Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting

Primary Care Antibiotic Prescribing and Infection-Related Hospitalisation

Inappropriate prescribing of antibiotics has been widely recognised as a leading cause of antimicrobial resistance, which in turn has become one of the most significant threats to global health. Given that most antibiotic prescriptions are issued in primary care settings, investigating the associations between primary care prescribing of antibiotics and subsequent infection-related hospitalisations affords a valuable opportunity to understand the long-term health implications of primary care antibiotic intervention. A narrative review of the scientific literature studying associations between primary care antibiotic prescribing and subsequent infection-related hospitalisation was conducted. The Web of Science database was used to retrieve 252 potentially relevant studies, with 23 of these studies included in this review (stratified by patient age and infection type). The majority of studies (n = 18) were published in the United Kingdom, while the remainder were conducted in Germany, Spain, Denmark, New Zealand, and the United States. While some of the reviewed studies demonstrated that appropriate and timely antibiotic prescribing in primary care could help reduce the need for hospitalisation, excessive antibiotic prescribing can lead to antimicrobial resistance, subsequently increasing the risk of infection-related hospitalisation. Few studies reported no association between primary care antibiotic prescriptions and subsequent infection-related hospitalisation. Overall, the disparate results in the extant literature attest to the conflicting factors influencing the decision-making regarding antibiotic prescribing and highlight the necessity of adopting a more patient-focussed perspective in stewardship programmes and the need for increased use of rapid diagnostic testing in primary care.

Evaluating the long-term portrayal of antibiotic resistance in major U.S. newspapers

BACKGROUND

Popular media play a critical role in informing the public about antibiotic resistance, which has remained a health concern for over seven decades. Media attention increases the notoriety of antibiotic resistance and shapes the public's perception of its severity, causes, and solutions. Therefore, it is critical the media accurately portray scientific knowledge that may shape personal and policy responses to antibiotic resistance.

METHODS

We analyzed articles from two major U.S. newspapers, The New York Times and Los Angeles Times, from 1940 to 2019 to assess trends in sentiment and lexicon surrounding antibiotic and antimicrobial resistance.

RESULTS

We observed a gradual increase in the number of relevant articles about resistance, although far fewer than other topics with comparable mortality rates. We found a consistently threatening portrayal of antibiotic resistance as a crisis, reflected in the usage of terms such as "superbug" to refer to some pathogens. Governmental agencies responsible for determining antibiotic usage policies were infrequently mentioned in articles. Blame for resistance was almost exclusively attributed to inappropriate antibiotic use, mainly in animals, rather than appropriate uses of antibiotics.

CONCLUSIONS

Collectively, our results provide insights into how popular media can more accurately inform the public about antibiotic resistance. Potential changes include increasing news coverage, avoiding fear-mongering, and adequately conveying the multiple uses of antibiotics that can potentiate resistance.

Providers' shared decision-making as a predictor of healthcare outcomes for college-aged adults managing upper respiratory tract infections

OBJECTIVES

Strategies that assist patients with upper respiratory tract infections (URTIs) to endorse non-antibiotic treatments are vital to curbing antibiotic resistance. This study examines the potential of shared decision-making (SDM) for improving stewardship-relevant outcomes and investigates patient affect as a mechanism that explains the beneficial impact of perceived SDM.

METHOD

Patients (N = 433) seeking care for URTIs at a university student health center and not prescribed antibiotics completed a pre-visit questionnaire and two surveys one day and 14 days post-visit. The day-one survey assessed perceived SDM, affect, and immediate stewardship-relevant outcomes, and the day-14 survey assessed long-term stewardship-relevant outcomes.

RESULTS

Perceived SDM was negatively associated with negative affect and positively associated with positive affect, favorable perceptions of non-antibiotic treatments and providers, and self-efficacy to manage symptoms and obtain follow-up care. Patient affect and day-one outcomes were mediators between perceived SDM and retrospective self-efficacy two weeks post-visit.

CONCLUSION

The study illustrated the beneficial influence of patient perceived SDM on antibiotic stewardship in both short and long terms and elucidated the mechanisms through which the influence occurs.

PRACTICE IMPLICATIONS

SDM can be an effective strategy for primary care providers to improve patients' outcomes with URTI visits without prescribing unwarranted antibiotics.

Identification of provider and patient characteristics associated with antibiotic prescription in the treatment of acute sinusitis

BACKGROUND

Inappropriate antibiotic use contributes to the development of antibiotic resistance. Sinusitis is the fifth most common diagnosis responsible for antibiotic use. Appropriate antibiotic prescribing for acute sinusitis treatment is crucial to mitigate antibiotic resistance threats.

PURPOSE

The purpose of this study was to identify patient and provider characteristics associated with antibiotic prescription and to assess provider adherence to antibiotic prescribing guidelines for acute sinusitis treatment.

METHODOLOGY

Retrospective chart review including acute sinusitis cases diagnosed over 12 months, at two express care clinics in the Southwestern United States. Data extraction identified 371 cases meeting inclusion criteria (age >18 years). Descriptive statistical data analyses included Chi square tests.

RESULTS

A majority of cases received antibiotic prescriptions (90.8%, n = 337). Sociodemographic characteristics significantly associated with antibiotic prescription ( p < .05) included race, ethnicity, insurance type, and smoking status. Patient-reported nature of symptoms, sinus tenderness, and erythema/edema nasal turbinates were also significantly associated with antibiotic prescription ( p < .05). Antibiotic prescription and watchful waiting for acute sinusitis treatment were significantly associated with provider types ( p < .05).

CONCLUSIONS

A gap exists between current guidelines and clinical practice for acute sinusitis treatment in outpatient settings. Antibiotic prescription occurred, although not indicated, along with incorrect antibiotic choice, dose, and duration of therapy.

IMPLICATIONS

Outpatient antimicrobial stewardship programs for acute sinusitis treatment with a focus on educational interventions for providers may reduce antibiotic overprescribing for acute sinusitis.

Knowledge, attitudes and practices regarding antimicrobial use and resistance among healthcare seekers in two tertiary hospitals in Ghana: a quasi-experimental study

OBJECTIVE

To evaluate knowledge of antimicrobial resistance (AMR), to study how the judgement of health value (HVJ) and economic value (EVJ) affects antibiotic use, and to understand if access to information on AMR implications may influence perceived AMR mitigation strategies.

DESIGN

A quasi-experimental study with interviews performed before and after an intervention where hospital staff collected data and provided one group of participants with information about the health and economic implications of antibiotic use and resistance compared with a control group not receiving the intervention.

SETTING

Korle-Bu and Komfo Anokye Teaching Hospitals, Ghana.

PARTICIPANTS

Adult patients aged 18 years and older seeking outpatient care.

MAIN OUTCOME MEASURES

We measured three outcomes: (1) level of knowledge of the health and economic implications of AMR; (2) HVJ and EVJ behaviours influencing antibiotic use and (3) differences in perceived AMR mitigation strategy between participants exposed and not exposed to the intervention.

RESULTS

Most participants had a general knowledge of the health and economic implications of antibiotic use and AMR. Nonetheless, a sizeable proportion disagreed or disagreed to some extent that AMR may lead to reduced productivity/indirect costs (71% (95% CI 66% to 76%)), increased provider costs (87% (95% CI 84% to 91%)) and costs for carers of AMR patients/societal costs (59% (95% CI 53% to 64%)). Both HVJ-driven and EVJ-driven behaviours influenced antibiotic use, but the latter was a better predictor (reliability coefficient >0.87). Compared with the unexposed group, participants exposed to the intervention were more likely to recommend restrictive access to antibiotics (p<0.01) and pay slightly more for a health treatment strategy to reduce their risk of AMR (p<0.01).

CONCLUSION

There is a knowledge gap about antibiotic use and the implications of AMR. Access to AMR information at the point of care could be a successful way to mitigate the prevalence and implications of AMR.

Patient Perspectives on the Drivers and Deterrents of Antibiotic Treatment of Acute Rhinosinusitis: a Qualitative Study

BACKGROUND

Antibiotics are prescribed in >80% of outpatient acute rhinosinusitis (ARS) visits, despite the low incidence of bacterial infection. Previous studies have shown patient expectations are the most robust predictor of antibiotics prescription in ARS. However, patient perceptions are not well known or understood.

OBJECTIVE

To understand patient perceptions regarding what drives or deters them from wanting, seeking, and taking antibiotic treatment of ARS.

DESIGN

Iterative thematic analysis of semi-structured interviews.

PARTICIPANTS

Nineteen adults diagnosed with ARS within the prior 60 days at the Northwestern Medicine General Internal Medicine clinic in Chicago, IL.

MAIN MEASURES

Perceptions of patients with ARS.

KEY RESULTS

We interviewed 19 patients, identifying the following drivers of antibiotic use: (1) symptoms, especially discolored rhinorrhea, and seeking relief, (2) belief that antibiotics are a convenient and/or effective way to relieve/cure sinusitis, and (3) desire for tangible outcomes of a clinic visit. For deterrents, the following themes emerged: (1) concern about antibiotic resistance, (2) preference for other treatments or preference to avoid medications, and (3) desire to avoid a healthcare visit. Patients identified that a trustworthy physician's recommendation for antibiotics was a driver, and a recommendation against antibiotics was a deterrent to taking antibiotics; a delayed antibiotic prescription also served as a deterrent. Antibiotic side effects were viewed neutrally by most participants, though they were a deterrent to some.

CONCLUSIONS

Patients have misconceptions about the indications and effectiveness of antibiotics for ARS. Intimate knowledge of key antibiotic drivers and deterrents, from the perspective of patients with ARS, can be leveraged to engage and increase patients' knowledge, and set appropriate expectations for antibiotics for ARS.

The vicious cycle of the public's irrational use of antibiotics for upper respiratory tract infections: A mixed methods systematic review

Background

The public's irrational use of antibiotics for upper respiratory tract infections (URTIs) is prevalent worldwide. This study aims to synthesize evidence on how people use antibiotics to treat URTIs, its prevalence and determinants.

Methods

A mixed methods systematic review was conducted using a convergent segregated approach. Relevant studies were searched from PubMed, Cochrane Library, Embase, and Web of Science. A qualitative analysis was initiated, exploring the public's antibiotic use experience for URTIS based on the Consumer Behavior Model (CBM). This was followed by a quantitative synthesis, tapping into the prevalence and predictors of public behavior in antibiotic usage for URTIs. The segregated syntheses complemented each other and were further integrated.

Results

A total of 86 studies were included: 48 quantitative, 30 qualitative, eight mixed methods studies. The included studies were conducted in Europe (n = 29), Asia (n = 27) and North America (n = 21), assessing the behaviors of patients (n = 46), their parents or caregivers (n = 31), or both (n = 9). Eleven themes emerged covering the six CBM stages: need recognition, information searching, alternative evaluation, antibiotic obtaining, antibiotic consumption, and post-consumption evaluation. The six stages reinforce each other, forming a vicious cycle. The high prevalence of the public's irrational use of antibiotics for URTIs is evident despite the high heterogeneity of the studies (ranging from 0.0 to 92.7%). The perceived seriousness of illness and misbelief in antibiotics were identified consistently across the studies as the major motivation driving the public's irrational use of antibiotics for URTIs. However, individual capacity (e.g., knowledge) and opportunity (e.g., contextual restriction) in reducing antibiotic use have mixed effect.

Conclusion

Systemic interventions concerning both supply and demand sides are warranted. The public needs to be educated about the appropriate management of URTIs and health care providers need to re-shape public attitudes toward antibiotic use for URTIs through communication and prescribing practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier: CRD42021266407.

Gist Representations and Decision-Making Processes Affecting Antibiotic Prescribing for Children with Acute Otitis Media

Objective. To test the predictions of fuzzy-trace theory regarding pediatric clinicians’ decision-making processes and risk perceptions about antibiotics for children with acute otitis media (AOM). Methods. We conducted an online survey experiment administered to a sample of 260 pediatric clinicians. We measured their risk perceptions and prescribing decisions across 3 hypothetical AOM treatment scenarios. Participants were asked to choose among the following options: prescribe antibiotics immediately, watchful waiting (“hedging”), or not prescribing antibiotics. Results. We identified 4 gists based on prior literature: 1) “why not take a risk?” 2) “antibiotics might not help but can hurt,” 3) “antibiotics do not have harmful side effects,” and 4) “antibiotics might have harmful side effects.” All 4 gists predicted risky choice (P < 0.001), and gist endorsements varied significantly between scenarios when antibiotics were indicated, F(2, 255) = 8.53, P < 0.001; F(2, 255) = 5.14, P < .01; and F(2, 255) = 3.56, P < 0.05 for the first 3 factors, respectively. In a logistic regression, more experienced clinicians were less likely to hedge (B = −0.05; P < 0.01). Conclusion. As predicted by fuzzy-trace theory, pediatric clinicians’ prescription decisions are associated with gist representations, which are distinct from verbatim risk estimates. Implications. Antibiotic stewardship programs can benefit by communicating the appropriate gists to clinicians who prescribe antibiotics for pediatric patients.

Communicating Commitment to Antibiotic Stewardship: an Effective Strategy for Responding to Online Patient Reviews

BACKGROUND

Public health officials have worked to address the growing threat of antibiotic resistance. To slow the emergence of antimicrobial-resistant bacteria, it is important to improve patients' understanding of antibiotics and adjust their expectations of them. This study explores strategic antibiotic resistance communication between patients and health care providers in an online review platform.

METHODS

Based on two experimental studies, we demonstrate the effectiveness of the provider's commitment messaging when dealing with patients' complaints about not receiving requested antibiotics during their visit.

RESULTS

The findings from study 1 show that communicating the commitment to antibiotic stewardship makes participants have more favorable feelings toward the provider. Commitment messaging also makes readers perceive the provider as more credible, and they are more willing to visit the clinic in the future. Study 2 findings demonstrate a robustness of commitment messaging in increasing readers' willingness to visit the clinic, while the provider's response exhibits the limited impact of correcting patients' common misunderstandings of antibiotics and adjusting their expectations of antibiotics.

CONCLUSIONS

Our findings illustrate some clear benefits of engaging with negative online patient reviews to minimize potential reputational damage and reestablish the credibility of care providers.

Reversing the Antibiotic Resistance “Yelp Effect” Through the Use of Emotionally Framed Responses to Negative Reviews of Providers: Questionnaire Study

Background

The overuse of antibiotics has rapidly made antimicrobial resistance a global public health challenge. There is an emerging trend where providers who perceive that their patients expect antibiotics are more likely to prescribe antibiotics unprompted or upon request. Particularly, health care providers have expressed concern that dissatisfied patients will provide disparaging online reviews, therefore threatening the reputation of the practice. To better deal with the negative reviews and inform patients, some health care staff directly respond to patients’ online feedback. Engaging with patients’ online reviews gives providers an opportunity to prevent reputational damage and improve patients’ understanding of the antibiotic resistance problem.

Objective

We aim to test the effectiveness of different response strategies to the negative patient online reviews on the readers’ perceptions of the health care provider and their perceptions related to antibiotics resistance.

Methods

Two experiments were conducted to examine the impact of message tactics (apologizing, inducing fear or guilt) that can be employed by health care providers when responding to patients’ negative online feedback related to not receiving an antibiotic.

Results

Overall, our results demonstrated positive impacts of responding to patients’ online reviews. In study 1, we found apologetic messaging and use of emotional appeals in the response were effective in making readers feel more favorable toward the message. Readers also expressed a greater credibility perception toward the provider and willingness to visit the clinic when emotional appeals were used. Findings from study 2 largely supported the effectiveness of a fear-based response in improving the readers’ credibility perceptions and willingness to visit the clinic. The fear-inducing information was particularly effective among parent readers.

Conclusions

This paper demonstrated that a strategic response to online patient complaints could prevent reputational damage and minimize the potential negative impacts of the review. The results also glean insight into the step toward developing a novel intervention—crafting a persuasive response to patients’ negative feedback that can help improve the understanding of antibiotic resistance problems.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

BACKGROUND

There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.

METHODS

We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.

RESULTS

Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.

CONCLUSIONS

This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England

BACKGROUND

Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients.

SETTING

We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population.

METHODS

We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing.

RESULTS

We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure.

CONCLUSIONS

Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45.

HIGHLIGHTS

Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].

Antibiotic Expectations of Emergency Department Patients with Upper Respiratory Tract Infections: Clinical and Antibiotic Use Behavioral Determinants

INTRODUCTION

Antibiotics are often prescribed for upper respiratory tract infections (URTIs) in emergency departments (EDs) due to patient requests and expectations as perceived by physicians. This study aimed to identify clinical and behavioral factors associated with patient antibiotic expectations.

METHODS

We performed a cross-sectional study on 717 patients attending at Tan Tock Seng Hospital (TTSH) ED for URTI, June 2016-November 2018., A questionnaire was administered and electronic medical records accessed. Principal components analysis derived latent behavioural factors associated with antibiotic use, which were applied in multivariable multinomial logistic regression analyses.Independent factors associated with patient antibiotic expectations and requests were identified.

RESULTS

Patients were predominantly young (mean age 40.5[SD 14.7] years), had no comorbidities (66.5%, 477/717), presented <7 days of symptom-onset (62.9%, 451/717), and did not fulfil the U.S. Centers for Disease Control and Prevention's Influenza-Like Illness (ILI) criteria (79.1%, 567/717). Behavioral factors identified were 1) Non-compliance to prescribed antibiotic regimen; 2) Self-administration of antibiotics that were not prescribed for the illness episode; and 3) Self-discontinuation of antibiotics upon experiencing adverse effects or allergies. After adjusting for age, gender, ethnicity, comorbidity, influenza vaccination history, and illness duration, patients with ILI (Adj OR 1.73, 95% CI (1.15, 2.59), P=0.008) or who self-administered antibiotics not prescribed for the illness episode (Adj OR 1.28, 95% CI (1.04, 1.57), P=0.021) were more likely to expect antibiotics from their visit.

CONCLUSION

Patients with ILI or who previously self-administered antibiotics were more likely to expect antibiotics at ED attendances. Public education on appropriate antibiotic use is imperative to ensure optimal antibiotic use.

Viruses, Vaccines, and COVID-19: Explaining and Improving Risky Decision-making

Risky decision-making lies at the center of the COVID-19 pandemic and will determine future viral outbreaks. Therefore, a critical evaluation of major explanations of such decision-making is of acute practical importance. We review the underlying mechanisms and predictions offered by expectancy-value and dual-process theories. We then highlight how fuzzy-trace theory builds on these approaches and provides further insight into how knowledge, emotions, values, and metacognitive inhibition influence risky decision-making through its unique mental representational architecture (i.e., parallel verbatim and gist representations of information). We discuss how social values relate to decision-making according to fuzzy-trace theory, including how categorical gist representations cue core values. Although gist often supports health-promoting behaviors such as vaccination, social distancing, and mask-wearing, why this is not always the case as with status-quo gist is explained, and suggestions are offered for how to overcome the "battle for the gist" as it plays out in social media.

Questioning the Yelp Effect: Mixed Methods Analysis of Web-Based Reviews of Urgent Cares

Background

Providers of on-demand care, such as those in urgent care centers, may prescribe antibiotics unnecessarily because they fear receiving negative reviews on web-based platforms from unsatisfied patients—the so-called Yelp effect. This effect is hypothesized to be a significant driver of inappropriate antibiotic prescribing, which exacerbates antibiotic resistance.

Objective

In this study, we aimed to determine the frequency with which patients left negative reviews on web-based platforms after they expected to receive antibiotics in an urgent care setting but did not.

Methods

We obtained a list of 8662 urgent care facilities from the Yelp application programming interface. By using this list, we automatically collected 481,825 web-based reviews from Google Maps between January 21 and February 10, 2019. We used machine learning algorithms to summarize the contents of these reviews. Additionally, 200 randomly sampled reviews were analyzed by 4 annotators to verify the types of messages present and whether they were consistent with the Yelp effect.

Results

We collected 481,825 reviews, of which 1696 (95% CI 1240-2152) exhibited the Yelp effect. Negative reviews primarily identified operations issues regarding wait times, rude staff, billing, and communication.

Conclusions

Urgent care patients rarely express expectations for antibiotics in negative web-based reviews. Thus, our findings do not support an association between a lack of antibiotic prescriptions and negative web-based reviews. Rather, patients’ dissatisfaction with urgent care was most strongly linked to operations issues that were not related to the clinical management plan.

Safety of reducing antibiotic prescribing in primary care: a mixed-methods study

Background

The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.

Objectives

To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.

Design

Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.

Data sources

The Clinical Practice Research Datalink.

Setting

This took place in UK general practices.

Participants

A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.

Main outcome measures

Sepsis and localised bacterial infections.

Results

Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.

Limitations

Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.

Conclusions

Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.

Future work

The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Effect of information on reducing inappropriate expectations and requests for antibiotics

People often expect antibiotics when they are clinically inappropriate (e.g., for viral infections). This contributes significantly to physicians' decisions to prescribe antibiotics when they are clinically inappropriate, causing harm to the individual and to society. In two pre-registered studies employing UK general population samples (n₁  = 402; n₂  = 190), we evaluated the relationship between knowledge and beliefs with antibiotic expectations, and the effects of information provision on such expectations. We conducted a correlational study (study 1), in which we examined the role of antibiotic knowledge and beliefs and an experiment (study 2) in which we assessed the causal effect of information provision on antibiotic expectations. In study 1, we found that both knowledge and beliefs about antibiotics predicted antibiotic expectations. In study 2, a 2 (viral information: present vs. absent) × 2 (antibiotic information: present vs. absent) experimental between-subjects design, information about antibiotic efficacy significantly reduced expectations for antibiotics, but viral aetiology information did not. Providing antibiotic information substantially diminishes inappropriate expectations of antibiotics. Health campaigns might also aim to change social attitudes and normative beliefs, since more complex sociocognitive processes underpin inappropriate expectations for antibiotics.

Perceptions of the Benefits and Risks of Antibiotics Among Adult Patients and Parents With High Antibiotic Utilization

Background

Inappropriate antibiotic use is common. Understanding how patients view antibiotic risks and/or benefits could inform development of patient education materials and clinician communication strategies. We explored current knowledge, attitudes, and behaviors related to antibiotics among populations with high antibiotic use.

Methods

We conducted 12 focus groups with adult patients and parents across the United States by telephone in March 2017. Purposive sampling was used to identify participants with high antibiotic use. We transcribed the discussions verbatim and performed thematic analysis.

Results

We identified 4 major themes. First, participants expressed uncertainty regarding which clinical syndromes required antibiotics, and emotion often influenced their desire for antibiotics. Second, they had a limited understanding of antibiotic risks. Antibiotic resistance was viewed as the primary risk but was seen as a “distant, future” issue, whereas immediate adverse events, such as side effects, were minimized; however, patients expressed concern when told about the risk of serious adverse events. Third, they prioritized antibiotic benefits over risks in their decision-making, both due to an inaccurate estimation of antibiotic risks and/or benefits and a tendency to prioritize instant gratification. Fourth, most participants were willing to defer to their clinicians’ decisions about antibiotics, especially if their clinician provided symptomatic treatment and anticipatory guidance.

Conclusions

Patients have a limited understanding of antibiotic risks, potentially explaining why they are willing to try antibiotics even if it is unclear antibiotics will help. Educating patients on the potential antibiotic risks versus benefits, rather than just antibiotic resistance, may have a bigger impact on their decision-making.

The Clinical Need for New Diagnostics in the Identification and Management of Patients with Suspected Sepsis in UK NHS Hospitals: A Survey of Healthcare Professionals

Development of a new diagnostic is ideally driven by an understanding of the clinical need that the test addresses and the optimal role the test will have within a care pathway. This survey aimed to understand the clinical need for new sepsis diagnostics and to identify specific clinical scenarios that could be improved by testing. An electronic, cross-sectional survey was circulated to UK National Health Service (NHS) doctors and nurses who care for patients with suspected sepsis in hospitals. Two hundred and sixty-five participants completed the survey, representing 64 NHS Trusts in England. Sixty-seven percent of respondents suggested that the major cause of delay was during the initial identification of sepsis and the subsequent recognition of patients who were deteriorating. Existing blood tests did not enhance the confidence of consultants making their diagnoses. Those surveyed identified a role for a near-patient test to "rule out" suspected sepsis and, thereby, stop or postpone use of antibiotics. Current diagnostic tests are slow, non-specific, and do not reliably identify patients with a high suspicion of sepsis. As a result, they have a limited use in patient management and antibiotic stewardship. Future development of sepsis diagnostics should focus on overcoming these limitations.

Risks of use and non-use of antibiotics in primary care: qualitative study of prescribers' views

PURPOSE

The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

METHODS

Qualitative study using semistructured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.

RESULTS

Thirty participants were recruited, including twenty-three general practitioners, five nurses and two pharmacists. Three main themes were identified: risk assessment, balancing treatment risks and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers' perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and Clostridium difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions and safety netting.

CONCLUSIONS

Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients' expectations.

A system dynamics model of infection risk, expectations, and perceptions on antibiotic prescribing in the United States

RATIONALE, AIMS, AND OBJECTIVES

Inappropriate antibiotic prescribing is still a major concern that can lead to devastating outcomes including antibiotic resistance. This study aimed to simulate the antibiotic prescribing behaviour by providers for acute respiratory tract infections (ARTIs) and to evaluate the impact of patient expectation, provider's perception of patient's expectation to receive a prescription, and patient's risk for bacterial infection, on the decision to prescribe.

METHODS

We developed a unique system dynamics (SD) simulation model based on the significant factors that impact the interaction between provider and patient during visits for ARTIs and the decision to prescribe antibiotics. In order to validate the model for different age groups and regions in the United States, we used the sample of 53 000 ARTI patient visits made at outpatient settings between 1993 and 2015, based on the National Ambulatory Medical Care Survey (NAMCS).

RESULTS

Simulation results reveal that physician diagnosis for prescribing antibiotics is based on physician's experience from their prior prescribing behaviour, their perception of patient's infection risk, and patient's expectation to receive antibiotics. Also, there are some variations depending on patient's age and residential region. The simulation analysis also depicts the decreasing trend in patient's expectation over the past two decades for most age groups and regions.

CONCLUSIONS

Given the high number of unnecessary prescriptions for ARTI, we found that policies are needed to influence provider's prescribing behaviour through patient's expectation and provider's perception regarding those expectations. Our simulation framework can further be used by policymakers to design and evaluate interventions that may modify the interaction between health providers and patients to optimize antibiotic prescriptions among ARTI patients for different regions and age groups.

The Effect of Expert Feedback on Antibiotic Prescribing in Pediatrics: Experimental Evidence

Background. Inappropriate prescribing of antibiotics, which is common in pediatric care, is a key driver of antimicrobial resistance. To mitigate the development of resistance, antibiotic stewardship programs often suggest the inclusion of feedback targeted at individual providers. Empirically, however, it is not well understood how feedback affects individual physicians’ antibiotic prescribing decisions. Also, the question of how physicians’ characteristics, such as clinical experience, relate to antibiotic prescribing decisions and to responses to feedback is largely unexplored. Objective. To analyze the causal effect of descriptive expert feedback (and individual characteristics) on physicians’ antibiotic prescribing decisions in pediatrics. Design. We employed a randomized, controlled framed field experiment, in which German pediatricians (n=73) decided on the length of first-line antibiotic treatment for routine pediatric cases. In the intervention group (n=39), pediatricians received descriptive feedback in form of an expert benchmark, which allowed them to compare their own prescribing decisions with expert recommendations. The recommendations were elicited in a survey of pediatric department directors (n=20), who stated the length of antibiotic therapies they would choose for the routine cases. Pediatricians’ characteristics were elicited in a comprehensive questionnaire. Results. Providing pediatricians with expert feedback significantly reduced the length of antibiotic therapies by 10% on average. Also, the deviation of pediatricians’ decisions from experts’ recommendations significantly decreased. Antibiotic therapy decisions were significantly related to pediatricians’ clinical experience, risk attitudes, and personality traits. The effect of feedback was significantly associated with physicians’ experience. Conclusion. Our results indicate that descriptive expert feedback can be an effective means to guide pediatricians, especially those who are inexperienced, toward more appropriate antibiotic prescribing. Therefore, it seems to be suitable for inclusion in antibiotic stewardship programs.

Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events

Importance

The benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Little is known about the harms associated with continuing antimicrobial prophylaxis after skin closure.

Objective

To characterize the association of type and duration of prophylaxis with surgical site infection (SSI), acute kidney injury (AKI), and Clostridium difficile infection.

Design, Setting, and Participants

In this multicenter, national retrospective cohort study, all patients within the national Veterans Affairs health care system who underwent cardiac, orthopedic total joint replacement, colorectal, and vascular procedures and who received planned manual review by a trained nurse reviewer for type and duration of surgical prophylaxis and for SSI from October 1, 2008, to September 30, 2013, were included. Data were analyzed using multivariable logistic regression, with adjustments for covariates determined a priori to be associated with the outcomes of interest. Data were analyzed from December 2016 to December 2018.

Exposures

Duration of postoperative antimicrobial prophylaxis (<24 hours, 24-<48 hours, 48-<72 hours, and ≥72 hours).

Main Outcomes and Measures

Surgical site infection, AKI, and C difficile infection.

Results

Of the 79 058 included patients, 76 109 (96.3%) were men, and the mean (SD) age was 64.8 (9.4) years. Among 79 058 surgical procedures in the cohort, all had SSI and C difficile outcome data available; 71 344 (90.2%) had AKI outcome data. After stratification by type of surgery and adjustment for age, sex, race, diabetes, smoking, American Society of Anesthesiologists score greater than 2, methicillin-resistant Staphylococcus aureus colonization, mupirocin, type of prophylaxis, and facility factors, SSI was not associated with duration of prophylaxis. Adjusted odds of AKI increased with each additional day of prophylaxis (cardiac procedure: 24-<48 hours: adjusted odds ratio [aOR], 1.03; 95% CI, 0.95-1.12; 48-<72 hours: aOR, 1.22; 95% CI, 1.08-1.39; ≥72 hours: aOR, 1.82; 95% CI, 1.54-2.16; noncardiac procedure: 24-<48 hours: aOR, 1.31; 95% CI, 1.21-1.42; 48-<72 hours: aOR, 1.72; 95% CI, 1.47-2.01; ≥72 hours: aOR, 1.79; 95% CI, 1.27-2.53). The risk of postoperative C difficile infection demonstrated a similar duration-dependent association (24-<48 hours: aOR 1.08; 95% CI, 0.89-1.31; 48-<72 hours: aOR, 2.43; 95% CI, 1.80-3.27; ≥72 hours: aOR, 3.65; 95% CI, 2.40-5.53). The unadjusted numbers needed to harm for AKI after 24 to less than 48 hours, 48 to less than 72 hours, and 72 hours or more of postoperative prophylaxis were 9, 6, and 4, respectively; and 2000, 90, and 50 for C difficile infection, respectively. Vancomycin receipt was also a significant risk factor for AKI (cardiac procedure: aOR, 1.17; 95% CI, 1.10-1.25; noncardiac procedure: aOR, 1.21; 95% CI, 1.13-1.30).

Conclusions and Relevance

Increasing duration of antimicrobial prophylaxis was associated with higher odds of AKI and C difficile infection in a duration-dependent fashion; extended duration did not lead to additional SSI reduction. These findings highlight the notion that every day matters and suggest that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI.