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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Avent ML, Hall L, van Driel M, Dobson A, Deckx L, Galal M, Plejdrup Hansen M, Gilks C. Reducing antibiotic prescribing in general practice in Australia: a cluster randomised controlled trial of a multimodal intervention. Aust J Prim Health 2024; 30:NULL. [PMID: 37844575 DOI: 10.1071/py23024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 09/19/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The health and economic burden of antimicrobial resistance (in Australia is significant. Interventions that help guide and improve appropriate prescribing for acute respiratory tract infections in the community represent an opportunity to slow the spread of resistant bacteria. Clinicians who work in primary care are potentially the most influential health care professionals to address the problem of antimicrobial resistance, because this is where most antibiotics are prescribed. METHODS A cluster randomised trial was conducted comparing two parallel groups of 27 urban general practices in Queensland, Australia: 13 intervention and 14 control practices, with 56 and 54 general practitioners (GPs), respectively. This study evaluated an integrated, multifaceted evidence-based package of interventions implemented over a 6-month period. The evaluation included quantitative and qualitative components, and an economic analysis. RESULTS A multimodal package of interventions resulted in a reduction of 3.81 prescriptions per GP per month. This equates to 1280.16 prescriptions for the 56GPs in the intervention practices over the 6-month period. The cost per prescription avoided was A$148. The qualitative feedback showed that the interventions were well received by the GPs and did not impact on consultation time. Providing GPs with a choice of tools might enhance their uptake and support for antimicrobial stewardship in the community. CONCLUSIONS A multimodal package of interventions to enhance rational prescribing of antibiotics is effective, feasible and acceptable in general practice. Investment in antimicrobial stewardship strategies in primary care may ultimately provide the important returns for public health into the future.
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Affiliation(s)
- Minyon L Avent
- UQ Centre for Clinical Research, The University of Queensland, Herston, Qld, Australia; and Queensland Statewide Antimicrobial Stewardship Program, Queensland Health, Herston, Qld, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | - Mieke van Driel
- General Practice, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Annette Dobson
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | - Laura Deckx
- General Practice, Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Mahmoud Galal
- School of Public Health, The University of Queensland, Herston, Qld, Australia
| | | | - Charles Gilks
- School of Public Health, The University of Queensland, Herston, Qld, Australia
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Sijbom M, Büchner FL, Saadah NH, Numans ME, de Boer MGJ. Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework. BMJ Open 2023; 13:e065006. [PMID: 37197815 DOI: 10.1136/bmjopen-2022-065006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVES This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR). DESIGN A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed. SETTING All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included. RESULTS Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR. CONCLUSIONS The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions. PROSPERO REGISTRATION NUMBER CRD42023396225.
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Affiliation(s)
- Martijn Sijbom
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederike L Büchner
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Nicholas H Saadah
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mattijs E Numans
- Public Health and Primary Care, Campus The Hague, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Mark G J de Boer
- Infectious Diseases, Leidsen University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Bjerrum A, García-Sangenís A, Modena D, Córdoba G, Bjerrum L, Chalkidou A, Lykkegaard J, Hansen MP, Søndergaard J, Nexøe J, Rebnord I, Sebjørnsen I, Jensen JN, Hansen MB, Taxis K, Lambert M, Benko R, González López-Valcárcel B, Raynal F, Barragán N, Touboul P, Bruno P, Radzeviciene R, Jaruseviciene L, Bandzaite A, Godycki-Cwirko M, Kowalczyk A, Lionis C, Karkana MN, Anastasaki M, Coleman J, Glasová H, van Agtmael M, Tattevin P, Borràs A, Llor C. Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol. BMC PRIMARY CARE 2022; 23:102. [PMID: 35501712 PMCID: PMC9063370 DOI: 10.1186/s12875-022-01710-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. METHODS/DESIGN HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. DISCUSSION HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics. STUDY REGISTRATION EU Health programmes project database https://webgate.ec.europa.eu/chafea_pdb/health/projects/900024/summary ; date of registration: 1 January 2021.
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Affiliation(s)
- Anders Bjerrum
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol, Barcelona, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol, Barcelona, Spain
| | - Daniela Modena
- Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol, Barcelona, Spain
| | | | | | | | - Jesper Lykkegaard
- Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense, Denmark
| | - Malene Plejdrup Hansen
- Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense, Denmark
| | - Jørgen Nexøe
- Department of Public Health, Research Unit for General Practice, University of Southern Denmark, Odense, Denmark
| | | | | | - Jette Nygaard Jensen
- The Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Matilde Bøgelund Hansen
- The Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Katja Taxis
- Rijksuniversiteit Groningen, Groningen, The Netherlands
| | | | - Ria Benko
- Rijksuniversiteit Groningen, Groningen, The Netherlands
| | | | - Fabiana Raynal
- University of Las Palmas de Gran Canaria and Fundación Canaria Parque Científico Tecnológico, Las Palmas, Spain
| | - Nieves Barragán
- Spanish Society for Family and Community Medicine, Barcelona, Spain
| | - Pia Touboul
- Department of Public Health, Nice University Hospital, Nice, France
| | - Pascale Bruno
- Department of Public Health, Nice University Hospital, Nice, France
| | | | | | | | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, the Faculty of Health Sciences, The Medical University of Lodz, Lodz, Poland
| | - Christos Lionis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Rethymno, Greece
| | - Maria-Nefeli Karkana
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Rethymno, Greece
| | - Marilena Anastasaki
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Rethymno, Greece
| | - Jamie Coleman
- European Association for Clinical Pharmacology and Therapeutics, London, UK
| | - Helena Glasová
- European Association for Clinical Pharmacology and Therapeutics, London, UK
| | | | | | - Alicia Borràs
- University Institute for Patient Care, Barcelona, Spain
| | - Carl Llor
- Institut Català de la Salut, Via Roma Health Centre, c. Manso, 19, 3rd floor, 08015, Barcelona, Spain.
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Changes in antibiotic prescription following an education strategy for acute respiratory infections. NPJ Prim Care Respir Med 2021; 31:34. [PMID: 34083534 PMCID: PMC8175562 DOI: 10.1038/s41533-021-00247-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/26/2021] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to assess the impact of an education intervention for primary health care physicians, based on the knowledge of clinical practice guidelines and availability of rapid antigen detection test for group A streptococci (GAS), on the improvement of antibiotic prescription for patients with acute respiratory tract infections. Before and after the intervention, physicians collected data from ten consecutive patients who attended during a 3-week period. This process was performed twice a year for 6 consecutive years (2012–2017). A total of 18,001 patients were visited by 391 primary care physicians during the study period, 55.6% before intervention and 44.4% after intervention. After intervention, the antibiotic prescription decreased significantly, from 33.0 to 23.4% (p < 0.01). However, there was a statistically significant increase (p < 0.01) in the use of penicillins. This study, carried out in daily practice conditions, confirms that the educational strategy was associated with an overall reduction in the use of antibiotics and an improvement in the antibiotic prescription profile in acute respiratory tract infections.
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Machowska A, Marrone G, Saliba-Gustafsson P, Borg MA, Saliba-Gustafsson EA, Stålsby Lundborg C. Impact of a Social Marketing Intervention on General Practitioners' Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta. Antibiotics (Basel) 2021; 10:371. [PMID: 33807404 PMCID: PMC8066227 DOI: 10.3390/antibiotics10040371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners' (GPs') antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs' antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs' antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.
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Affiliation(s)
- Anna Machowska
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Gaetano Marrone
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Peter Saliba-Gustafsson
- Center for Molecular Medicine at BioClinicum, Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden;
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, MSD 2090 Msida, Malta;
- Faculty of Medicine and Surgery, University of Malta, MSD 2090 Msida, Malta
| | - Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
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Oliveira I, Rego C, Semedo G, Gomes D, Figueiras A, Roque F, Herdeiro MT. Systematic Review on the Impact of Guidelines Adherence on Antibiotic Prescription in Respiratory Infections. Antibiotics (Basel) 2020; 9:E546. [PMID: 32867122 PMCID: PMC7557871 DOI: 10.3390/antibiotics9090546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022] Open
Abstract
Overuse and inappropriate antibiotic prescription for respiratory tract infections (RTI) are one of the major contributors to the current antibiotic resistance problem. Guidelines provide support to prescribers for proper decision-making. Our purpose is to review the impact of prescribers' exposure to guidelines in antibiotic prescription for RTIs. A systematic review was performed searching in the scientific databases MEDLINE PubMed and EMBASE for studies which exposed prescribers to guidelines for RTI and compared antibiotic prescription rates/quality before and after the implementation, with thirty-four articles included in the review. The selected studies consisted on a simple intervention in the form of guideline implementation while others involved multifaceted interventions, and varied in population, designs, and settings. Prescription rate was shown to be reduced in the majority of the studies, along with an improvement in appropriateness, defined mainly by the prescription of narrow-spectrum rather than broad-spectrum antibiotics. Intending to ascertain if this implementation could decrease prescription costs, 7 articles accessed it, of which 6 showed the intended reduction. Overall interventions to improve guidelines adherence can be effective in reducing antibiotic prescriptions and inappropriate antibiotic selection for RTIs, supporting the importance of implementing guidelines in order to decrease the high levels of antibiotic prescriptions, and consequently reduce antimicrobial resistance.
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Affiliation(s)
- Inês Oliveira
- Faculty of Health, Medicine and Life Sciences, University of Maastricht, 6200 MD Maastricht, The Netherlands;
| | - Catarina Rego
- Faculty of Pharmacy of the University of Lisbon, 1649 Lisbon, Portugal;
| | - Guilherme Semedo
- Department of Medical Sciences, University of Aveiro, 3810 Aveiro, Portugal;
| | - Daniel Gomes
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain;
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), 28001 Madrid, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine–iBiMED, University of Aveiro, 3810 Aveiro, Portugal;
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Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Borg MA, Stålsby Lundborg C. Antibiotic prescribing for respiratory tract complaints in Malta: a 1 year repeated cross-sectional surveillance study. J Antimicrob Chemother 2020; 74:1116-1124. [PMID: 30624733 DOI: 10.1093/jac/dky544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta. METHODS In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs' prescribing patterns. RESULTS Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed. CONCLUSIONS GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.
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Affiliation(s)
- Erika A Saliba-Gustafsson
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
| | - Alexandra Dunberger Hampton
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
| | - Peter Zarb
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida MSD, Malta
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida MSD, Malta.,Faculty of Medicine and Surgery, University of Malta, Msida MSD, Malta
| | - Cecilia Stålsby Lundborg
- Department of Public Health Sciences, Global Health - Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
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Long-term impact of an intervention on rapid antigen detection tests in acute pharyngitis. Aten Primaria 2020; 52:637-644. [PMID: 32482364 PMCID: PMC7713413 DOI: 10.1016/j.aprim.2020.02.016] [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: 11/30/2019] [Accepted: 02/18/2020] [Indexed: 11/22/2022] Open
Abstract
Objective This study was aimed at evaluating the appropriateness of use and interpretation of rapid antigen detection testing (RADT) and antibiotic prescribing for acute pharyngitis six years after a multifaceted intervention. Design Before-and-after audit-based study. Location Primary care centres in eight autonomous Communities. Participants General practitioners (GP) who had participated in the HAPPY AUDIT intervention study in 2008 and 2009 were invited to participate in a third audit-based study six years later (2015). Method RADTs were provided to the participating practices and the GPs were requested to consecutively register all adults with acute pharyngitis. A registration form specifically designed for this study was used. Results A total of 121 GPs out of the 210 who participated in the first two audits agreed to participate in the third audit (57.6%). They registered 3394 episodes of pharyngitis in the three registrations. RADTs were used in 51.7% of all the cases immediately after the intervention, and in 49.4% six years later. Antibiotics were prescribed in 21.3% and 36.1%, respectively (P < .001), mainly when tonsillar exudates were present, and in 5.3% and 19.2% of those with negative RADT results (P< .001). On adjustment for covariables, compared to the antibiotic prescription observed just after the intervention, significantly more antibiotics were prescribed six years later (odds ratio: 2.24, 95% confidence interval: 1.73–2.89). Conclusions This study shows that that the long-term impact of a multifaceted intervention, focusing on the use and interpretation of RADT in patients with acute pharyngitis, is reducing.
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Llor C, Bjerrum L, Molero JM, Moragas A, González López-Valcárcel B, Monedero MJ, Gómez M, Cid M, Alcántara JDD, Cots JM, Ribas JM, García G, Ortega J, Pineda V, Guerra G, Munuera S. Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections. J Antimicrob Chemother 2019; 73:2215-2222. [PMID: 29718420 DOI: 10.1093/jac/dky137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/20/2018] [Indexed: 11/13/2022] Open
Abstract
Objectives Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs). Methods The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. Results A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001). Conclusions This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.
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Affiliation(s)
- Carl Llor
- Via Roma Health Centre, Barcelona, Spain
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ana Moragas
- University Rovira i Virgili, Jaume I Health Centre, Tarragona, Spain
| | | | | | | | | | | | - Josep M Cots
- University of Barcelona, La Marina Health Centre, Barcelona, Spain
| | | | | | | | | | - Gloria Guerra
- Escaleritas Health Centre, Las Palmas de Gran Canaria, Spain
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11
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Malmgren A, Biswanger K, Lundqvist A, Zaoutis T. Education, decision support, feedback and a minor reward: a novel antimicrobial Stewardship intervention in a Swedish paediatric emergency setting. Infect Dis (Lond) 2019; 51:559-569. [PMID: 31088317 DOI: 10.1080/23744235.2019.1606933] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Sweden enjoys a favourable situation with regard to antimicrobial resistance. However, healthcare costs are expected to increase exponentially, along with increased morbidity and mortality, due to the emergence of resistant bacterial strains. Our aim was to design an antimicrobial stewardship programme suitable for Scandinavian settings. Methods: A quasi-experimental pre-post study was conducted in a Swedish paediatric emergency department, evaluating adherence to national guidelines for acute otitis media and acute tonsillitis. The programme consisted of educational outreach, decision support, feedback, and a minor reward upon reaching a pre-defined adherence rate. Results: The largest impact, significant for both diagnoses, was on the practice of refraining from antibiotic use when recommended. The other variables evaluated showed no significant improvement for either condition; however, in most cases, pre-interventional adherence was already high. Conclusions: This relatively easily implementable ASP intervention showed a significant effect on correctly refraining from the use of antibiotics. Previous interventions in Scandinavia either failed to accomplish this or have been more logistically difficult. The combination of education, decision support, email-based feedback and a minor reward, offers an alternative. Future research will be needed to assess whether the result is sustainable, as well as to identify additional barriers to the judicious use of antibiotics not addressed in this study.
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Affiliation(s)
- Annika Malmgren
- a Department of Pediatric Medicine , Queen Silvia Children's Hospital , Gothenburg , Sweden
| | - Karin Biswanger
- b Department of Pediatric Medicine , Södra Älvsborg Hospital , Borås , Sweden
| | - Anders Lundqvist
- c Department of Infectious Diseases , Södra Älvsborg Hospital , Borås , Sweden
| | - Theoklis Zaoutis
- d Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness , Children's Hospital of Philadelphia , Philadelphia , PA , USA
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12
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Molero JM, Moragas A, González López-Valcárcel B, Bjerrum L, Cots JM, Llor C. Reducing antibiotic prescribing for lower respiratory tract infections 6 years after a multifaceted intervention. Int J Clin Pract 2019; 73:e13312. [PMID: 30664320 DOI: 10.1111/ijcp.13312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/21/2018] [Accepted: 01/18/2019] [Indexed: 01/01/2023] Open
Abstract
AIMS Few studies have evaluated the long-term impact of interventions on antibiotic prescription for lower respiratory tract infections (LRTI). This study was aimed at evaluating the use of antibiotics prescribed for LRTIs by general practitioners (GP) who underwent a multifaceted intervention carried out 6 years earlier. METHODS General practitioners who had completed two registrations in 2008 and 2009 were again invited to participate in a third audit-based study in 2015. A multifaceted intervention was held 1-3 months before the second registration. A new group of GPs with no previous training on the rational use of antibiotics were also invited to participate and acted as controls. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable. RESULTS A total of 121 GPs of the 210 who underwent the intervention (57.6%) and 117 control GPs registered 4333 episodes of LRTIs. On adjustment for covariables, compared with the antibiotic prescription for LRTIs observed just after the intervention, antibiotic prescription slightly increased 6 years later among GPs who had undergone the intervention (OR 1.17, 95% CI 0.95-1.43), while control GPs prescribed significantly more antibiotics (OR 2.31, 95% CI 1.62-3.29). However, withholding antibiotic prescribing with C-reactive protein (CRP) values <10 mg/L was more frequently observed just after the intervention compared 6 years later (12.7% vs 32.2%; P < 0.01). CONCLUSIONS Antibiotic prescribing for LRTIs remains low 6 years after an intervention, although GPs are less confident to withhold antibiotic therapy in patients with low CRP levels.
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Affiliation(s)
- José M Molero
- San Andrés Primary Health Centre, Department Preventive Medicine, University Rey Juan Carlos, Madrid, Spain
| | - Ana Moragas
- Jaume I Health Centre, University Rovira i Virgili, Tarragona, Spain
| | - Beatriz González López-Valcárcel
- Department of Quantitative Methods for Economics and Management, University of Las Palmas, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josep M Cots
- La Marina Health Centre, University of Barcelona, Barcelona, Spain
| | - Carl Llor
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Via Roma Health Centre, University Institute in Primary Care Research Jordi Gol, Barcelona, Spain
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13
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Stuhr JK, Lykkegaard J, Kristensen JK, Kornum JB, Hansen MP. Danish GPs' and practice nurses' management of acute sore throat and adherence to guidelines. Fam Pract 2019; 36:192-198. [PMID: 29924311 DOI: 10.1093/fampra/cmy059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses. OBJECTIVES We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines. METHODS A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method. RESULTS A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines. CONCLUSION Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.
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Affiliation(s)
- Janni Katharina Stuhr
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jesper Lykkegaard
- Audit Project Odense, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jette Kolding Kristensen
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Malene Plejdrup Hansen
- Research Unit for General Practice, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Molero JM, Gómez M, Guerra G, Alcántara JDD, Ortega J, García G, Pineda V, Munuera S, Cid M, Monedero MJ, Ribas JM, Cots JM, Moragas A, Bjerrum L, Llor C. [Utilisation of first-line antibiotics six years after a multifaceted intervention]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:520-527. [PMID: 30421882 PMCID: PMC6254481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE No study has evaluated the impact of a multifaceted intervention on the quality of the antibiotics prescribed more than 5 years later. METHODS A total of 210 general practitioners (GP) from eight different regions of Spain were asked to participate in two registrations of respiratory tract infections (RTI) in 2008, before, and in 2009, just after a multifaceted intervention including prescriber feedback, clinical guidelines, training sessions focused on appropriate antibiotic prescribing, workshop on rapid tests and provision of these tests in the GP consultation. They were all again invited to participate in a similar registration in 2015. A new group of clinicians from the same areas who had never participated in antimicrobial stewardship courses were also invited to participate and acted as controls. RESULTS The 121 GPs who continued the study (57.6%) and the 117 control GPs registered 22,407 RTIs. The antibiotic most commonly prescribed was amoxicillin and clavulanic acid, prescribed in 1,801 cases (8.1% of the total), followed by amoxicillin (1,372 prescriptions, 6.2%), being lower among GPs just after the intervention. The third leading antibiotic among GPs just after the intervention was penicillin V (127 cases, 3.3%) whereas macrolides ranked third in the other three groups of GPs. CONCLUSIONS The use of first-line antibiotic for RTIs wanes over time after an intervention, but their utilisation is still significantly greater among intervened clinicians six years later compared to GPs who have never been exposed to any antimicrobial stewardship programmes.
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Affiliation(s)
- José M. Molero
- Estudiante de PhD de Epidemiología y Salud Pública URJC. Centro de Salud San Andrés, Madrid
| | | | - Gloria Guerra
- Centro de Salud Escaleritas, Las Palmas de Gran Canaria
| | | | | | | | | | | | | | | | | | - Josep M. Cots
- Universidad de Barcelona, Centro de Salud La Marina, Barcelona
| | - Ana Moragas
- Universidad Rovira i Virgili, Centro de Salud Jaume I, Tarragona
| | - Lars Bjerrum
- Sección de Atención Primaria y Unidad de Investigación en Atención Primaria, Departamento de Salud Pública, Universidad de Copenhague, Dinamarca
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15
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Bordado Sköld M, Aabenhus R, Guassora AD, Mäkelä M. Antibiotic treatment failure when consulting patients with respiratory tract infections in general practice. A qualitative study to explore Danish general practitioners' perspectives. Eur J Gen Pract 2018; 23:120-127. [PMID: 28394180 PMCID: PMC5774263 DOI: 10.1080/13814788.2017.1305105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Prescribing antibiotics for acute respiratory tract infections (RTIs) is common in primary healthcare although most of these infections are of viral origin and antibiotics may not be helpful. Some of these prescriptions will not be associated with a quick recovery, and might be regarded as cases of antibiotic treatment failure (ATF). OBJECTIVES We studied antibiotic treatment failure in patients with acute RTIs from a general practitioner (GP) perspective, aiming to explore (i) GPs' views of ATF in primary care; (ii) how ATF influences the doctor-patient relationship; and (iii) GPs' understanding of patients' views of ATF. METHODS Qualitative study based on semi-structured, recorded interviews of 18 GPs between August and October 2012. The interviews started with discussion of a unique case of acute RTI involving ATF, followed by a more general reflection of the topic. Interviews were analysed using qualitative content analysis. RESULTS In patients with acute RTIs, GPs proposed and agreed to a medical definition of antibiotic treatment failure but believed patients' views to differ significantly from this medical definition. GPs thought ATF affected their daily work only marginally. GPs used many communicative tools to maintain trust with patients in cases of ATF, but they did not consider such incidents to affect the doctor-patient relationship adversely. CONCLUSION These findings suggest a possible communication gap between doctors and patients, partly due to a narrow medical definition of ATF. Studies describing patients' views are still missing. General practitioners' experiences and views on antibiotic treatment failure in acute respiratory infections or its effects on the doctor-patient relationship have not been studied previously.
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Affiliation(s)
- Margrethe Bordado Sköld
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Rune Aabenhus
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Ann Dorrit Guassora
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Marjukka Mäkelä
- a Center for Education and Research in General Practice, Department of Public Health, Faculty of Health Sciences , University of Copenhagen , Copenhagen , Denmark.,b Finnish Office for Health Technology Assessment (FINOHTA) , THL (National Institute for Health and Welfare) , Helsinki , Finland
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16
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Raft CF, Bjerrum L, Arpi M, Jarløv JO, Jensen JN. Delayed antibiotic prescription for upper respiratory tract infections in children under primary care: Physicians' views. Eur J Gen Pract 2018; 23:190-195. [PMID: 28714782 PMCID: PMC5774269 DOI: 10.1080/13814788.2017.1347628] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Overprescribing antibiotics for common or inaccurately diagnosed childhood infections is a frequent problem in primary healthcare in most countries. Delayed antibiotic prescriptions have been shown to reduce the use of antibiotics in primary healthcare. OBJECTIVE The aim was to examine primary care physicians' views on delayed antibiotic prescriptions to preschool children with symptoms of upper respiratory tract infections (URTIs). METHODS A questionnaire was sent to 1180 physicians working in general practice in the Capital Region of Denmark, between January and March 2015. The questions focused on physicians' attitude and use of delayed antibiotic prescriptions to children with URTIs. RESULTS The response rate was 49% (n = 574). Seven per cent of the physicians often used delayed prescriptions to children with symptoms of URTI, but 46% believed that delayed prescription could reduce antibiotic use. The physicians' views on delayed antibiotic prescription were significantly associated with their number of years working in general practice. Parents' willingness to wait-and-see, need for reassurance, and knowledge about antibiotics influenced the physicians' views. Also, clinical symptoms and signs, parents' willingness to shoulder the responsibility, the capability of observation without antibiotic treatment, and structural factors like out-of-hour services were relevant factors in the decision. CONCLUSIONS Most physicians, especially those with fewer years of practice, had a positive attitude towards delayed antibiotic prescription. Several factors influence the views of the physicians-from perceptions of parents to larger structural elements and years of experience.
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Affiliation(s)
- Camilla Flintholm Raft
- a Department of Clinical Microbiology, Herlev and Gentofte Hospital , University of Copenhagen , Herlev , Denmark.,b Danish Patient Safety Authority , Copenhagen , Denmark
| | - Lars Bjerrum
- c Department of Public Health , Section of General Practice, University of Copenhagen , Copenhagen , Denmark
| | - Magnus Arpi
- a Department of Clinical Microbiology, Herlev and Gentofte Hospital , University of Copenhagen , Herlev , Denmark
| | - Jens Otto Jarløv
- a Department of Clinical Microbiology, Herlev and Gentofte Hospital , University of Copenhagen , Herlev , Denmark
| | - Jette Nygaard Jensen
- a Department of Clinical Microbiology, Herlev and Gentofte Hospital , University of Copenhagen , Herlev , Denmark
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17
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Ellegård LM, Dietrichson J, Anell A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? HEALTH ECONOMICS 2018; 27:e39-e54. [PMID: 28685902 PMCID: PMC5836891 DOI: 10.1002/hec.3535] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 03/27/2017] [Accepted: 05/15/2017] [Indexed: 05/05/2023]
Abstract
Antibiotic resistance is a major threat to public health worldwide. As the healthcare sector's use of antibiotics is an important contributor to the development of resistance, it is crucial that physicians only prescribe antibiotics when needed and that they choose narrow-spectrum antibiotics, which act on fewer bacteria types, when possible. Inappropriate use of antibiotics is nonetheless widespread, not least for respiratory tract infections (RTI), a common reason for antibiotics prescriptions. We examine if pay-for-performance (P4P) presents a way to influence primary care physicians' choice of antibiotics. During 2006-2013, 8 Swedish healthcare authorities adopted P4P to make physicians select narrow-spectrum antibiotics more often in the treatment of children with RTI. Exploiting register data on all purchases of RTI antibiotics in a difference-in-differences analysis, we find that P4P significantly increased the share of narrow-spectrum antibiotics. There are no signs that physicians gamed the system by issuing more prescriptions overall.
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Affiliation(s)
| | - Jens Dietrichson
- SFIThe Danish National Centre for Social ResearchCopenhagenDenmark
| | - Anders Anell
- Department of Business AdministrationLund UniversityLundSweden
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18
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Decreasing Inappropriate Use of Antibiotics in Primary Care in Four Countries in South America-Cluster Randomized Controlled Trial. Antibiotics (Basel) 2017; 6:antibiotics6040038. [PMID: 29240687 PMCID: PMC5745481 DOI: 10.3390/antibiotics6040038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 11/16/2022] Open
Abstract
High antibiotic prescribing and antimicrobial resistance in patients attending primary care have been reported in South America. Very few interventions targeting general practitioners (GPs) to decrease inappropriate antibiotic prescribing have been investigated in this region. This study assessed the effectiveness of online feedback on reducing antibiotic prescribing in patients with suspected respiratory tract infections (RTIs) attending primary care. The aim was to reduce antibiotic prescribing in patients with acute bronchitis and acute otitis media. Both are RTIs for which antibiotics have a very limited effect. A cluster randomized two-arm control trial was implemented. Healthcare centres from Bolivia, Argentina, Paraguay and Uruguay participating in the quality improvement program HAPPY AUDIT were randomly allocated to either intervention or control group. During ten consecutive weeks, GPs in the intervention group received evidence-based online feedback on the management of suspected RTIs. In patients with acute bronchitis, the intervention reduced the antibiotic prescribing rate from 71.6% to 56% (control group from 61.2% to 52%). In patients with acute otitis media, the intervention reduced the antibiotic prescribing from 94.8% to 86.2% (no change in the control group). In all RTIs, the intervention reduced antibiotic prescribing rate from 37.4% to 28.1% (control group from 29% to 27.2%). Online evidence-based feedback is effective for reducing antibiotic prescribing in patients with RTIs attending primary care in South America.
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Saliba-Gustafsson EA, Borg MA, Rosales-Klintz S, Nyberg A, StålsbyLundborg C. Maltese Antibiotic Stewardship Programme in the Community (MASPIC): protocol of a prospective quasiexperimental social marketing intervention. BMJ Open 2017; 7:e017992. [PMID: 28947463 PMCID: PMC5623537 DOI: 10.1136/bmjopen-2017-017992] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/18/2017] [Accepted: 08/03/2017] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Antibiotic misuse is a key driver of antibiotic resistance. In 2015/2016, Maltese respondents reported the highest proportions of antibiotic consumption in Europe. Since antibiotics are prescription-only medicines in Malta, research on effective strategies targeting general practitioners' (GPs) knowledge and behaviour is needed. Multifaceted behaviour change (BC) interventions are likely to be effective. Social marketing (SM) can provide the tools to promote sustained BC; however, its utilisation in Europe is limited. This paper aims to describe the design and methods of a multifaceted SM intervention aimed at changing Maltese GPs' antibiotic prescribing behaviour for patients with acute respiratory tract infections (aRTIs). METHODS AND ANALYSIS This 4-year quasiexperimental intervention study will be carried out in Malta and includes three phases: preintervention, intervention and postintervention. The preintervention phase intends to gain insight into the practices and attitudes of GPs, pharmacists and parents through interviews, focus group discussions and antibiotic prescribing surveillance. A 6-month intervention targeting GPs will be implemented following assessment of their prescribing intention and readiness for BC. The intervention will likely comprise: prescribing guidelines, patient educational materials, delayed antibiotic prescriptions and GP education. Outcomes will be evaluated in the postintervention phase through questionnaires based on the theory of planned behaviour and stages-of-change theory, as well as postintervention surveillance. The primary outcome will be the antibiotic prescribing rate for all patients with aRTIs. Secondary outcomes will include the proportion of diagnosis-specific antibiotic prescription and symptomatic relief medication prescribed, and the change in GPs stage-of-change and their intention to prescribe antibiotics. ETHICS AND DISSEMINATION The project received ethical approval from the University of Malta's Research Ethics Committee. Should this intervention successfully decrease antibiotic prescribing, it may be scaled up locally and transferred to similar settings. TRIAL REGISTRATION NUMBER NCT03218930; Pre-results.
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Affiliation(s)
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | | | - Anna Nyberg
- Department of Marketing and Strategy, Stockholm School of Economics, Stockholm, Sweden
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Saust LT, Bjerrum L, Arpi M, Hansen MP. Quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections in general practice: a RAND Appropriateness Method. Scand J Prim Health Care 2017; 35:192-200. [PMID: 28574299 PMCID: PMC5499320 DOI: 10.1080/02813432.2017.1333305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To develop quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections, tailored to the Danish general practice setting. DESIGN A RAND/UCLA Appropriateness Method was used. SETTING General practice. SUBJECTS A panel of nine experts, mainly general practitioners, was asked to rate the relevance of 64 quality indicators for the diagnosis and antibiotic treatment of acute respiratory tract infections based on guidelines. Subsequently, a face-to-face meeting was held to resolve misinterpretations and to achieve consensus. MAIN OUTCOME MEASURES The experts were asked to rate the indicators on a nine-point Likert scale. Consensus of appropriateness for a quality indicator was reached if the overall panel median rating was 7-9 with agreement. RESULTS A total of 50 of the 64 proposed quality indicators attained consensus. Consensus was achieved for 12 indicators focusing on the diagnostic process and 19 indicators focusing on the decision about antibiotic treatment and choice of antibiotics, respectively. CONCLUSION These newly developed quality indicators may be used to strengthen Danish general practitioners' focus on their management of patients with acute respiratory tract infections and to identify where there is a need for future quality improvements.
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Affiliation(s)
- Laura Trolle Saust
- Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- CONTACT Laura Trolle Saust Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Magnus Arpi
- Department of Clinical Microbiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Malene Plejdrup Hansen
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Research Unit for General Practice in Aalborg and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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21
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Tyrstrup M, Beckman A, Mölstad S, Engström S, Lannering C, Melander E, Hedin K. Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records. BMC Infect Dis 2016; 16:709. [PMID: 27887585 PMCID: PMC5124268 DOI: 10.1186/s12879-016-2018-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/11/2016] [Indexed: 11/25/2022] Open
Abstract
Background Swedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines. Methods A descriptive study of Sweden’s largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013. Results Although the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0–6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs). Conclusion Falling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2018-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mia Tyrstrup
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.
| | - Anders Beckman
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
| | - Sigvard Mölstad
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden
| | - Sven Engström
- Unit of Research and Development in Primary Care, Jönköping, Sweden
| | | | - Eva Melander
- Department of Infection Control, Malmö, Skåne County, Sweden.,Department of translational medicine, Lund University, Malmö, Sweden
| | - Katarina Hedin
- Department of Clinical Sciences, Family Medicine, Lund University, Malmö, Sweden.,Department of Research and Development, Region Kronoberg, Växjö, Sweden
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Llor C, Moragas A, Cots JM, López-Valcárcel BG. Estimated saving of antibiotics in pharyngitis and lower respiratory tract infections if general practitioners used rapid tests and followed guidelines. Aten Primaria 2016; 49:319-325. [PMID: 27884552 PMCID: PMC6876040 DOI: 10.1016/j.aprim.2016.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/20/2016] [Accepted: 07/20/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction General practitioners (GP) in Spain do not have access to rapid tests and adherence to guidelines is usually suboptimal. The aim of the study is to evaluate the estimated number of antibiotics that could have been saved if GPs had appropriately used these tests and had followed the guidelines. Design Observational study. Setting Primary care centres from eight Autonomous Communities in Spain. Participants GPs who had not participated in previous studies on rational use of antibiotics. Intervention GPs registered all the cases of pharyngitis and lower respiratory tract infections (LRTI) during 15 working days in 2015, by means of a 47-item audit. Main measurements Actual GPs’ antibiotic prescription and estimated number of antibiotics that could have been saved according to recent guidelines. Results A total of 126 GPs registered 1012 episodes of pharyngitis and 1928 LRTIs. Antibiotics were given or patients were referred in 497 patients with pharyngitis (49.1%) and 963 patients with LRTI (49.9%). If GPs had appropriately used rapid antigen detection tests and C-reactive protein tests and had strictly followed current guidelines, antibiotics would have been given to 7.6% and 15.1%, respectively, with an estimated saving of 420 antibiotics in patients with sore throat (estimated saving of 84.5%; 95% CI: 81.1–87.4%) and 672 antibiotics in LRTIs (estimated saving of 69.8%,95% CI: 67.1–72.5%). Conclusions GP adherence to guidelines and a correct introduction of rapid tests in clinical practice in Spain could result in a considerable saving of unnecessary prescription of antibiotics in pharyngitis and LRTIs.
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Affiliation(s)
- Carles Llor
- Primary Care Centre Via Roma, Barcelona, Spain.
| | - Ana Moragas
- University Rovira i Virgili, Primary Care Centre Jaume I, Tarragona, Spain
| | - Josep M Cots
- University of Barcelona, Coordinator of the GdT Enfermedades Infecciosas, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Primary Care Centre La Marina, Barcelona, Spain
| | - Beatriz González López-Valcárcel
- Economist Department of Quantitative Methods for Economics and Management, University of Las Palmas, Las Palmas de Gran Canaria, Spain
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Cordoba G, Caballero L, Sandholdt H, Arteaga F, Olinisky M, Ruschel LF, Makela M, Bjerrum L. Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America. J Antimicrob Chemother 2016; 72:305-310. [PMID: 27624570 DOI: 10.1093/jac/dkw370] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To describe and compare antibiotic prescribing patterns for primary care patients with respiratory tract infections (RTIs) in four South American countries. METHODS This was a prospective observational study. General practitioners (GPs) from Argentina, Bolivia, Paraguay and Uruguay registered data about all consultations of patients with suspected RTIs in the winter of 2014 (June-August). Variation in antibiotic prescriptions was assessed using a two-level hierarchical logistic model. RESULTS Participating GPs (n = 171) registered 11 446 patients with suspected RTI; 3701 (33%) of these received an antibiotic prescription. There was a wide variation across countries in the use and selection of antibiotics. For example, 94% of patients with acute bronchitis were prescribed antibiotics in Bolivia, while in Uruguay only 21% received antibiotics. Amoxicillin was the most commonly prescribed antibiotic across countries, but prescription rates varied between 45% in Bolivia and 69% in Uruguay. Compared with the overall mean prescribing rate, and after adjusting for clinical presentation and demographics, prescribing of antibiotics varied by a factor of 6, the OR ranging from 0.37 (95% CI = 0.21-0.65) in Uruguay to 2.58 (95% CI = 1.66-4) in Bolivia. CONCLUSIONS The large variation in use and selection of antibiotics across countries is not explained by different patient populations. It could be explained by diagnostic uncertainty and contextual characteristics beyond clinical practice. Reducing uncertainty and country variation requires greater support from the healthcare systems by providing GPs with evidence-based guidelines and tools to apply them.
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Affiliation(s)
- Gloria Cordoba
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lidia Caballero
- Dr Pedro Baliña Hospital, Public Health Ministry, Posadas - Misiones, Argentina
| | - Håkon Sandholdt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Fátima Arteaga
- Policlínica Central de la Caja Nacional de Salud, La Paz, Bolivia
| | - Monica Olinisky
- Department of Family and Community Medicine, Faculty of Medicine, University of the Republic, Montevideo, Uruguay
| | | | - Marjukka Makela
- Finnish Office for Health Technology Assessment (FINOHTA) - National Institute for Health and Welfare, Helsinki, Finland
| | - Lars Bjerrum
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Saust LT, Monrad RN, Hansen MP, Arpi M, Bjerrum L. Quality assessment of diagnosis and antibiotic treatment of infectious diseases in primary care: a systematic review of quality indicators. Scand J Prim Health Care 2016; 34:258-66. [PMID: 27450462 PMCID: PMC5036015 DOI: 10.1080/02813432.2016.1207143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 04/07/2016] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To identify existing quality indicators (QIs) for diagnosis and antibiotic treatment of patients with infectious diseases in primary care. DESIGN A systematic literature search was performed in PubMed and EMBASE. We included studies with a description of the development of QIs for diagnosis and antibiotic use in patients with infectious diseases in primary care. We extracted information about (1) type of infection; (2) target for quality assessment; (3) methodology used for developing the QIs; and (4) whether the QIs were developed for a national or international application. The QIs were organised into three categories: (1) QIs focusing on the diagnostic process; (2) QIs focusing on the decision to prescribe antibiotics; and (3) QIs concerning the choice of antibiotics. RESULTS Eleven studies were included in this review and a total of 130 QIs were identified. The majority (72%) of the QIs were focusing on choice of antibiotics, 22% concerned the decision to prescribe antibiotics, and few (6%) concerned the diagnostic process. Most QIs were either related to respiratory tract infections or not related to any type of infection. A consensus method (mainly the Delphi technique), based on either a literature study or national guidelines, was used for the development of QIs in all of the studies. CONCLUSIONS The small number of existing QIs predominantly focuses on the choice of antibiotics and is often drug-specific. There is a remarkable lack of diagnostic QIs. Future development of new QIs, especially disease-specific QIs concerning the diagnostic process, is needed. KEY POINTS In order to improve the use of antibiotics in primary care, measurable instruments, such as quality indicators, are needed to assess the quality of care being provided. A total of 11 studies were found, including 130 quality indicators for diagnosis and antibiotic treatment of infectious diseases in primary care. The majority of the identified quality indicators were focusing on the choice of antibiotics and only a few concerned the diagnostic process. All quality indicators were developed by means of a consensus method and were often based on literature studies or guidelines.
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Affiliation(s)
- Laura Trolle Saust
- Department of Clinical Microbiology, Herlev University Hospital, Herlev, Denmark
- Department of Public Health, Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Nygaard Monrad
- Department of Clinical Microbiology, Herlev University Hospital, Herlev, Denmark
- Department of Public Health, Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Malene Plejdrup Hansen
- Centre for Research in Evidence-Based Practice, Bond University, Robina, Australia
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Magnus Arpi
- Department of Clinical Microbiology, Herlev University Hospital, Herlev, Denmark
| | - Lars Bjerrum
- Department of Public Health, Research Unit for General Practice and Section of General Practice, University of Copenhagen, Copenhagen, Denmark
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Bjerrum S, Bonsu F, Hanson-Nortey NN, Kenu E, Johansen IS, Andersen AB, Bjerrum L, Jarbøl D, Munck A. Tuberculosis screening in patients with HIV: use of audit and feedback to improve quality of care in Ghana. Glob Health Action 2016; 9:32390. [PMID: 27569593 PMCID: PMC5002398 DOI: 10.3402/gha.v9.32390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Tuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce. OBJECTIVES To assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana. DESIGN Healthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations' guidelines for symptom-based tuberculosis screening among PLHIV. RESULTS Twenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09-3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19-4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25-5.86). CONCLUSIONS A simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.
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Affiliation(s)
- Stephanie Bjerrum
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark;
| | - Frank Bonsu
- National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Nii Nortey Hanson-Nortey
- National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Ernest Kenu
- Department of Medicine-Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana
- School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Aase Bengaard Andersen
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Bjerrum
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Jarbøl
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anders Munck
- Department of Public Health, University of Southern Denmark, Odense, Denmark
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Dyar OJ, Beović B, Vlahović-Palčevski V, Verheij T, Pulcini C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti Infect Ther 2016; 14:403-13. [PMID: 26853235 DOI: 10.1586/14787210.2016.1151353] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.
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Affiliation(s)
- Oliver J Dyar
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Bojana Beović
- b Department of Infectious Diseases, University Medical Centre Ljubljana and Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Vera Vlahović-Palčevski
- c Department of Clinical Pharmacology, University Hospital Rijeka and Medical Faculty , University of Rijeka , Rijeka , Croatia
| | - Theo Verheij
- d Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Céline Pulcini
- e EA 4360 APEMAC , Université de Lorraine and Service de maladies infectieuses et tropicales, CHU de Nancy , Nancy , France
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Strykowski DF, Nielsen ABS, Llor C, Siersma V, Bjerrum L. An intervention with access to C-reactive protein rapid test reduces antibiotic overprescribing in acute exacerbations of chronic bronchitis and COPD. Fam Pract 2015; 32:395-400. [PMID: 25902912 DOI: 10.1093/fampra/cmv020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In acute exacerbation of chronic obstructive pulmonary disease (AECOPD) antibiotic overprescribing leads to antimicrobial resistance and underprescribing may cause poor patient outcomes. OBJECTIVE This study aimed to evaluate changes in over- and underprescribing of antibiotics after two interventions to optimize antibiotic prescribing in AECOPD in Spain. METHODS In 2008 and 2009, general practitioners (GPs) registered patients in a 3-week period before and after interventions. Two types of intervention were conducted: GPs in the full-intervention group (FIG) were exposed to a multifaceted intervention and given access to C-reactive protein (CRP) rapid test; partial-intervention group (PIG) was only exposed to the multifaceted intervention. Overprescribing was defined as antibiotic given to type III* exacerbation (≤ one Anthonisen Criteria); underprescribing was defined as no antibiotic given to type I exacerbation (three Anthonisen Criteria). A multivariate logistic regression model was used, considering antibiotic prescribing as the dependent variable. RESULTS A total of 210 GPs and 70 GPs were assigned to FIG and PIG, respectively, and 952 AECOPD patients were eligible for main analysis. After adjusting for clustering at GP level and for patient age and sex, we found that GPs in FIG significantly reduced antibiotic overprescribing; odds ratio (OR) = 0.35 (95% CI: 0.18-0.68, P = 0.003) and underprescribing was not significantly increased; OR = 0.25 (95% CI: 0.06 to 1.0, P = 0.075). No statistically significant changes were found in the PIG. CONCLUSION Antibiotic overprescribing was only reduced when CRP test was available. Simultaneously, underprescribing was not significantly increased, but this could be due to sample size limitations.
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Affiliation(s)
- David F Strykowski
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark and
| | - Anni B S Nielsen
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark and
| | - Carl Llor
- Primary Healthcare Centre Jaume I, University Rovira i Virgili, Tarragona, Spain
| | - Volkert Siersma
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark and
| | - Lars Bjerrum
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark and
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Technology identities explain under- and non-adoption of community-based point-of-care tests in the UK NHS. HEALTH POLICY AND TECHNOLOGY 2015. [DOI: 10.1016/j.hlpt.2014.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bagger K, Nielsen ABS, Siersma V, Bjerrum L. Inappropriate antibiotic prescribing and demand for antibiotics in patients with upper respiratory tract infections is hardly different in female versus male patients as seen in primary care. Eur J Gen Pract 2015; 21:118-23. [PMID: 25712495 DOI: 10.3109/13814788.2014.1001361] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics is a major public health concern. General practitioners (GPs) prescribe most antibiotics, often for upper respiratory tract infections (URTIs), and have in general been shown to prescribe antibiotics more often to women. No studies have examined the influence of patient gender on unnecessary antibiotic prescribing. OBJECTIVES To study a possible gender difference in unnecessary antibiotic prescriptions for URTIs in general practice; to assess whether a possible difference is explained by patient demand for antibiotics. METHODS Post-hoc analysis of a cross-sectional study including 15,022 patients with URTI (acute rhinitis, acute otitis media, acute sinusitis, acute pharyngotonsillitis) from Argentina, Denmark, Lithuania, Russia, Spain and Sweden (HAPPY AUDIT Project). The association between gender and unnecessary antibiotic prescriptions, unadjusted and adjusted for treatment demand, was analysed using logistic regression models. RESULTS A total of 25% of patients with URTI received antibiotics; in 45% of the cases, antibiotics were unnecessary. Overall, no gender difference for unnecessary prescribing of antibiotics for URTIs was found. Women with acute otitis media received an unnecessary antibiotic twice as often as men (14.4% versus 7.1%). In Danish patients with acute pharyngotonsillitis, there was a gender difference in unnecessary prescriptions for antibiotics (women 29.1% versus men 48.6%). Some 14% of patients receiving unnecessary antibiotics demonstrated a demand for antibiotics, but no gender difference was found in this group. CONCLUSION This study indicated a high rate of unnecessary antibiotic prescribing for URTIs in general practice, but overall found no gender differences in receiving unnecessary antibiotic prescriptions.
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Affiliation(s)
- Kathrine Bagger
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen , Denmark
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Cordoba G, Siersma V, Lopez-Valcarcel B, Bjerrum L, Llor C, Aabenhus R, Makela M. Prescribing style and variation in antibiotic prescriptions for sore throat: cross-sectional study across six countries. BMC FAMILY PRACTICE 2015; 16:7. [PMID: 25630870 PMCID: PMC4316394 DOI: 10.1186/s12875-015-0224-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/12/2015] [Indexed: 11/18/2022]
Abstract
Background Variation in prescription of antibiotics in primary care can indicate poor clinical practice that contributes to the increase of resistant strains. General Practitioners (GPs), as a professional group, are expected to have a fairly homogeneous prescribing style. In this paper, we describe variation in prescribing style within and across groups of GPs from six countries. Methods Cross-sectional study with the inclusion of 457 GPs and 6394 sore throat patients. We describe variation in prescribing antibiotics for sore throat patients across six countries and assess whether variation in “prescribing style” – understood as a subjective tendency to prescribe – has an important effect on variation in prescription of antibiotics by using the concept of prescribing style as a latent variable in a multivariable model. We report variation as a Median Odds Ratio (MOR) which is the transformation of the random effect variance onto an odds ratio; Thus, MOR = 1 means similar odds or strict homogeneity between GPs’ prescribing style, while a MOR higher than 1 denotes heterogeneity in prescribing style. Results In all countries some GPs always prescribed antibiotics to all their patients, while other GPs never did. After adjusting for patient and GP characteristics, prescribing style in the group of GPs from Russia was about three times more heterogeneous than the prescribing style in the group of GPs from Denmark – Median Odds Ratio (6.8, 95% CI 3.1;8.8) and (2.6, 95% CI 2.2;4.4) respectively. Conclusion Prescribing style is an important source of variation in prescription of antibiotics within and across countries, even after adjusting for patient and GP characteristics. Interventions aimed at influencing the prescribing style of GPs must encompass context-specific actions at the policy-making level alongside GP-targeted interventions to enable GPs to react more objectively to the external demands that are in place when making the decision of prescribing antibiotics or not.
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Affiliation(s)
- Gloria Cordoba
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Beatriz Lopez-Valcarcel
- Universityof Las Palmas de Gran Canaria, Campus Universitario de Tafira, Las Palmas de GC, CanaryIslands, Spain.
| | - Lars Bjerrum
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Carl Llor
- University Rovira i Virgili, Spanish Society of Family Medicine, Primary Healthcare Centre Jaume I, Tarragona, Spain.
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark.
| | - Marjukka Makela
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, ØsterFarimagsgade 5, P. O. Box 2099, DK-1440, Copenhagen, Denmark. .,Finnish Office for Health Technology Assessment, National Institute for Health and Welfare, Helsinki, Finland.
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Rún Sigurðardóttir N, Nielsen ABS, Munck A, Bjerrum L. Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland. Scand J Prim Health Care 2015; 33:269-74. [PMID: 26683287 PMCID: PMC4750736 DOI: 10.3109/02813432.2015.1114349] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the appropriateness of antibiotic prescribing for upper respiratory tract infections (URTIs) in two countries with different prevalence of antimicrobial resistance: Denmark and Iceland. DESIGN A cross-sectional study. SETTINGS AND SUBJECTS General practitioners (GPs) in Denmark (n = 78) and Iceland (n = 21) registered all patients with URTI according to the Audit Project Odense (APO) method during a three-week period in the winter months of 2008 and 2009. MAIN OUTCOME MEASURES Appropriateness of antibiotic prescribing in patients with URTI in Denmark and Iceland. RESULTS A total of 1428 patients were registered (Denmark: n = 1208; Iceland: n = 220). A majority of patients in both countries were prescribed antibiotics, and only a minority of the prescriptions could be classified as appropriate prescribing. In general, Icelandic GPs more often prescribed antibiotics (Iceland = 75.8% vs. Denmark = 59.3%), but Danish GPs had a higher percentage of inappropriate antibiotic prescribing for sinusitis, and Icelandic GPs for pharyngotonsillitis. No differences were found for acute otitis media (AOM). The different antibiotic prescribing patterns between Denmark and Iceland could not fully be explained by different symptoms and signs among patients. CONCLUSION Icelandic GPs have a higher antibiotic prescribing rate compared with Danish GPs, but the percentage of inappropriate antibiotic prescribing is highest in Denmark for sinusitis, and in Iceland for pharyngotonsillitis. Key points Within the Nordic countries there are marked differences in antimicrobial resistance and antibiotic use. Iceland differs from Denmark by a higher antibiotic prescribing rate and a higher prevalence of antimicrobial resistance. The majority of antibiotics are prescribed in primary care and most often for upper respiratory infections (URTIs). Only a minor amount of antibiotic prescriptions for URTIs can be classified as appropriate; inappropriate antibiotic prescribing is higher in Denmark than in Iceland for sinusitis and the opposite for pharyngotonsillitis. The different antibiotic prescribing patterns between Denmark and Iceland cannot be fully explained by different clinical criteria among patients.
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Affiliation(s)
- Nanna Rún Sigurðardóttir
- Section and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- CONTACT Nanna Rún Sigurðardóttir Section of General Practice, Department of Public Health, Øster Farimagsgade 5, DK-1014 Copenhagen K, Denmark
| | - Anni Brit Sternhagen Nielsen
- Section and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Munck
- Audit Project Odense, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Lars Bjerrum
- Section and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Roque F, Herdeiro MT, Soares S, Teixeira Rodrigues A, Breitenfeld L, Figueiras A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014; 14:1276. [PMID: 25511932 PMCID: PMC4302109 DOI: 10.1186/1471-2458-14-1276] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings. Methods We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011. Results We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively. Conclusion The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Maria Teresa Herdeiro
- Centre for Cell Biology, University of Aveiro (Centro de Biologia Celular - CBC/UA); Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
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Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014; 5:229-41. [PMID: 25436105 DOI: 10.1177/2042098614554919] [Citation(s) in RCA: 893] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.
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Affiliation(s)
- Carl Llor
- School of Medicine, Cardiff University, Department of Primary Care and Public Health, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Malo S, Bjerrum L, Feja C, Lallana MJ, Moliner J, Rabanaque MJ. Compliance with recommendations on outpatient antibiotic prescribing for respiratory tract infections: the case of Spain. Basic Clin Pharmacol Toxicol 2014; 116:337-42. [PMID: 25168517 DOI: 10.1111/bcpt.12316] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 08/25/2014] [Indexed: 11/30/2022]
Abstract
Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This study aimed at describing the current pattern of outpatient antibiotic use in acute RTIs in Spain and evaluating adherence to national recommendations. A retrospective observational study was performed including all the episodes of RTIs registered during a 1-year period in a north-eastern Spanish region. Data related to patient demography, diagnoses and antibiotic prescriptions were collected from the electronic medical history database in the region, and adherence to recommendations for antibiotic prescribing was assessed. One third of patients with a RTI were prescribed an antibiotic, with young adults (aged 15-64 years) being the most treated. High prescribing rates were observed in patients with acute otitis, sinusitis and acute tonsillitis (about 70%), whereas low rates were found in acute bronchitis (50%) and non-specific upper RTIs (24%) episodes. A high prescription of broad-spectrum agents and antibiotics not recommended as first choice was observed. In accordance with Spanish guidelines, there exists a potential over-prescribing of antibiotics for all the diagnoses studied, especially in the adult population. Moreover, the choice of antibiotics is frequently based on agents with a high risk of increasing antimicrobial resistance. Multifaceted strategies should be implemented to improve the quality of antibiotic prescribing in primary care.
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Affiliation(s)
- Sara Malo
- Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Zaragoza, Spain
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Christensen SF, Jørgensen LC, Cordoba G, Llor C, Siersma V, Bjerrum L. Marked differences in GPs' diagnosis of pneumonia between Denmark and Spain: a cross-sectional study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 22:454-8. [PMID: 24248329 PMCID: PMC6442862 DOI: 10.4104/pcrj.2013.00093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: In patients with lower respiratory tract infections (LRTIs) it is a challenge to identify who should be treated with antibiotics. According to international guidelines, antibiotics should be prescribed to patients with suspected pneumonia while acute bronchitis is considered a viral infection and should, generally, not be treated with antibiotics. Overdiagnosis of pneumonia in patients with LRTIs may lead to antibiotic overprescribing. Aims: To investigate the prevalence of presumed pneumonia in patients with LRTI in two countries with different antibiotic prescribing rates (Denmark and Spain) and to compare which symptoms and clinical tests are of most importance for the GP when choosing a diagnosis of pneumonia rather than acute bronchitis. Methods: A cross-sectional study including GPs from Denmark and Spain was conducted as part of the EU-funded project HAPPY AUDIT. A total of 2,698 patients with LRTI were included. Results: In Denmark, 47% of the patients with LRTI were classified with a diagnosis of pneumonia compared with 11% in Spain. In Spain, fever and a positive x-ray weighted significantly more in the diagnosis of pneumonia than in Denmark. Danish GPs, however, attached more importance to dyspnoea/polypnoea and C-reactive protein levels >50mg/L. None of the other typical symptoms of pneumonia had a significant influence. Conclusions: Our results indicate that GPs' diagnostic criteria for pneumonia differ substantially between Denmark and Spain. The high prevalence of pneumonia among Danish patients with LRTI may indicate overdiagnosis of pneumonia which, in turn, may lead to antibiotic overprescribing.
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Affiliation(s)
- Sarah Friis Christensen
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Reducing antibiotic prescribing for children with respiratory tract infections in primary care: a systematic review. Br J Gen Pract 2014; 63:e445-54. [PMID: 23834881 DOI: 10.3399/bjgp13x669167] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) in children are common and often result in antibiotic prescription despite their typically self-limiting course. AIM To assess the effectiveness of primary care based interventions to reduce antibiotic prescribing for children with RTIs. DESIGN AND SETTING Systematic review. METHOD MEDLINE(®), Embase, CINAHL(®), PsycINFO, and the Cochrane library were searched for randomised, cluster randomised, and non-randomised studies testing educational and/or behavioural interventions to change antibiotic prescribing for children (<18 years) with RTIs. Main outcomes included change in proportion of total antibiotic prescribing or change in 'appropriate' prescribing for RTIs. Narrative analysis of included studies was used to identify components of effective interventions. RESULTS Of 6301 references identified through database searching, 17 studies were included. Interventions that combined parent education with clinician behaviour change decreased antibiotic prescribing rates by between 6-21%; structuring the parent-clinician interaction during the consultation may further increase the effectiveness of these interventions. Automatic computerised prescribing prompts increased prescribing appropriateness, while passive information, in the form of waiting room educational materials, yielded no benefit. CONCLUSION Conflicting evidence from the included studies found that interventions directed towards parents and/or clinicians can reduce rates of antibiotic prescribing. The most effective interventions target both parents and clinicians during consultations, provide automatic prescribing prompts, and promote clinician leadership in the intervention design.
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Malo S, Bjerrum L, Feja C, Lallana MJ, Abad JM, Rabanaque-Hernández MJ. The quality of outpatient antimicrobial prescribing: a comparison between two areas of northern and southern Europe. Eur J Clin Pharmacol 2013; 70:347-53. [DOI: 10.1007/s00228-013-1619-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 11/26/2013] [Indexed: 11/24/2022]
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Milos V, Jakobsson U, Westerlund T, Melander E, Mölstad S, Midlöv P. Theory-based interventions to reduce prescription of antibiotics--a randomized controlled trial in Sweden. Fam Pract 2013; 30:634-40. [PMID: 23960104 DOI: 10.1093/fampra/cmt043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Upper respiratory tract infections (URTIs) are the most common reason for consulting a GP and for receiving an antibiotic prescription, although evidence shows poor benefit but rather increasing antibiotic resistance. Interventions addressing physicians have to take into consideration the complexity of prescribing behaviour. OBJECTIVE To study whether interventions based on behavioural theories can reduce the prescribing of antibiotics against URTIs in primary care. Setting and subjects. GPs at 19 public primary health care centres in southern Sweden. METHODS We performed a randomized controlled study using two behavioural theory-based interventions, the persuasive communication intervention (PCI) and the graded task intervention (GTI), which emerged from social cognitive theory and operant learning theory. GPs were randomized to a control group or one of two intervention groups (PCI and GTI). MAIN OUTCOME MEASURES Changes in the rate of prescription of antibiotics against URTIs in primary care patients of all ages and in patients aged 0-6 years. RESULTS No significant differences were seen in the prescription rates before and after the interventions when patients of all ages were analysed together. However, for patients aged 0-6 years, there was a significant lower prescription rate in the PCI group (P = 0.037), but not the GTI group, after intervention. CONCLUSION Theory-based interventions have limited impact on reducing the prescription of antibiotics against URTIs in primary care. Future studies are needed to draw firm conclusions about their effects.
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Affiliation(s)
- Veronica Milos
- Primärvården Skåne, Laröd Health Care Centre, Helsingborg
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Yardley L, Douglas E, Anthierens S, Tonkin-Crine S, O’Reilly G, Stuart B, Geraghty AWA, Arden-Close E, van der Velden AW, Goosens H, Verheij TJM, Butler CC, Francis NA, Little P. Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial. Implement Sci 2013; 8:134. [PMID: 24238118 PMCID: PMC3922910 DOI: 10.1186/1748-5908-8-134] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/12/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes. METHODS GPs were cluster randomised to one of three intervention groups or a control group. The intervention groups received web-based training in either use of the C-reactive protein (CRP) test, communication skills and use of a patient booklet, or training in both. GP attitudes were measured before and after the intervention using constructs from the Theory of Planned Behaviour and a Website Satisfaction Questionnaire. Effects of the interventions on patients were assessed by a post-intervention questionnaire assessing patient enablement, satisfaction with the consultation, and beliefs about the risks and need for antibiotics. RESULTS GPs in all countries and intervention groups had very positive perceptions of the intervention and the web-based training, and felt that taking part had helped them to reduce prescribing. All GPs perceived reducing prescribing as more important and less risky following the intervention, and GPs in the communication groups reported increased confidence to reduce prescribing. Patients in the communication groups who received the booklet reported the highest levels of enablement and satisfaction and had greater awareness that antibiotics could be unnecessary and harmful. CONCLUSIONS Our findings suggest that the interventions should be broadly acceptable to both GPs and patients, as well as feasible to roll out more widely across Europe. There are also some indications that they could help to engender changes in GP and patient attitudes that will be helpful in the longer-term, such as increased awareness of the potential disadvantages of antibiotics and increased confidence to manage LRTI without them. Given the positive effects of the booklet on patient beliefs and attitudes, it seems logical to extend the use of the patient booklet to all patients.
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Affiliation(s)
- Lucy Yardley
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Elaine Douglas
- Department of Epidemiology & Public Health, Health Behaviour Research Centre, UCL, Gower Street, London WC1E 6BT, UK
| | - Sibyl Anthierens
- Department of Primary and Interdisciplinary Care, University of Antwerp, Universiteitsplein 1 Wilrijk, Antwerp BE-2610, Belgium
| | - Sarah Tonkin-Crine
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Gilly O’Reilly
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Beth Stuart
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Adam W A Geraghty
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Emily Arden-Close
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Highfield, Southampton SO17 1BG, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Herman Goosens
- Laboratory of Medical Microbiology, VAXINFECTIO, University of Antwerp, Antwerp, Belgium
| | - Theo JM Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht 3584 CX, The Netherlands
| | - Chris C Butler
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Nick A Francis
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4YS, UK
| | - Paul Little
- Primary Care and Population Sciences Division, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
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Strandberg EL, Brorsson A, Hagstam C, Troein M, Hedin K. "I'm Dr Jekyll and Mr Hyde": are GPs' antibiotic prescribing patterns contextually dependent? A qualitative focus group study. Scand J Prim Health Care 2013; 31:158-65. [PMID: 23941086 PMCID: PMC3750438 DOI: 10.3109/02813432.2013.824156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To explore factors and circumstances contributing to prudent antibiotic prescribing for respiratory tract infections in primary care. DESIGN Two focus groups representing rural and urban areas. A semi-structured interview guide with open-ended questions and an editing analysis style was used. They were examined to identify meaning units that were sorted into categories in an iterative process throughout the analysis. SETTING Primary health care in two counties in southern Sweden. SUBJECTS Two groups including seven and six general practitioners (GPs) respectively, men and women of different ages with different professional experiences. MAIN OUTCOME MEASURES Exploration of categories, determination of themes, construction of models. RESULTS The decision to prescribe antibiotics takes place in the encounter between GP and patient, initially characterized by harmony or fight and the subsequent process by collaboration or negotiation, resulting in agreement, compromise, or disagreement. Several factors influence the meeting and contribute to enhancing the conditions for rational prescribing. These conditions are connected to the GP, the relationship, and the setting; organization as well as professional culture. The findings indicate synergies between the factors, and that one factor can sometimes compensate for lack of another. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. CONCLUSIONS The findings emphasize the importance of the encounter between the GP and the patient for prudent antibiotic prescribing. Furthermore, the importance of an appropriate organization of primary care, which promotes continuity and encourages professional autonomy, is demonstrated.
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Jørgensen LC, Friis Christensen S, Cordoba Currea G, Llor C, Bjerrum L. Antibiotic prescribing in patients with acute rhinosinusitis is not in agreement with European recommendations. Scand J Prim Health Care 2013; 31:101-5. [PMID: 23659709 PMCID: PMC3656392 DOI: 10.3109/02813432.2013.788270] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To assess the potential overprescribing in patients with acute rhinosinusitis across six countries with different antibiotic prescribing rates and different prevalence of antibiotic resistance. DESIGN, SETTING AND SUBJECTS A cross-sectional study including GPs from two Nordic countries, two Baltic countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) during three weeks in January 2008 as part of the EU-funded project "Health Alliance for Prudent Prescribing, Yield And Use of antimicrobial Drugs In the Treatment of respiratory tract infections" (HAPPY AUDIT). MAIN OUTCOME MEASURES Use of antibiotics for acute rhinosinusitis based on the recommendations in the European Position Paper on Rhinosinusitis and Nasal Polyps 2007 (EP3OS). RESULTS In total, 618 participating GPs registered 33 273 patients with RTI of whom 1150 (3.46%) were considered to have acute rhinosinusitis. Over 50% of the patients with acute rhinosinusitis had symptoms for < 5 days and 81% were prescribed antibiotics. In total, 68% of the patients included were not prescribed antibiotics according to guidelines; 45% had symptoms < 5 days or no fever (possible overprescribing) and 23% had symptoms < 5 days and no fever (probable overprescribing). CONCLUSION A considerable number of patients with symptoms of acute rhinosinusitis were not managed according to European recommendations (EP3OS guidelines). To prevent overprescribing, efforts should be made to implement the recommendations in daily practice.
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Affiliation(s)
- Lars Christian Jørgensen
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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Jaruseviciene L, Radzeviciene Jurgute R, Bjerrum L, Jurgutis A, Jarusevicius G, Lazarus JV. Enabling factors for antibiotic prescribing for upper respiratory tract infections: perspectives of Lithuanian and Russian general practitioners. Ups J Med Sci 2013; 118:98-104. [PMID: 23521359 PMCID: PMC3633337 DOI: 10.3109/03009734.2013.778925] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION General practitioners (GPs) write about 80% of all antibiotic prescriptions, the greatest number of them for patients with respiratory tract infections. However, there is a lack of research targeting the influence of external factors on antibiotic prescribing by physicians. This study aimed to explore experiences of GPs in Lithuania and the Russian Federation with regard to antibiotic prescription for upper respiratory tract infections. By such means it might be possible to reveal external enabling factors that influence antibiotic prescribing in these countries. METHOD Five focus groups were performed with 22 GPs from Lithuania and 29 GPs from the Kaliningrad Region of the Russian Federation; then, thematic analysis of data was performed. RESULTS Six thematic categories were identified that are related to external forces enabling antibiotic prescription: the necessity for political leadership to encourage clinically grounded antibiotic use; over-the-counter sale of antibiotics; designation of antibiotics as reimbursable medications; supervision by external oversight institutions; lack of guidelines for the treatment of upper respiratory tract infections; and pharmaceutical company activities. CONCLUSIONS Comprehensive efforts to reduce the burden of non-clinically grounded antibiotic prescription should go beyond addressing factors at the physician-patient level and take into account important factors in the enabling environment as well.
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Affiliation(s)
- Lina Jaruseviciene
- Department of Family Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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Sistanizad M, Kouchek M, Miri M, Goharani R, Solouki M, Ayazkhoo L, Foroumand M, Mokhtari M. Carbapenem Restriction and its Effect on Bacterial Resistance in an Intensive Care unit of a Teaching Hospital. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2013; 12:503-9. [PMID: 24250656 PMCID: PMC3813286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
UNLABELLED Development of antibiotic resistance in Intensive Care Units (ICUs) is a worldwide problem. The purpose of this study was to evaluate the effect of an antibiotic stewardship program (ASP) by carbapenems restriction on gram-negative antimicrobial resistance in ICU. The study was designed in a 21 bedded general ICU of a teaching hospital with two wings (one and two) in Tehran, Iran. Carbapenem prescription in ICU1 was restricted to only the culture proven multi-drug-resistant bacteria with the absence of sensitivity to other antimicrobial agents. Carbapenem had to be prescribed by a trained ICU physician with close consultation with infectious disease specialist and the clinical pharmacist posted in ICU. Post-prescription reviews and de-escalations were carried out by the same team on regular basis. Restriction policy was commenced in January 2011 in ICU1. All documented infections and resistance patterns of isolated pathogens were recorded in both ICUs during two periods of 6 months before and 9 months after restriction policy implementation. During this study bacterial growth was detected in 51.5% of 1601 samples. Carbapenem administration was decreased from 6.86 to 2.75 DDD/100 patients day (60% decreases) pre-restriction and post-restriction respectively. Significant increase in sensitivity of pseudomonas to imipenem was observed in ICU1 comparing with pre-restriction period six months post restriction (p = 0.000). Sensitivity of Klebsiella and Acinetobacter to imipenem did not change significantly during the study period. CONCLUSION Our study demonstrated that restriction of carbapenems can increase sensitivity of P. aeroginosa to imipenem.
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Affiliation(s)
- Mohammad Sistanizad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mehran Kouchek
- Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohammad Miri
- Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Reza Goharani
- Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mehrdad Solouki
- Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ladan Ayazkhoo
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Masoumeh Foroumand
- Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Majid Mokhtari
- Department of Critical Care, Imam Hussein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: E-mail:
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Altiner A, Berner R, Diener A, Feldmeier G, Köchling A, Löffler C, Schröder H, Siegel A, Wollny A, Kern WV. Converting habits of antibiotic prescribing for respiratory tract infections in German primary care--the cluster-randomized controlled CHANGE-2 trial. BMC FAMILY PRACTICE 2012; 13:124. [PMID: 23256712 PMCID: PMC3548682 DOI: 10.1186/1471-2296-13-124] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/14/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND With an average prescription rate of 50%, in German primary care antibiotics are still too frequently prescribed for respiratory tract infections. The over-prescription of antibiotics is often explained by perceived patient pressure and fears of a complicated disease progression. The CHANGE-2 trial will test the effectiveness of two interventions to reduce the rate of inappropriate antibiotic prescriptions for adults and children suffering from respiratory tract infections in German primary care. METHODS/DESIGN The study is a three-arm cluster-randomized controlled trial that measures antibiotic prescription rates over three successive winter periods and reverts to administrative data of the German statutory health insurance company AOK. More than 30,000 patients in two regions of Germany, who visit their general practitioner or pediatrician for respiratory tract infections will be included. Interventions are: A) communication training for general practitioners and pediatricians and B) intervention A plus point-of-care testing. Both interventions are tested against usual care. Outcome measure is the physicians' antibiotic prescription rate for respiratory tract infections derived from data of the health insurance company AOK. Secondary outcomes include reconsultation rate, complications, and hospital admissions. DISCUSSION Major aim of the study is to improve the process of decision-making and to ensure that patients who are likely to benefit from antibiotics are treated accordingly. Our approach is simple to implement and might be used rapidly among general practitioners and pediatricians. We expect the results of this trial to have major impact on antibiotic prescription strategies and practices in Germany, both among general practitioners and pediatricians. TRIAL REGISTRATION The study is registered at the Current Controlled Trials Ltd (ISRCTN01559032).
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Affiliation(s)
- Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
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Llor C, Bjerrum L, Arranz J, García G, Cots JM, González López-Valcárcel B, Monedero MJ, Gómez M, Ortega J, Guerra G, Cid M, Paredes J, Pineda V, Pérez C, Alcántara JDD, Hernández S. C-reactive protein testing in patients with acute rhinosinusitis leads to a reduction in antibiotic use. Fam Pract 2012; 29:653-8. [PMID: 22447979 DOI: 10.1093/fampra/cms026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate the effect of C-reactive protein (CRP) testing on the antibiotic prescribing in patients with acute rhinosinusitis. METHODS Audit-based study carried out in primary care centres in Spain. GPs registered episodes of rhinosinusitis during 3-week period before and after an intervention. Two types of intervention were considered: full intervention group (FIG) consisting in individual feedback based on results from the first registry, courses in rational antibiotic prescribing, guidelines, patient information leaflets, workshops on rapid tests and use of the CRP test. GPs in the partial intervention group (PIG) underwent all the above intervention except for the workshop and they did not have access to CRP. Multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable. RESULTS Two hundred and ten physicians were assigned to FIG and 71 to PIG. In 2009, 59 new physicians were included as a control group. Two hundred and sixty-seven GPs visited contacts with rhinosinusitis (78.5%) registering a total of 836 cases. In the group of GPs with access to CRP rapid test, 207 patients with rhinosinusitis (75.3%) were tested and antibiotics were prescribed in 156 patients (56.7%). Antibiotics were prescribed in 87 patients (82.9%) in the group of GPs exposed to PIG and in 52 patients (86.7%) in the control group (P < 0.001). Antibiotic prescription was significantly reduced after the intervention among physicians assigned to FIG, with an odds ratio of antibiotic prescribing of 0.12 (95% confidence interval: 0.01-0.32). CONCLUSION Physicians with access to CRP tests significantly reduced antibiotic prescription in patients with rhinosinusitis.
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Affiliation(s)
- Carl Llor
- Primary Healthcare Centre Jaume I, University Rovira i Virgili, Tarragona, Spain.
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Hansen MP, Bjerrum L, Gahrn-Hansen B, Christensen RDP, Davidsen JR, Munck A, Jarbol DE. Quality indicators for treatment of respiratory tract infections? An assessment by Danish general practitioners. Eur J Gen Pract 2012; 19:85-91. [DOI: 10.3109/13814788.2012.730515] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Campos J. [Antibiotic use in the community--the prevalence as a starting point]. Enferm Infecc Microbiol Clin 2012; 30:589-90. [PMID: 22955003 DOI: 10.1016/j.eimc.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 10/27/2022]
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Hansen MP, Jarbol DE, Gahrn-Hansen B, Depont Christensen R, Munck A, Ellegaard Trankjær Ryborg C, Bjerrum L. Treatment of acute otitis media in general practice: quality variations across countries. Fam Pract 2012; 29:63-8. [PMID: 21817089 DOI: 10.1093/fampra/cmr042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recommendations for antibiotic treatment of acute otitis media (AOM) have changed over the years, and today many experts recommend initial observation. However, antibiotic prescribing should be considered in children aged <2 years or if AOM is accompanied by discharging ear. OBJECTIVES To investigate the quality of treatment of AOM in general practice and to explore the influence of selected GP and patient characteristics on antibiotic prescribing. METHODS During the winter 2008, a prospective registration of patients diagnosed with AOM was conducted in general practice in Lithuania, Kaliningrad, Spain, Argentina, Sweden and Denmark. Some 1175 patients diagnosed with AOM were registered. Information about age and sex of the patient, duration of symptoms (days), temperature >38.5°C, ear discharge and the antibiotic treatment given was recorded. RESULTS Danish GPs had the lowest antibiotic prescription rate for AOM [72.7% (95% confidence interval (CI) = 67.0-77.8)] and GPs in Kaliningrad had the highest [97.1% (95% CI = 89.8-99.6)]. Narrow-spectrum penicillin was almost exclusively prescribed in the two Nordic countries, while broad-spectrum penicillins, often in combination with clavulanic acid, were prescribed in the other four countries. Macrolides comprised 5-10% of prescriptions. Antibiotic prescribing was associated with the following characteristics of the patients: symptoms for >3 days, ear discharge and fever. CONCLUSION The majority of patients with AOM were treated with antibiotics in all six countries, but considerable variations in both prescribing rate and choice of antibiotics were identified.
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Affiliation(s)
- Malene Plejdrup Hansen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark.
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