Internal Medicine, Inje University Sanggye-Paik Hospital, Seoul, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myoung Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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23
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Lam TP, Wun YT, Lam KF, Sun KS. Differences in antibiotic use between patients with and without a regular doctor in Hong Kong. BMC Pharmacol Toxicol 2015; 16:40. [PMID: 26671017 PMCID: PMC4681134 DOI: 10.1186/s40360-015-0041-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/03/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Literature shows that continuity of care from a primary care physician is associated with better patient satisfaction and preventive care. This may also have an effect on patients' use of antibiotics. This study investigated the differences in antibiotic use between patients with and without a regular doctor in a pluralistic health care system. METHODS A cross-sectional telephone questionnaire survey using randomly selected household phone numbers was conducted in Hong Kong. Several key areas about antibiotic use were compared between the respondents with a regular doctor and those without. RESULTS The response rate was 68.3 %. Of the 2,471 respondents, 1,450 (58.7 %) had a regular doctor, 942 (38.1 %) without, and 79 (3.2 %) did not give a clear answer. The respondents with a regular doctor were more likely to report that they always finished the full course of antibiotics (74.2 % vs 62.4 %), as well as using antibiotics for their last upper respiratory tract infections (17.4 % vs 10.1 %). The association with antibiotic use remained significant in the multivariable logistic regression analysis after adjusting for other confounding factors (P < 0.001, OR = 1.76, 95 % CI:(1.27, 2.48)). CONCLUSIONS While patients with a regular doctor, compared to those without, were more likely to report finishing the full course of antibiotics, they also had nearly twice the chance of reporting antibiotic use for upper respiratory tract infections. This challenges the common belief of the benefits in having a regular doctor.
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Affiliation(s)
- Tai Pong Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.
| | - Yuk Tsan Wun
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.
| | - Kwok Fai Lam
- Department of Statistics and Actuarial Science, The University of Hong Kong, Pok Fu Lam, Hong Kong.
| | - Kai Sing Sun
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.
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Kamikawa J, Granato CFH, Bellei N. Viral aetiology of common colds of outpatient children at primary care level and the use of antibiotics. Mem Inst Oswaldo Cruz 2015; 110:884-9. [PMID: 26560978 PMCID: PMC4660617 DOI: 10.1590/0074-02760150154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/22/2015] [Indexed: 11/22/2022] Open
Abstract
Although antibiotics are ineffective against viral respiratory infections, studies
have shown high rates of prescriptions worldwide. We conducted a study in Brazil to
determine the viral aetiologies of common colds in children and to describe the use
of antibiotics for these patients. Children up to 12 years with common colds were
enrolled from March 2008-February 2009 at a primary care level facility and followed
by regular telephone calls and medical consultations. A nasopharyngeal wash was
obtained at enrollment and studied by direct fluorescence assay and polymerase chain
reaction for nine different types of virus. A sample of 134 patients was obtained,
median age 2.9 years (0.1-11.2 y). Respiratory viruses were detected in 73.9%
(99/134) with a coinfection rate of 30.3% (30/99). Rhinovirus was the most frequent
virus (53/134; 39.6%), followed by influenza (33/134; 24.6%) and respiratory
syncytial virus (8/134; 13.4%). Antibiotic prescription rate was 39.6% (53/134) and
69.8% (37/53) were considered inappropriate. Patients with influenza infection
received antibiotics inappropriately in a greater proportion of cases when compared
to respiratory syncytial virus and rhinovirus infections (p = 0.016). The rate of
inappropriate use of antibiotics was very high and patients with influenza virus
infection were prescribed antibiotics inappropriately in a greater proportion of
cases.
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Affiliation(s)
- Janete Kamikawa
- Laboratório de Virologia Clínica, Departamento de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - Nancy Bellei
- Laboratório de Virologia Clínica, Departamento de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Yaeger JP, Temte JL, Hanrahan LP, Martinez-Donate P. Roles of Clinician, Patient, and Community Characteristics in the Management of Pediatric Upper Respiratory Tract Infections. Ann Fam Med 2015; 13:529-36. [PMID: 26553892 PMCID: PMC4639378 DOI: 10.1370/afm.1856] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Prior studies have evaluated factors predictive of inappropriate antibiotic prescription for upper respiratory tract infections (URIs). Community factors, however, have not been examined. The aim of this study was to evaluate the roles of patient, clinician, and community factors in predicting appropriate management of URIs in children. METHODS We used a novel database exchange, linking electronic health record data with community statistics, to identify all patients aged 3 months to 18 years in whom URI was diagnosed in the period from 2007 to 2012. We followed the Healthcare Effectiveness Data and Information Set (HEDIS) quality measurement titled "Appropriate treatment for children with upper respiratory infection" to determine the rate of appropriate management of URIs. We then stratified data across individual and community characteristics and used multiple logistic regression modeling to identify variables that independently predicted antibiotic prescription. RESULTS Of 20,581 patients, the overall rate for appropriate management for URI was 93.5%. Family medicine clinicians (AOR = 1.5; 95% CI 1.31, 1.71; reference = pediatric clinicians), urgent care clinicians (AOR = 2.23; 95% CI 1.93, 2.57; reference = pediatric clinicians), patients aged 12 to 18 years (AOR = 1.44; 95% CI 1.25, 1.67; reference = age 3 months to 4 years), and patients of white race/ ethnicity (AOR = 1.83; 95% CI 1.41, 2.37; reference = black non-Hispanic) were independently predictive of antibiotic prescription. No community factors were independently predictive of antibiotic prescription. CONCLUSIONS Results correlate with prior studies in which non-pediatric clinicians and white race/ethnicity were predictive of antibiotic prescription, while association with older patient age has not been previously reported. Findings illustrate the promise of linking electronic health records with community data to evaluate health care disparities.
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Affiliation(s)
- Jeffrey P Yaeger
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Department of Pediatrics, Philadelphia, Pennsylvania
| | - Jonathan L Temte
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, Wisconsin
| | - Lawrence P Hanrahan
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, Wisconsin
| | - P Martinez-Donate
- Drexel University Dornsife School of Public Health, Department of Community Health and Prevention, Philadelphia, Pennsylvania
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Coon ER, Maloney CG, Shen MW. Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness. Hosp Pediatr 2015; 5:111-118. [PMID: 25732983 DOI: 10.1542/hpeds.2014-0110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. METHODS Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding children's hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. RESULTS A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. CONCLUSIONS Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.
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Affiliation(s)
- Eric R Coon
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah; and
| | - Christopher G Maloney
- Division of Inpatient Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah; and
| | - Mark W Shen
- University of Texas Southwestern, Dell Children's Hospital, Austin, Texas
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Holstiege J, Mathes T, Pieper D. Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review. J Am Med Inform Assoc 2014; 22:236-42. [PMID: 25125688 DOI: 10.1136/amiajnl-2014-002886] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care. METHODS A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes. RESULTS Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8-62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers. CONCLUSIONS CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.
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Affiliation(s)
- Jakob Holstiege
- Institute of Research in Rehabilitational Medicine at Ulm University, Bad Buchau, Germany
| | - Tim Mathes
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
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Llor C, Cots JM, Hernández S, Ortega J, Arranz J, Monedero MJ, Alcántara JDD, Pérez C, García G, Gómez M, Guerra G, Cid M, Cigüenza ML, Pineda V, Paredes J, Burgazzoli JL, Munck A, Cordoba-Currea G, Bjerrum L. Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study. Aten Primaria 2014; 46:492-500. [PMID: 24768657 PMCID: PMC6985636 DOI: 10.1016/j.aprim.2014.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 02/01/2014] [Accepted: 02/04/2014] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the effectiveness of two types of intervention in reducing antibiotic prescribing in respiratory tract infections (RTI). Design Before–after audit-based study. Setting Primary Care centres in Spain. Participants General practitioners (GPs) registered all patients with RTIs for 15 days in winter 2008 (pre-intervention), and again in winter 2009 (post-intervention). Interventions Intervention activities included meetings, with the presentation and discussion of the results, and several training meetings on RTI guidelines, information brochures for patients, workshops on point-of-care tests – rapid antigen detection tests and C-reactive protein rapid test – and provision of these tests in the clinic. All GPs, with the exception of those in Catalonia, made up the full intervention group (FIG); conversely, Catalan doctors underwent the same intervention, except for the workshop on rapid tests (partial intervention group, PIG). Multilevel logistic regression was performed taking the prescription of antibiotics as the dependent variable. Results Out of a total of 309 GPs involved in the first register, 281 completed the intervention and the second register (90.9%), of which 210 were assigned to the FIG, and 71 to the PIG. The odds ratio of antibiotic prescribing after the intervention was 0.99 (95% CI: 0.89–1.10) among GPs assigned to PIG, and 0.50 (95% CI: 0.44–0.57, p < 0.001) among those who were allocated to FIG. The reduction in antibiotic prescribing in FIG was more marked in flu infection, common cold, acute pharyngitis, acute tonsillitis, and acute bronchitis. Conclusions Active participation of GPs with the performance of point-of-care tests in the clinic is accompanied by a drastic reduction of antibiotic use in RTIs, primarily in infections considered as mainly viral.
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Affiliation(s)
- Carles Llor
- University Rovira i Virgili, Primary Care Jaume I, Tarragona, Spain.
| | - Josep Maria Cots
- Leader of the Happy Audit Study in Spain and Coordinator of the GdT Enfermedades Infecciosas, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), University of Barcelona. Primary Care La Marina, Barcelona, Spain
| | - Silvia Hernández
- University Rovira i Virgili, Primary Care Jaume I, Tarragona, Spain
| | | | - Javier Arranz
- Primary Care Arquitecte Bennàssar, Palma de Mallorca, Spain
| | | | | | | | | | | | - Gloria Guerra
- Primary Care Escaleritas, Las Palmas de Gran Canaria, Spain
| | | | | | | | | | | | - Anders Munck
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Gloria Cordoba-Currea
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Lars Bjerrum
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Denmark
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Ackerman SL, Gonzales R, Stahl MS, Metlay JP. One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis. BMC Health Serv Res 2013; 13:462. [PMID: 24188573 PMCID: PMC4228248 DOI: 10.1186/1472-6963-13-462] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 10/22/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians. METHODS Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29). RESULTS Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions-including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components' effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy. CONCLUSIONS Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA.
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30
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Gonzales R, Anderer T, McCulloch CE, Maselli JH, Bloom FJ, Graf TR, Stahl M, Yefko M, Molecavage J, Metlay JP. A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis. JAMA Intern Med 2013; 173:267-73. [PMID: 23319069 PMCID: PMC3582762 DOI: 10.1001/jamainternmed.2013.1589] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis. METHODS We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis. RESULTS Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites. CONCLUSIONS Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00981994.
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Affiliation(s)
- Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94118, USA.
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Koller D, Hoffmann F, Maier W, Tholen K, Windt R, Glaeske G. Variation in antibiotic prescriptions: is area deprivation an explanation? Analysis of 1.2 million children in Germany. Infection 2012; 41:121-7. [PMID: 22826031 DOI: 10.1007/s15010-012-0302-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/04/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Inadequate use of antibiotics can lead to problems such as resistance. Overuse is especially a problem for children, since they are more affected by acute (often virus-caused) infections. While the problem has been addressed internationally over the past several years, regional variations in prescriptions are striking. Therefore, the present study aims to analyze regional variations in antibiotic prescription on a district level in Germany and tries to identify reasons for those variations through adding possible influencing factors to the analysis on individual and district levels. METHODS We analyzed 1.2 million children insured in a German health insurance fund. Antibiotic prescriptions were quantified in 2010 and reasons for prescriptions were analyzed in multilevel regressions based on the district of residence, regional deprivation, and age and sex of the child. RESULTS Thirty-six percent of all children aged 0-17 years received an antibiotic prescription in 2010. In the south, prevalences are generally lower, and also to the very north. The highest prevalences are found in the close-to-border districts in the west, as well as in a band throughout the middle of Germany, in rather low population density areas. Regional variation in the prevalence range from 19 to 53 % between districts. Regional deprivation can explain part of this variation. CONCLUSIONS Including area deprivation measures helped identify an influence of especially regional income and occupational deprivation on antibiotic prescriptions for children. Regional analysis such as this can help identify specific regions and groups of persons to address information programs on the risks of preventable antibiotic consumption and alternative treatment methods.
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Affiliation(s)
- D Koller
- Centre for Social Policy Research, University of Bremen, UNICOM-Gebäude, Mary-Somerville-Str. 5, 28359, Bremen, Germany.
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Greene SK, Kleinman KP, Lakoma MD, Rifas-Shiman SL, Lee GM, Huang SS, Finkelstein JA. Trends in antibiotic use in Massachusetts children, 2000-2009. Pediatrics 2012; 130:15-22. [PMID: 22732172 PMCID: PMC3382917 DOI: 10.1542/peds.2011-3137] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2012] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Antibiotic use rates have declined dramatically since the 1990s. We aimed to determine if, when, and at what level the decline in antibiotic-dispensing rates ended and which diagnoses contributed to the trends. METHODS Antibiotic dispensings and diagnoses were obtained from 2 health insurers for 3- to <72-month-olds in 16 Massachusetts communities from 2000 to 2009. Population-based antibiotic-dispensing rates per person-year (p-y) were determined according to year (September-August) for 3 age groups. Fit statistics were used to identify the most likely year for a change in trend. Rates for the first and last years were compared according to antibiotic category and associated diagnosis. RESULTS From 2000-2001 to 2008-2009, the antibiotic-dispensing rate for 3- to <24-month-olds decreased 24% (2.3-1.8 antibiotic dispensings per p-y); for 24- to <48-month-olds, it decreased 18% (1.6-1.3 antibiotic dispensings per p-y); and for 48- to <72-month-olds, it decreased 20% (1.4-1.1 antibiotic dispensings per p-y). For 3- to <48-month-olds, rates declined until 2004-2005 and remained stable thereafter; the downward trend for 48- to <72-month-olds ended earlier in 2001-2002. Among 3- to <24-month-olds, first-line penicillin use declined 26%. For otitis media, the dispensing rate decreased 14% and the diagnosis rate declined 9%, whereas the treatment fraction was stable at 63%. CONCLUSIONS The downward trend in antibiotic dispensings to young children in these communities ended by 2004-2005. This trend was driven by a declining otitis media diagnosis rate. Continued monitoring of population-based dispensing rates will support efforts to avoid returning to previous levels of antibiotic overuse.
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Affiliation(s)
- Sharon K. Greene
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Kenneth P. Kleinman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Matthew D. Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sheryl L. Rifas-Shiman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Grace M. Lee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases and Department of Laboratory Medicine, and
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange, California
| | - Jonathan A. Finkelstein
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of General Pediatrics, Children's Hospital Boston, Boston, Massachusetts; and
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Murphy M, Bradley CP, Byrne S. Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing--an Irish perspective. BMC FAMILY PRACTICE 2012; 13:43. [PMID: 22640399 PMCID: PMC3430589 DOI: 10.1186/1471-2296-13-43] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Accepted: 05/28/2012] [Indexed: 11/29/2022]
Abstract
Background Information about antibiotic prescribing practice in primary care is not available for Ireland, unlike other European countries. The study aimed to ascertain the types of antibiotics and the corresponding conditions seen in primary care and whether general practitioners (GPs) felt that an antibiotic was necessary at the time of consultation. This information will be vital to inform future initiatives in prudent antibiotic prescribing in primary care. Methods Participating GPs gathered data on all antibiotics prescribed by them in 100 consecutive patients’ consultations as well as data on the conditions being treated and whether they felt the antibiotic was necessary. Results 171 GPs collected data on 16,899 consultations. An antibiotic was prescribed at 20.16% of these consultations. The majority were prescribed for symptoms or diagnoses associated with the respiratory system; the highest rate of prescribing in these consultations were for patients aged 15–64 years (62.23%). There is a high rate of 2nd and 3rd line agents being used for common ailments such as otitis media and tonsillitis. Amoxicillin, which is recommended as 1st line in most common infections, was twice as likely to be prescribed if the prescription was for deferred used or deemed unnecessary by the GP. Conclusion The study demonstrates that potentially inappropriate prescribing is occurring in the adult population and the high rate of broad-spectrum antimicrobial agents is a major concern. This study also indicates that amoxicillin may be being used for its placebo effect rather than specifically for treatment of a definite bacterial infection.
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Affiliation(s)
- Marion Murphy
- Department of General Practice, School of Medicine, University College Cork, Cork, Ireland
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Ponda P, Mithani S, Kopyltsova Y, Sison C, Gupta P, Larenas D, Bonagura VR. Allergen immunotherapy practice patterns: a worldwide survey. Ann Allergy Asthma Immunol 2012; 108:454-459.e7. [PMID: 22626600 DOI: 10.1016/j.anai.2012.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 04/02/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Allergists around the world have different practice styles when administering subcutaneous aeroallergen immunotherapy (IT) in peak pollen seasons, especially when changing doses or frequency of IT. The Immunotherapy practice parameters do not specifically address this issue. OBJECTIVE Given the paucity of good data about adjustment of allergen immunotherapy during the pollen seasons, we examined whether a significant difference is present in the way allergists administer immunotherapy during allergy seasons. METHODS To quantify the practice styles of allergists who are members of the American Academy of Allergy, Asthma and Immunology (AAAAI), a self-reported electronic survey was disseminated in September 2010 with the help of the AAAAI Needs Assessment Committee. The responses were tallied and analyzed according to demographic information. RESULTS A total of 1,201 allergists in the AAAAI responded to the survey. Most responders practice in an urban or suburban nonacademic practice in the United States and have been in practice for more than 10 years. The size of their practice was variable. Those in practice for more than 10 years were more likely to adjust the dose and frequency of immunotherapy in pollen seasons. CONCLUSION This survey highlights the differences in the practice styles of AAAAI member allergists, and these differences may be associated with their demographic characteristics. Given the wide variability in how allergists adjust dose and frequency of immunotherapy during pollen seasons, establishing guidelines regarding this routine dilemma might help standardize the delivery of treatment to patients.
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Affiliation(s)
- Punita Ponda
- North Shore-Long Island Jewish Health System, 865 Northern Boulevard, Great Neck, NY 11021, USA.
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Emergency department visits for symptoms experienced by oncology patients: a systematic review. Support Care Cancer 2012; 20:1589-99. [PMID: 22526151 DOI: 10.1007/s00520-012-1459-y] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 03/26/2012] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this review was to explore the range and prevalence of cancer treatment or disease-related symptoms in the emergency department and their associated outcomes. METHODS A systematic review examined studies cited in Medline, Embase, PsycINFO, and CINAHL published from 1980 to July 2011. Eligible studies measured emergency department visits for symptom assessment in adult oncology patients. Two reviewers independently screened citations and double data extraction was used. Descriptive analysis was conducted. RESULTS Of 1,298 citations, six prospective and 12 retrospective descriptive studies were included. Of these, eight focused on multiple symptoms and 10 targeted specific symptoms. The studies were published between 1995 and 2011, conducted in seven countries, and had a median sample size of 143 (range 9-27,644). Of the 28 symptoms reported, the most common were febrile neutropenia, infection, pain, fever, and dyspnea. Definitions provided for individual symptoms were inconsistent. Of 16 studies reporting admission rates, emergency visits resulted in hospital admissions 58 % (median) of the time in multi-symptom studies (range 31 % to 100 %) and 100 % (median) of the time in targeted symptoms studies (range 39 % to 100 %). Of 11 studies reporting mortality rates, 13 % (median) of emergency visits captured in multi-symptom studies (range 1 % to 56 %) and 20 % (median) of visits in targeted symptoms studies (range 4 % to 67 %) resulted in death. CONCLUSIONS Individuals with cancer present to emergency departments with a myriad of symptoms. Over half of emergency department visits resulted in hospital admissions. Few symptoms were defined adequately to compare data across studies, thereby revealing an important gap in cancer symptom reporting.
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