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Boaitey KP, Hoffmann T, Baillie E, Bakhit M. Exploring general practitioners' perception of the value of natural history information and their awareness and use of guidelines' resources to support antibiotic prescribing for self-limiting infections: a qualitative study in Australian general practice. Aust J Prim Health 2023; 29:558-565. [PMID: 37258410 DOI: 10.1071/py22258] [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: 11/15/2022] [Accepted: 05/08/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The newest version of the Therapeutic Guidelines' antibiotic chapter introduced patient- and clinician-facing resources to support decision-making about antibiotic use for self-limiting infections. It is unclear whether general practitioners (GPs) are aware of and use these resources, including the natural history information they contain. We explored GPs' perceptions of the value and their use of natural history information, and their use of the Therapeutic Guidelines' resources (summary table, discussion boxes, decision aids) to support antibiotic decision-making. METHODS Semi-structured interviews with 21 Australian GPs were conducted. Interviews were recorded, transcribed and thematically analysed by two independent researchers. RESULTS Four themes emerged: (1) GPs perceive natural history information as valuable in consultations for self-limiting conditions and use it for a range of purposes, but desire specific information for infectious and non-infectious conditions; (2) GPs' reasons for using patient-facing resources were manifold, including managing patients' expectations for antibiotics, legitimising the decision not to provide antibiotics and as a prescription substitute; (3) the guidelines are a useful and important educational resource, but typically not consulted at the time of deciding whether to prescribe antibiotics; and (4) experience and attitude towards shared decision-making and looking up information during consultations influenced whether GPs involved patients in decision-making and used a decision aid. CONCLUSIONS GPs perceived natural history information to be valuable in discussions about antibiotic use for self-limiting conditions. Patient and clinician resources were generally perceived as useful, although reasons for use varied, and a few barriers to use were reported.
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Affiliation(s)
- Kwame Peprah Boaitey
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Qld 4229, Australia
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Qld 4229, Australia
| | - Emma Baillie
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Qld 4229, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Qld 4229, Australia
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Bloomfield M, Todd S, van der Werff K, Blackmore T, Balm M. Post-report antibiotic initiation following community non-sterile-site microbiology results: an opportunity for labs to lead stewardship? J Antimicrob Chemother 2023; 78:2715-2722. [PMID: 37712940 DOI: 10.1093/jac/dkad288] [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: 05/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES Positive culture results from non-sterile sites (NSSs) are poorly predictive of clinical infection. Despite this, these results are often interpreted as an indication for antibiotics, even in patients with limited signs of infection. We sought to quantify the influence of NSS culture results on post-report antibiotic initiation (PRAI) in patients who had not been started on antibiotics pre-report. METHODS All community wound/skin swab and sputum cultures were matched to antibiotic dispensing records from February 2017 to July 2022. Prescribing behaviour was assessed pre- and post-report. Sampling without treatment pre-report was termed 'test-and-wait' (TaW). Following TaW, PRAI was identified if antibiotics were started within 5 days post-report. RESULTS There were 65 480 wound/skin swabs and 8126 sputum samples, with TaW occurring in 21 740 (35.1%) and 4185 (54.4%), respectively. Following a TaW approach PRAI occurred in 43.3% when an organism was reported, versus 10.8% (P < 0.01) for a 'no growth' report for wound/skin swabs. For the same comparison with sputum, PRAI occurred in 47.9% versus 10.8% (P < 0.01). On multivariate analysis reporting an organism remained strongly associated with PRAI. CONCLUSIONS Reporting an organism in those not already on antibiotics was strongly associated with PRAI. We hypothesize that for many patients TaW suggests limited evidence of infection (i.e. insufficient to justify antibiotic treatment at time of sampling), meaning positive NSS results may be driving a considerable volume of potentially unnecessary antibiotic use. Further study on this topic is required, but strategies to reduce PRAI may offer laboratories an opportunity to meaningfully impact antimicrobial stewardship efforts.
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Affiliation(s)
- Max Bloomfield
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
| | - Sue Todd
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
- Ora Toa Cannons Creek General Practice, Porirua, New Zealand
| | - Koen van der Werff
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
| | - Tim Blackmore
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Michelle Balm
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
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Cai T, Verze P, Arcaniolo D, Pandolfo SD, Smarrazzo F, Manfredi C, Tascini C, Caciagli P, Lanzafame M, De Sio M, Wagenlehner F, Johansen TEB, Palmieri A. Antibiotic Resistance Patterns Among Uropathogens in Female Outpatients Affected by Uncomplicated Cystitis: Focus on Fosfomycin Trometamol. Int J Antimicrob Agents 2023; 62:106974. [PMID: 37739241 DOI: 10.1016/j.ijantimicag.2023.106974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/30/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVES To report the resistance rate against fosfomycin trometamol among outpatient women with symptoms related to urinary tract infections over a 6-year period in a multicentre, cross-sectional study. METHODS Urinary samples were collected from three high-volume laboratories from January 2015 to December 2020. The pattern of resistance to fosfomycin was analysed by using the Vitek II automated system. RESULTS A total of 7289 urinary samples were collected and 8321 strains were analysed during the study period. The most commonly isolated uropathogen was Escherichia coli (n = 6583, 79.1%). The mean resistance rate against fosfomycin was 9.7% (range 7.1-11.3). No statistically significant difference was found between the three laboratories (P = 0.53). There was no significant increase in resistance rate during the study period. The mean resistance rate against fosfomycin was higher among extended-spectrum β-lactamase (ESBL)-producing bacteria when compared with non-ESBL-producing strains (10.8% vs. 7.9%; P < 0.001). CONCLUSION Uropathogens isolated from women affected by cystitis remained highly susceptible to fosfomycin. These findings confirm recommendations in international guidelines that advocate fosfomycin trometamol for empirical treatment of uncomplicated cystitis in women.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, Trento, Italy; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Paolo Verze
- Department of Medicine, Surgery, Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Davide Arcaniolo
- Department of Urology, University of Naples, Vanvitelli, Naples, Italy
| | - Savio Domenico Pandolfo
- Department of Medicine, Surgery, Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Francesco Smarrazzo
- Department of Medicine, Surgery, Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Celeste Manfredi
- Department of Urology, University of Naples, Vanvitelli, Naples, Italy
| | - Carlo Tascini
- Department of Medicine, Infectious Diseases Clinic, University of Udine, Udine, Italy
| | - Patrizio Caciagli
- Department of Laboratory Medicine, Santa Chiara Regional Hospital, Trento, Italy
| | | | - Marco De Sio
- Department of Urology, University of Naples, Vanvitelli, Naples, Italy
| | - Florian Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig-University Giessen, Giessen, Germany
| | - Truls E Bjerklund Johansen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Urology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Aarhus, Aarhus, Denmark
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Williams OM, Hamilton F, Brindle R. The Natural History of Antibiotic-Treated Lower Limb Cellulitis: Analysis of Data Extracted From a Multicenter Clinical Trial. Open Forum Infect Dis 2023; 10:ofad488. [PMID: 37849504 PMCID: PMC10578506 DOI: 10.1093/ofid/ofad488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023] Open
Abstract
Background Although cellulitis is a relatively common skin infection, there remains uncertainty about management, particularly the length and route of antimicrobials required. Further information on the symptomatology and biomarker changes associated with cellulitis over time would guide clinicians and patients as to the expected natural history. Methods We extracted data from a randomized clinical trial (NCT01876628) of clindamycin as adjunctive therapy in cellulitis to illustrate the evolution of local parameters (pain, swelling, local erythema, and warmth) and the resolution of biomarkers over time. Results Data from 247 individuals with mild to moderate unilateral lower limb cellulitis, who attended at least 1 face-to-face interview following recruitment, were used to examine response dynamics. Although there was a local improvement in swelling, warmth, erythema, and pain by day 5 compared with baseline, some individuals still had evidence of local inflammation at 10 days. Most biomarkers demonstrated a return to normal by day 3, although the initial fall in albumin only returned to baseline by day 10. Conclusions Although there was initial resolution, a significant number of individuals still had local symptoms persisting to day 10 and beyond. Clinicians can use these data to reassure themselves and their patients that ongoing local symptoms and signs after completion of antibiotic treatment do not indicate treatment failure or warrant extension of the initial antibiotic treatment or a change in antibiotic class or mode of administration.
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Affiliation(s)
- O Martin Williams
- UK Health Security Agency Microbiology Laboratory Services Bristol, Bristol Royal Infirmary, Bristol, UK
- University Hospitals and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol, UK
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Infection Sciences, North Bristol NHS Trust, Bristol, UK
| | - Richard Brindle
- School of Clinical Services, University of Bristol, Bristol, UK
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Correction to: Information about the natural history of acute infections commonly seen in primary care: a systematic review of clinical practice guidelines. BMC Infect Dis 2023; 23:13. [PMID: 36624398 PMCID: PMC9830691 DOI: 10.1186/s12879-022-07964-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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