Antibiotics prescription and guidelines adherence in elderly: impact of the comorbidities

Management of Urinary Tract Infection Symptoms in Older Women: A Survey of Practitioners

IMPORTANCE

Urinary tract infection (UTI) is the most common bacterial infection for which empiric antibiotics are prescribed despite limited progression to urosepsis. More than half of antibiotics prescribed to older adults for a suspected UTI are considered unnecessary.

OBJECTIVE

The aim of the study was to assess knowledge, attitudes, and practices regarding management of older women (>65 years) with symptoms attributed to UTIs among family and internal medicine providers.

STUDY DESIGN

This cross-sectional study surveyed 330 primary care providers in November 2021 regarding management of UTI symptoms. The primary outcome was the proportion of primary care providers who felt safe waiting for urine culture results before prescribing antibiotics in older women.

RESULTS

The response rate was 43.0% (n = 142) with the majority of primary care providers practicing medicine more than 15 years (56.3%). For the primary outcome, 26.1% (n = 37) of primary care providers felt safe waiting for a urine culture result before prescribing antibiotics, while 62.0% (n = 88) felt delaying antibiotics depended on multiple factors, and 9.2% (n = 13) felt it was never safe to delay antibiotics. Primary care providers that either never felt it was safe to delay antibiotics or felt that "it depends" on a variety of factors, attributed their antibiotics administration to concern for progression to sepsis (n = 50, 49.5%) or progression of symptoms (n = 28, 27.7%). A higher proportion of primary care providers practicing more than 15 years felt safe delaying antibiotics compared with primary care providers with less experience (33.8% vs 18.3%, P = 0.04), and 70.3% of those who felt safe delaying antibiotics had more than 15 years of experience.

CONCLUSION

Primary care providers with more clinical experience have more comfort delaying antibiotics in older women with UTI symptoms.

Patterns of antibiotic administration in patients with burn injuries: A TriNetX study

BACKGROUND

In the advent of increasing antibiotic resistance, several studies sought to determine antibiotic prescription trends; however, no pattern has been firmly identified particularly for the burned population. We performed a query of burned patients in a large established database to understand differences in antibiotic use related to patient-specific factors.

METHODS

Burned patients with systemic antibiotics given within 7 days of injury were identified on the TriNetX database. The patient population was stratified by age, 1-year time intervals of antibiotic prescription from 2004 to 2019, time of antibiotic prescription in 1-day intervals after injury, and % TBSA burned in 10% intervals ranging from < 10% to > 90%. Data were analyzed using χ2 with p < 0.05 considered significant. Pearson coefficients (r2) values were used to correlate differences in antibiotic prescription between age groups and to changes over time.

RESULTS

Stratification by age revealed higher use of antibiotics in older burned patients compared to younger patients. Surprisingly, 87.6% of burn patients of those who received antibiotic therapy was on the day of injury. Penicillins and beta-lactam antimicrobials were used most often at a frequency of 64%. No statistically significant differences in rates of antibiotic therapy were observed in burned patients when stratified by %TBSA burned.

CONCLUSIONS

The study elucidates current patterns of antibiotic use in burn care in the United States, allowing for improved understanding of both past and present patterns of antibiotic prescription.

The impact of antibiotic stewardship interventions and patient related factors on antibiotic prescribing in a vascular surgical department

PURPOSE

The development of guidelines tailored to the departments' needs and counselling during ward rounds are important antibiotic stewardship (AS) strategies. The aim was to analyse the impact of AS ward rounds and institutional guidelines as well as patient-related factors on antibiotic use in vascular surgical patients.

METHODS

A retrospective prescribing-analysis of 3 months (P1, P2) before and after implementing weekly AS ward rounds and antimicrobial treatment guidelines was performed. Choice of systemic antibiotics, days of antibiotic therapy and clinical data were obtained from electronic patient records.

RESULTS

During P2, the overall antibiotic consumption as well as the use of last-resort compounds like linezolid and fluoroquinolones decreased distinctly (overall: 47.0 days of therapy (DOT)/100 patient days (PD) vs. 35.3 DOT/100PD, linezolid: 3.7 DOT/100PD vs. 1.0 DOT/100PD, fluoroquinolones: 7.0 DOT/100PD vs. 3.2 DOT/100PD) while narrow-spectrum beta-lactams increased by 48.4%. Courses of antibiotics were de-escalated more often during P2 (30.5% vs. 12.1%, p = 0.011). Only in P2, an antibiotic therapy was initiated in patients suffering from more comorbidities (i.e. higher Charlson Comorbidity Index) more frequently. Other patient factors had no distinct impact on antibiotic prescribing.

CONCLUSION

Weekly AS ward rounds improved adherence to institutional antibiotic treatment guidelines and antibiotic prescribing in vascular surgical patients. Clear patient-related determinants affecting choice of antibiotic therapies could not be identified.

Antibiotic Misuse Behaviours of Older People: Confirmation of the Factor Structure of the Antibiotic Use Questionnaire

Antibacterial resistance (AR) is responsible for steadily rising numbers of untreatable bacterial infections, most prevalently found in the older adult (OA) population due to age-related physical and cognitive deterioration, more frequent and long-lasting hospital visits, and reduced immunity. There are currently no established measures of antibiotic use behaviours for older adults, and theory-informed approaches to identifying the drivers of antibiotic use in older adults are lacking in the literature. The objective of this study was to identify predictors of antibiotic use and misuse in older adults using the Antibiotic Use Questionnaire (AUQ), a measure informed by the factors of the Theory of Planned Behaviour (TPB): attitudes and beliefs, social norms, perceived behavioural control, behaviour, and a covariate-knowledge. A measure of social desirability was included, and participants scoring highly were excluded to control for social desirability bias. Confirmatory Factor Analyses and regression analyses were conducted to test the hypotheses in a cross-sectional, anonymous survey. A total of 211 participants completed the survey, 47 of which were excluded due to incompletion and high social desirability scores (≥5). Results of the factor analysis confirmed that some (but not all) factors from previous research in the general population were confirmed in the OA sample. No factors were found to be significant predictors of antibiotic use behaviour. Several suggestions for the variance in results from that of the first study are suggested, including challenges with meeting requirement for statistical power. The paper concludes that further research is required to determine the validity of the AUQ in an older adult population.

Characteristics of dentists and patients associated with appropriate antibiotic prescriptions by French dentists: a cross-sectional study using Health Insurance databases

BACKGROUND

The use of antibiotics in dental care is often unnecessary or inappropriate. Our objectives were to identify (i) Clusters of dentists grouped according to their appropriateness score based on proxy indicators' results; and (ii) Dentists' and patients' characteristics associated with the appropriateness of antibiotic prescriptions.

METHODS

We used data of the Health Insurance reimbursement databases on antibiotics prescribed in 2019 by general dental practitioners of the Grand Est region in France. The appropriateness of antibiotic prescriptions was estimated by the results of recently published proxy indicators. We conducted a cluster analysis according to an appropriateness score calculated for each dentist, using the Ward method. We then conducted bivariate and multivariable analyses to identify characteristics associated with these clusters.

RESULTS

We included 3,014 dentists, who prescribed 373,975 antibiotics in 2019, and which were grouped into three clusters: average practices (n = 1,241), better (n = 686), and worse (n = 1,087) than average practices. Overall, dentists had more appropriate prescription practices when they were male (OR for belonging to cluster with "worse than average practices" = 1.37 (p = 0.003) for female), having a predominant surgery practice (p = 0.028) in the Lorraine area (p < 0.0001) for less years (p = 0.0002), when they had healthier patients (i.e., younger, with no chronic diseases, and who received less procedures), and when they had a more prudent use of drugs in general (i.e., less prescriptions of drugs, antibiotics, and non-steroidal anti-inflammatory).

CONCLUSIONS

We identified clusters and characteristics associated with the appropriateness of antibiotic prescriptions made by dentists, which might help guiding antimicrobial stewardship interventions.

Antibacterial-associated acute kidney injury among older adults: A post-marketing surveillance study using the FDA adverse events reporting system

PURPOSE

Antibacterials induce a differential risk of acute kidney injury (AKI) in older adults. This study investigated the reporting risk of AKI associated with antibacterials using the individual case safety reports (ICSRs) submitted to the Food and Drug Administration Adverse Event Reporting System (FAERS) database.

METHODS

A case/non-case method was used to assess AKI risk associated with antibacterials between 1 January 2000 and 30 September 2021. Cases were ICSRs for antibacterials with AKI as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'Renal and urinary disorders' disorders. The analyses were completed on a de-duplicated data set containing only the recent version of the ICSR. Signals were defined by a lower 95% confidence interval (CI) of reporting odds ratio (ROR) ≥ 2, proportional reporting ratio (PRR) ≥ 2, information component (IC) > 0, Empirical Bayes Geometric Mean (EBGM) > 1 and reports ≥4. Sensitivity analyses were conducted a priori to assess the robustness of signals.

RESULTS

A total of 3 680 621 reports on ADEs were retrieved from FAERS over the study period, of which 92 194 were antibacterial reports. Gentamicin, sulfamethoxazole, trimethoprim and vancomycin consistently gave strong signals of disproportionality on all four disproportionality measures and across the different sensitivity analyses: gentamicin (ROR = 2.95[2.51-3.46]), sulfamethoxazole (ROR = 2.97[2.68-3.29]), trimethoprim (ROR = 2.81[2.29-3.46]) and vancomycin (ROR = 3.35[3.08-3.64]).

CONCLUSION

Signals for gentamicin, sulfamethoxazole, trimethoprim and vancomycin were confirmed by using antibacterials as a comparator, adjusting for drug-related competition bias and event-related competition bias.

An innovative telemedical network to improve infectious disease management in critically ill patients and outpatients: a stepped-wedge, cluster randomized controlled trial (TELnet@NRW)

BACKGROUND

Evidence-based infectious disease and intensive care management is more relevant than ever. Medical expertise in the two disciplines is often geographically limited to university institutions. In addition, the interconnection between inpatient and outpatient care is often insufficient (e.g., no shared electronic health record, no digital transfer of patient findings).

OBJECTIVE

To establish and evaluate a telemedical inpatient-outpatient network based on expert teleconsultations to increase treatment quality in intensive care medicine and infectious diseases.

METHODS

We performed a multicentre, stepped-wedge cluster randomised trial (Feb 2017 - Jan 2020) to establish a telemedicine inpatient-outpatient network among university hospitals, hospitals, and outpatient physicians in North Rhine Westphalia, Germany. Patients ≥ 18 years of age in the intensive care unit (ICU) or consulting with a physician in the outpatient setting were eligible. We provided expert knowledge from intensivists and infectious disease specialists through advanced training courses and expert teleconsultations with 24/7/365 availability on demand resp. once per week to enhance treatment quality. The primary outcome was adherence to the ten Choosing Wisely® recommendations for infectious disease management. Guideline adherence was analysed using binary logistic regression models.

RESULTS

Overall, 159,424 patients (10,585 inpatients, 148,839 outpatients) from 17 hospitals and 103 outpatient physicians were included. There was a significant increase in guideline adherence in the management of Staphylococcus aureus infections (OR 4.00 [95% CI 1.83, 9.20], P<.01) and in sepsis management in critically ill patients (OR 6.82 [95% CI 1.27, 56.61], P=.04). There was a statistically non-significant decrease in sepsis related mortality from 28.8% (19/66) in the control group to 23.8% (50/210) in the intervention group. Furthermore, the extension of treatment with prophylactic antibiotics after surgery was significantly less likely (OR 9.37 [95% CI 1.52, 111.47], P=.04). Patients treated by outpatient physicians, who were regularly taking part in expert teleconsultations, were also more likely to be treated according to guideline recommendations regarding antibiotic therapy for uncomplicated upper respiratory tract infections (OR 1.34 [95% CI 1.16, 1.56], P<.01) and asymptomatic bacteriuria (OR 9.31 [95% CI 3.79, 25.94], P<.01). For the other recommendations, we found no significant effects, or we had too few observations to generate models. Key limitations of our study include selection effects due to the applied on-site triage of patients as well as the limited possibilities to control for secular effects.

CONCLUSIONS

Telemedicine facilitates a direct round-the-clock interaction over broad distances between intensivists or infectious disease experts and physicians who care for patients in hospitals without ready access to these experts. Expert teleconsultations increase guideline adherence and treatment quality in infectious disease and intensive care management creating added value for critically ill patients.

CLINICALTRIAL

ClinicalTrials.gov, NCT03137589, https://clinicaltrials.gov/ct2/show/NCT03137589.

Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness

METHODS

A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression.

RESULTS

A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents days (DRD) in the preintervention period to 22.8 in the intervention period (- 63.8%), with a significant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness.

CONCLUSIONS

Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.

Therapeutic Drug Monitoring of Antibiotics in the Elderly: A Narrative Review

PURPOSE

Antibiotic dosing adaptation in elderly patients is frequently complicated by age-related changes affecting the processes of drug absorption, distribution, metabolism, and/or elimination. These events eventually result in treatment failure and/or development of drug-related toxicity. Therapeutic drug monitoring (TDM) can prevent suboptimal antibiotic exposure in adult patients regardless of age. However, little data are available concerning the specific role of TDM in the elderly.

METHODS

This review is based on a PubMed search of the literature published in the English language. The search involved TDM studies of antibiotics in the elderly performed between 1990 and 2021. Additional studies were identified from the reference lists of the retrieved articles. Studies dealing with population pharmacokinetic modeling were not considered.

RESULTS

Only a few studies, mainly retrospective and with observational design, have specifically dealt with appropriate antibiotic dosing in the elderly based on TDM. Nevertheless, some clinical situations in which the selection of optimal antibiotic dosing in the elderly was successfully guided by TDM were identified.

CONCLUSIONS

Elderly patients are at an increased risk of bacterial infections and inadequate drug dosing compared to younger patients. Therefore, the availability of TDM services can improve the appropriateness of antibiotic prescriptions in this population.

The appropriateness of ceftriaxone utilization in government hospitals of Eastern Ethiopia: A retrospective evaluation of clinical practice

Introduction:

Drug use evaluation is a method of obtaining information to identify problems related to drug use and if properly developed, a means of correcting the problems. Ceftriaxone is among the most commonly utilized cephalosporins. Owing to a broad spectrum of activity and being used empirically, ceftriaxone has been used inappropriately posing a risk for development of antimicrobial resistance. This study is, therefore, designed to evaluate the appropriateness of ceftriaxone utilization in government hospitals in Harar town.

Methods:

A retrospective cross-sectional study was conducted in four government hospitals of Harar town by reviewing the medical records of 271 patients who received ceftriaxone from 1 January to 31 December 2016. Systematic random sampling was utilized to capture the medical records. Data were entered and analyzed using SPSS version 22.

Results:

From the 271 medical records reviewed majority of patients were from surgical ward (n = 85, 31.4%) followed by gynecology and obstetrics ward (n = 67, 24.7%). Demographically, the majority of the patients were female (n = 142, 52.4%). Patients in the age group of 20–29 years were dominant (n = 98, 36.2%). A total of 71 drugs were co-administered with ceftriaxone, the most common being metronidazole followed by tramadol. Among the co-administered drugs, unfractionated heparin (n = 6), warfarin (n = 5), and enoxaparin (n = 1) were found to have a moderate drug interaction with ceftriaxone. Ceftriaxone was commonly used for post-operative prophylaxis (n = 80, 27.5%) followed by for the management of pneumonia (n = 62, 21.3%). The result of ceftriaxone use evaluation showed that majority (n = 190, 70.1%) were found to be inappropriate. The inappropriate utilization was primarily due to wrong indication (indications for which ceftriaxone was not the primary option) (n = 114, 60.0%) followed by wrong duration (n = 54, 28.4%).

Conclusion:

Ceftriaxone was used inappropriately in more than two-thirds of the patients, with wrong indication and wrong duration contributing the majority. Inappropriate use of antibiotics may potentially lead to the emergence and spread of drug-resistant microorganisms and also ultimately exposes the patient to treatment failure, prolonged hospital stay, and higher cost of therapy.

Pharmacist-driven antimicrobial stewardship program in a long-term care facility by assessment of appropriateness

Antimicrobials are the most frequently prescribed drugs in long-term care facilities (LTCF). Antibiotic stewardship programs (ASP) are coordinated interventions promoting the responsible use of antibiotics to improve patient outcomes and reduce antibiotic resistant bacterias. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a LTCF, to characterise antibiotic therapy and assess the appropriateness of antibiotic prescriptions. A prospective quasi-experimental study to implement an ASP in a LTCF. Antibiotic prescriptions for suspected infections initiated in any setting for LTCF residents were included. We assessed appropriateness and prospective audits and feedback of each inappropriate antimicrobial prescription were carried out. Associations of variables with appropriate antibiotic prescribing were estimated using logistic regression. A total of 416 antibiotic prescriptions were included. The mean consumption of antibiotics was reduced from 63.2 defined daily doses per 1000 residents-days (DRD) in the preintervention period to 22.8 in the intervention period (- 63.8%), with a signifcant drop in fluoroquinolones (81.4%). Overall, 46.6% of antibiotic prescriptions were judged inappropriate, mainly because of a use not recommended in treatment guidelines (63.2%). Multivariable analysis showed that empirical therapy, some classes of antibiotics (cephalosporins, fluoroquinolones, fosfomycin calcium, macrolides) and prescription initiation in the emergency department were independent predictors of antimicrobial inappropriateness. Pharmacist-led ASP in a LTCF has being effective in reducing consumption of antibiotics by improving appropriateness of treatment decisions. However, ASP should include interventions in the emergency department because of the high inappropriate use in this setting.

Influence of Physician Sex and Gender on Prescribing Practices Among Older Adults

Although prescribing is the most common intervention provided by physicians, limited research has examined the role of physician sex and gender on prescribing practices. In this article, we briefly summarize research relating to differences in prescribing behaviors based on physician sex and gender. To identify articles, PubMed was searched for studies from the last 20 years reporting on prescribing differences by physician sex or gender for the general population and specifically for older adults. We describe major themes emerging from the studies, illustrate findings from key studies, and note the major gaps in the literature, notably the lack of evidence on prescribing for older adults. Given the paucity of research in this area, we also explore evidence on the impact of physician sex and gender on other aspects of healthcare delivery, such as communication within the patient-physician relationship, and consider how these findings may also apply to prescribing behaviors. In general, we note that female physicians have been observed to engage in more careful and conservative healthcare provision including prescribing. A careful and conservative approach to prescribing may reduce the incidence of adverse drug events in older adults and be linked to a more patient-centered approach to care. To what extent these differences in prescribing are important for patient health outcomes is unknown, and further research is required to identify optimal prescribing practices that minimize harms.