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Evaluation of the Clinical Outcome and Cost Analysis of Antibiotics in the Treatment of Acute Respiratory Tract Infections in the Emergency Department in Saudi Arabia. Antibiotics (Basel) 2022; 11:antibiotics11111478. [PMID: 36358133 PMCID: PMC9686469 DOI: 10.3390/antibiotics11111478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022] Open
Abstract
This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.
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Sills J, Boccio E, Govindarajan P, Duanmu Y. Less is more: Recommendations for achieving best practices in antibiotic use for acute upper respiratory infections. J Am Coll Emerg Physicians Open 2022; 3:e12767. [PMID: 35765308 PMCID: PMC9206846 DOI: 10.1002/emp2.12767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joe Sills
- Department of Emergency Medicine UMass Chan Medical School – Baystate Springfield Massachusetts USA
| | - Eric Boccio
- Department of Emergency Medicine UMass Chan Medical School – Baystate Springfield Massachusetts USA
- Institute for Healthcare Delivery and Population Science UMass Chan Medical School ‐ Baystate Springfield Massachusetts USA
| | - Prasanthi Govindarajan
- Department of Emergency Medicine Stanford Health Care, Stanford Medicine Palo Alto California USA
| | - Youyou Duanmu
- Department of Emergency Medicine Stanford Health Care, Stanford Medicine Palo Alto California USA
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Lim DW, Htun HL, Ong LS, Guo H, Chow A. Systematic review of determinants influencing antibiotic prescribing for uncomplicated acute respiratory tract infections in adult patients at the emergency department. Infect Control Hosp Epidemiol 2022; 43:366-375. [PMID: 33118891 DOI: 10.1017/ice.2020.1245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Overuse of antibiotics in the emergency department (ED) for uncomplicated acute respiratory tract infections (uARTIs) is a public health issue that needs to be addressed. We aimed to identify factors associated with antibiotic use for uARTIs in adults presenting at the ED. DESIGN We searched Medline, Embase, PsycINFO and the Cochrane Library for articles published from 1 January 2005 to 30 June 2017 using a predetermined search strategy. Titles and abstracts of English articles on antibiotic prescription and inappropriate antibiotic use for adult ARTI at EDs were assessed, followed by full article review, by 2 authors. SETTING Emergency departments. PARTICIPANTS Adults aged 18 years and older. RESULTS Of the 2,591 articles retrieved, 12 articles met the inclusion criteria and 11 studies were conducted in the United States. Patients with normal C-reactive protein levels and positive influenza tests were less likely to receive antibiotic treatment. Nonclinical factors associated with antibiotic use were longer waiting time and perceived patient desire for antibiotics. Patients attended by internal medicine physicians comanaged by house staff or who visited an ED which provided education to healthcare providers on antibiotics use were less likely to receive antibiotics. CONCLUSIONS English-language articles that fulfilled the selection criteria outside the United States were limited. Factors associated with antibiotics use are multifaceted. Education of healthcare providers presents an opportunity to improve antibiotic use.
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Affiliation(s)
- Dwee Wee Lim
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Htet Lin Htun
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Lay See Ong
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Huiling Guo
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
| | - Angela Chow
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge (OCEAN), Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Schroeder AM, Lewis SS, Sahmoun AE, Beal JR. Antibiotic utilization for adult acute respiratory tract infections in United States Emergency Departments. Am J Emerg Med 2021; 47:66-69. [PMID: 33774452 DOI: 10.1016/j.ajem.2021.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Antibiotic stewardship programs have been a major focus in recent years to curtail antibiotic resistance. The purpose of this study was to evaluate antibiotic utilization for acute respiratory tract infections (ARTI) in the Emergency Department (ED) setting. MATERIAL AND METHODS A retrospective analysis of adult ARTI visits to EDs utilizing 2011-2017 National Hospital Ambulatory Medical Care Survey- Emergency Department (NHAMCS-ED) datasets was conducted. Included were all visits of adults (≥18 years) diagnosed with ARTI. Antibiotics were determined based upon NHAMCS-ED use of the Multum Lexicon Drug Database coding system. All significance tests were two-sided, P-value <0.05 for significance. RESULTS A total of 4632 unweighted ED visits, which represented more than 28 million US ED visits from 2011 to 2017, with 57.2% receiving a prescription for antibiotics. Antibiotic prescriptions for ARTI significantly declined from 65.8% in 2011 to 54.3% in 2017 (P = 0.046). Among all visits, patients were more likely to receive an antibiotic if they were over age 45 (33.0% vs 27.6%, P = 0.005), male (36.7% vs. 32.3%, P = 0.039), and presenting in a non-MSA ED (21.4% vs. 14.5%, P = 0.002). No association was found between antibiotic prescription and race (P = 0.076) insurance (P = 0.488), CBC (P = 0.148), x-ray (P = 0.278), and blood cultures (P = 0.182). CONCLUSION We found a significant reduction in the utilization of antibiotics among adult ARTI visits to U.S. EDs from 2011 to 2017. This is an improvement from previous studies which showed no change, suggesting that antimicrobial stewardship efforts may be impacting overall antibiotic use and should continue to be practiced.
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Affiliation(s)
| | - Sarah S Lewis
- University of North Dakota School of Medicine, Grand Forks, ND, USA
| | - Abe E Sahmoun
- University of North Dakota School of Medicine, Department of Internal Medicine, Grand Forks, ND, USA
| | - James R Beal
- University of North Dakota School of Medicine, Department of Family and Community Medicine, Grand Forks, ND, USA.
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El Feghaly RE, Nolen JD, Lee BR, Abraham G, Nedved A, Hassan F, Selvarangan R. Impact of Rapid Influenza Molecular Testing on Management in Pediatric Acute Care Settings. J Pediatr 2021; 228:271-277.e1. [PMID: 32828881 DOI: 10.1016/j.jpeds.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To measure the impact of rapid influenza real-time qualitative reverse transcriptase polymerase chain reaction (RT-PCR) on patient management in busy pediatric emergency department (ED) and urgent care clinic settings. STUDY DESIGN We developed a brief, elective survey that clinicians completed when an influenza RT-PCR order was placed in the ED or urgent care clinic between February 18, 2019, and March 13, 2019. We captured the clinical suspicion for influenza, intended management plans, and actual management plans once influenza RT-PCR results were available. RESULTS We evaluated 339 encounters, of which 164 (48.4%) had a positive influenza RT-PCR. Clinical suspicion for influenza was a nonsignificant predictor for influenza PT-PCR positivity (P = .126). After rapid influenza RT-PCR results were available, clinicians changed their original plans in 44.5% of influenza RT-PCR positive vs 92.6% of influenza RT-PCR negative cases (P < .0001). Change in plans for antiviral use was observed in 26% of influenza positive vs 77% of influenza negative cases (P < .0001). A total of 135 antiviral prescriptions were avoided in patients with negative influenza RT-PCR. CONCLUSIONS Implementation of a rapid and accurate influenza RT-PCR in the acute care setting is important to systematically diagnose influenza in children and improve outpatient management decisions, because clinical suspicion for influenza is inaccurate. A negative influenza RT-PCR decreases unnecessary antiviral use and has the potential for significant cost savings.
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Affiliation(s)
- Rana E El Feghaly
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - John David Nolen
- University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Brian R Lee
- University of Missouri Kansas City, Kansas City, MO; Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | - George Abraham
- University of Missouri Kansas City, Kansas City, MO; Division of Emergency Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Amanda Nedved
- University of Missouri Kansas City, Kansas City, MO; Division of Urgent Care, Children's Mercy Kansas City, Kansas City, MO
| | - Ferdaus Hassan
- University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Rangaraj Selvarangan
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO.
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Wong JG, Aung AH, Lian W, Lye DC, Ooi CK, Chow A. Risk prediction models to guide antibiotic prescribing: a study on adult patients with uncomplicated upper respiratory tract infections in an emergency department. Antimicrob Resist Infect Control 2020; 9:171. [PMID: 33138859 PMCID: PMC7605344 DOI: 10.1186/s13756-020-00825-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Appropriate antibiotic prescribing is key to combating antimicrobial resistance. Upper respiratory tract infections (URTIs) are common reasons for emergency department (ED) visits and antibiotic use. Differentiating between bacterial and viral infections is not straightforward. We aim to provide an evidence-based clinical decision support tool for antibiotic prescribing using prediction models developed from local data. METHODS Seven hundred-fifteen patients with uncomplicated URTI were recruited and analysed from Singapore's busiest ED, Tan Tock Seng Hospital, from June 2016 to November 2018. Confirmatory tests were performed using the multiplex polymerase chain reaction (PCR) test for respiratory viruses and point-of-care test for C-reactive protein. Demographic, clinical and laboratory data were extracted from the hospital electronic medical records. Seventy percent of the data was used for training and the remaining 30% was used for validation. Decision trees, LASSO and logistic regression models were built to predict when antibiotics were not needed. RESULTS The median age of the cohort was 36 years old, with 61.2% being male. Temperature and pulse rate were significant factors in all 3 models. The area under the receiver operating curve (AUC) on the validation set for the models were similar. (LASSO: 0.70 [95% CI: 0.62-0.77], logistic regression: 0.72 [95% CI: 0.65-0.79], decision tree: 0.67 [95% CI: 0.59-0.74]). Combining the results from all models, 58.3% of study participants would not need antibiotics. CONCLUSION The models can be easily deployed as a decision support tool to guide antibiotic prescribing in busy EDs.
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Affiliation(s)
- Joshua Guoxian Wong
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - Aung-Hein Aung
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - Weixiang Lian
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Chien Lye
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chee-Kheong Ooi
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Angela Chow
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
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Madaline T, Wadskier Montagne F, Eisenberg R, Mowrey W, Kaur J, Malik M, Gendlina I, Guo Y, White D, Pirofski LA, Sarwar U. Early Infectious Disease Consultation Is Associated With Lower Mortality in Patients With Severe Sepsis or Septic Shock Who Complete the 3-Hour Sepsis Treatment Bundle. Open Forum Infect Dis 2019; 6:ofz408. [PMID: 31687417 PMCID: PMC6821928 DOI: 10.1093/ofid/ofz408] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
Objective Severe sepsis and septic shock (SS/SS) treatment bundles reduce mortality, and early infectious diseases (ID) consultation also improves patient outcomes. We retrospectively examined whether early ID consultation further improves outcomes in Emergency Department (ED) patients with SS/SS who complete the sepsis bundle. Method We included 248 adult ED patients with SS/SS who completed the 3-hour bundle. Patients with ID consultation within 12 hours of ED triage (n = 111; early ID) were compared with patients who received standard care (n = 137) for in-hospital mortality, 30-day readmission, length of hospital stay (LOS), and antibiotic management. A competing risk survival analysis model compared risks of in-hospital mortality and discharge alive between groups. Results In-hospital mortality was lower in the early ID group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25–0.89; P = .02). There was no significant difference in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived. A trend toward shorter time to antibiotic de-escalation in the early ID group (log-rank test P = .07) was observed. Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36–1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11–2.23; P-value .01) after adjustment. Conclusions Among patients receiving the SS/SS bundle, early ID consultation was associated with a 40% risk reduction for in-hospital mortality. The impact of team-based care and de-escalation on SS/SS outcomes warrants further study.
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Affiliation(s)
- Theresa Madaline
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Francis Wadskier Montagne
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Ruth Eisenberg
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Wenzhu Mowrey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | | | - Maria Malik
- Princeton University, Princeton, New Jersey, USA
| | - Inessa Gendlina
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Yi Guo
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Deborah White
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Liise-Anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Uzma Sarwar
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Ha DR, Haste NM, Gluckstein DP. The Role of Antibiotic Stewardship in Promoting Appropriate Antibiotic Use. Am J Lifestyle Med 2019; 13:376-383. [PMID: 31285722 PMCID: PMC6600622 DOI: 10.1177/1559827617700824] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are one of the most significant medical discoveries in human history. The widespread use of antibiotics has resulted in the emergence of antibiotic-resistant pathogens. This fact, coupled with the paucity of new antibiotic developments, has spurred efforts to combat antibiotic resistance. One of the most critical components of these efforts is antibiotic stewardship, a multidisciplinary endeavor, employing a collection of interventions in a variety of health care settings with the aim of promoting appropriate utilization of antibiotics. This article describes antibiotic stewardship programs and key practices used to minimize the development and spread of antibiotic-resistant pathogens including the optimization of antibiotic pharmacokinetics and pharmacodynamics, the application of rapid diagnostic tools, and the use of computerized provider order entry tools.
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Affiliation(s)
- David R. Ha
- David R. Ha, PharmD, Keck Graduate Institute
School of Pharmacy, 535 Watson Drive, Claremont, CA 91711; e-mail:
| | - Nina M. Haste
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
| | - Daniel P. Gluckstein
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Evaluating antibiotic therapies prescribed to adult patients in the emergency department. Med Mal Infect 2017; 46:207-14. [PMID: 27210280 DOI: 10.1016/j.medmal.2016.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/12/2016] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The proper use of antibiotics is a public health priority to preserve their effectiveness. Little data is available on outpatient antibiotic prescriptions, especially in the emergency department. We aimed to assess the quality of outpatient antibiotic prescriptions in our hospital. PATIENTS AND METHODS Retrospective monocentric study of antibiotic prescriptions written to adult patients managed at the emergency department without hospitalization (November 15th, 2012-November 15th, 2013). Prescriptions were evaluated by an infectious disease specialist and an emergency physician on the basis of local recommendations compiled from national and international guidelines. RESULTS A total of 760 prescriptions were reviewed. The most frequent indications were urinary tract infections (n=263; 34.6%), cutaneous infections (n=198; 26.05%), respiratory tract infections (n=101; 13.28%), and ENT infections (n=62; 8.15%). The most frequently prescribed antibiotics were fluoroquinolones (n=314; 40.83%) and amoxicillin-clavulanic acid (n=245; 31.85%). Overall, 455 prescriptions (59.86%) did not comply with guidelines. The main reasons for inadequacy were the absence of an indication for antibiotic therapy (n=197; 40.7%), an inadequate spectrum of activity, i.e. too broad, (n=95; 19.62%), and excessive treatment duration (n=87; 17.97%). Rates of inadequate prescriptions were 82.26% for ENT infections, 71.2% for cutaneous infections, 46.53% for respiratory tract infections, and 38.4% for urinary tract infections. CONCLUSION Antibiotic prescriptions written to outpatients in the emergency department are often inadequate. Enhancing prescribers' training and handing out guidelines is therefore necessary. The quality of these prescriptions should then be re-assessed.
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72:2418-2430. [PMID: 28859445 PMCID: PMC5890780 DOI: 10.1093/jac/dkx194] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Mark Pearson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Schools of Medicine & Dentistry, Plymouth University, Drake Circus Plymouth, Devon PL4 8AA, UK
| | - Simon Briscoe
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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Baclet N, Ficheur G, Alfandari S, Ferret L, Senneville E, Chazard E, Beuscart JB. Explicit definitions of potentially inappropriate prescriptions of antibiotics in older patients: a compilation derived from a systematic review. Int J Antimicrob Agents 2017; 50:640-648. [PMID: 28803931 DOI: 10.1016/j.ijantimicag.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 12/23/2022]
Abstract
Potentially inappropriate prescriptions (PIPs) of antibiotics (antibiotic-PIPs) are generally detected by applying implicit definitions based on expert opinion. Explicit definitions are less frequently used, even though this approach would enable the automated detection of antibiotic-PIPs in electronic health records. Here, explicit definitions of antibiotic-PIPs used in studies of older adults were systematically reviewed. The MEDLINE®, Scopus® and Web of ScienceTM core collection databases were searched with a combination of three terms and their synonyms: 'potentially inappropriate prescription' AND 'antibiotic treatment' AND 'older patients'. Following standardised selection of publications, explicit definitions of antibiotic-PIPs were extracted and were classified into infectious diseases domains and subdomains. A total of 600 search queries identified 4270 records, 93 of which were selected for review. A total of 160 mentions of antibiotic-PIPs were found, corresponding to 62 distinct definitions in 19 infectious diseases domains. Nearly one-half of the definitions were related to upper respiratory tract infections (n = 11 definitions; 17.7%), lower respiratory tract infections (n = 8; 12.9%) and drug-drug interactions (n = 11; 17.7%). Almost 75% of definitions (n = 46) were mentioned in a single study only. Only three definitions concerned critically important antibiotics such as third-generation cephalosporins and fluoroquinolones. This systematic review identified 62 explicit definitions of antibiotic-PIPs. Most of the definitions were not found in more than one study and they varied in the degree of precision. We advocate the implementation of an expert consensus on explicit definitions of antibiotic-PIPs that correspond to today's challenges in public health.
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Affiliation(s)
- Nicolas Baclet
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Lille Catholic Hospitals, Department of Infectious Diseases, F-59160 Lille, France.
| | - Grégoire Ficheur
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Serge Alfandari
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Laurie Ferret
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Valenciennes General Hospital, Pharmacy Department, F-59300 Valenciennes, France
| | - Eric Senneville
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Emmanuel Chazard
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; CHU Lille, Department of Geriatric Medicine, F-59000 Lille, France
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Zeng L, Hu D, Choonara I, Mu D, Zhang L, Li X, Zhang Z, Hu Z, Quan S. A prospective study of the use of antibiotics in the Emergency Department of a Chinese University Hospital. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2017; 25:89-92. [PMID: 28097718 DOI: 10.1111/ijpp.12335] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 11/24/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Linan Zeng
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
| | - Die Hu
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
| | - Imti Choonara
- Academic Division of Child Health; University of Nottingham; Derbyshire Children's Hospital; Derby UK
| | - Dezhi Mu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
- Department of Neonatology; West China Second University Hospital; Sichuan University; Chengdu China
| | - Lingli Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
| | - Xihong Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
- Department of Emergency; West China Second University Hospital; Sichuan University; Chengdu China
| | - Zuojie Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
- West China School of Pharmacy; Sichuan University; Chengdu China
| | - Zhiqiang Hu
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
- West China School of Pharmacy; Sichuan University; Chengdu China
| | - Shuyan Quan
- Department of Pharmacy/Evidence-Based Pharmacy Center; West China Second University Hospital; Sichuan University; Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children; Sichuan University; Ministry of Education; Chengdu China
- West China School of Pharmacy; Sichuan University; Chengdu China
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Teixeira Rodrigues A, Ferreira M, Piñeiro-Lamas M, Falcão A, Figueiras A, Herdeiro MT. Determinants of physician antibiotic prescribing behavior: a 3 year cohort study in Portugal. Curr Med Res Opin 2016; 32:949-57. [PMID: 26878083 DOI: 10.1185/03007995.2016.1154520] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives Antibiotic misprescription is a major driver of resistance, which is a worldwide public health problem. Therefore, our aim is to assess the influence of the determinants of physician prescribing on the quality of antibiotic use. Methods A 3 year cohort study including all primary-care physicians working in Portugal's Central Regional Health Administration (n = 1094) was conducted. We assessed the determinants of prescribing using a pre-validated, personally addressed, reply-paid, self-administered questionnaire (sent four times to non-responders, between September 2011 and February 2012) designed to collect information on physicians' attitudes to and knowledge of antibiotic prescribing as well as their socio-demographic and professional data. To evaluate antibiotic prescribing, we've calculated ESAC 12 quality indicators per physician per year, allowing us to stratify them as good or poor prescribers according to their performance on those indicators. Associations between determinants and outcomes were fitted with generalized linear mixed models. Results The overall response rate was 46.1%. Emergency activity (OR [95% CI] = 0.29 [0.16-0.54]; p < 0.05) and workload (number of patients seen per day: OR [95% CI] = 0.97 [0.94-1.00]; p < 0.05; number of patients seen per week in emergencies: OR [95% CI] = 0.98 [0.97-0.99]; p < 0.05) were both related to poor quality of antibiotic prescribing. Statistically significant odds ratios were also obtained for ignorance (IqOR [95% CI] = 2.14 [1.31-3.52]), complacency (1/IqOR [95% CI] = 1.19 [1.01-1.41]) and responsibility of others (1/IqOR [95% CI] = 1.78 [1.10-3.06]). Conclusions The above results serve to emphasize workload, working at emergency departments and physicians' attitudes identified as critical factors affecting antibiotic prescribing. This provides new insights for clinicians, researchers and policy makers when it comes to developing and improving the clinical and economic outcomes of antibiotic use. Key limitations of the study included the difficulty of results extrapolation and the limitations of the stratification method based on the antibiotic prescribing quality indicators.
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Affiliation(s)
- António Teixeira Rodrigues
- a Department of Medical Sciences and Institute for Biomedicine - iBiMED , University of Aveiro , Aveiro , Portugal
- b Faculty of Pharmacy , University of Coimbra (Faculdade de Farmácia da Universidade de Coimbra - FFUC) , Coimbra , Portugal
| | - Mónica Ferreira
- a Department of Medical Sciences and Institute for Biomedicine - iBiMED , University of Aveiro , Aveiro , Portugal
| | - Maria Piñeiro-Lamas
- c Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP) , Santiago de Compostela , Spain
| | - Amílcar Falcão
- b Faculty of Pharmacy , University of Coimbra (Faculdade de Farmácia da Universidade de Coimbra - FFUC) , Coimbra , Portugal
- d Centre for Neuroscience and Cell Biology, University of Coimbra (CNC/UC) , Coimbra , Portugal
| | - Adolfo Figueiras
- c Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP) , Santiago de Compostela , Spain
- e University of Santiago de Compostela , Santiago de Compostela , Spain
| | - Maria T Herdeiro
- a Department of Medical Sciences and Institute for Biomedicine - iBiMED , University of Aveiro , Aveiro , Portugal
- f CESPU, IINFACTS, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde , Gandra , Portugal
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Abstract
UNLABELLED POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts. CONTEXT The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care. METHODS We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings. FINDINGS We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse. CONCLUSIONS Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.
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Affiliation(s)
- Nancy R Kressin
- VA Boston Healthcare System; Boston University School of Medicine
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Association between point-of-care CRP testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies. Br J Gen Pract 2014; 63:e787-94. [PMID: 24267862 DOI: 10.3399/bjgp13x674477] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Most patients with respiratory tract infections (RTIs) are prescribed antibiotics in general practice. However, there is little evidence that antibiotics bring any value to the treatment of most RTIs. Point-of-care C-reactive protein testing may reduce antibiotic prescribing. AIM To systematically review studies that have examined the association between point-of-care (POC) C-reactive protein testing and antibiotic prescribing for RTIs in general practice. DESIGN AND SETTING Systematic review and meta-analysis of randomised controlled trials and observational studies. METHOD MEDLINE(®) and Embase were systematically searched to identify relevant publications. All studies that examined the association between POC C-reactive protein testing and antibiotic prescribing for patients with RTIs were included. Two authors independently screened the search results and extracted data from eligible studies. Dichotomous measures of outcomes were combined using risk ratios (RRs) with 95% confidence intervals (CIs) either by fixed or random-effect models. RESULTS Thirteen studies containing 10 005 patients met the inclusion criteria. POC C-reactive protein testing was associated with a significant reduction in antibiotic prescribing at the index consultation (RR 0.75, 95% CI = 0.67 to 0.83), but was not associated with antibiotic prescribing at any time during the 28-day follow-up period (RR 0.85, 95% CI = 0.70 to 1.01) or with patient satisfaction (RR 1.07, 95% CI = 0.98 to 1.17). CONCLUSION POC C-reactive protein testing significantly reduced antibiotic prescribing at the index consultation for patients with RTIs. Further studies are needed to analyse the confounders that lead to the heterogeneity.
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McCulloh RJ, Andrea S, Reinert S, Chapin K. Potential Utility of Multiplex Amplification Respiratory Viral Panel Testing in the Management of Acute Respiratory Infection in Children: A Retrospective Analysis. J Pediatric Infect Dis Soc 2014; 3:146-53. [PMID: 26625367 DOI: 10.1093/jpids/pit073] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 09/15/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND Multiplex real-time polymerase chain reaction respiratory viral panel (RVP) testing offers enhanced test performance characteristics compared with older testing methods. However, the impact of RVP testing on physician antimicrobial prescription practices remains unclear. Our objective was to assess the potential relationship of RVP testing to physician treatment practices for children hospitalized with acute respiratory illness (ARI). METHODS We performed a retrospective chart review of children hospitalized for ARI during peak prevalence of respiratory viral infections in 2009-2011. Demographics, diagnostic testing, antimicrobial use, and clinical outcomes were abstracted from the electronic medical record. Antimicrobial use was compared with RVP testing data. RESULTS A total of 1727 patients met inclusion criteria. Of these patients, 254 (14.7%) children who were hospitalized for ARI received oseltamivir and 856 (49.6%) children received antibiotics. More children who received oseltamivir were positive for influenza by RVP (76.9% vs 18.0%; P < .0001). Children who underwent RVP testing received antibiotics more often than those who were not tested (53.7% vs 46.0%; P = .001), but children with a positive RVP test result received antibiotics less often (51.6% vs 67.0%; P = .003). A total of 5.8% of children who were positive for a viral pathogen by RVP had antibiotics discontinued. Antibiotics were started in fewer children when RVP results were positive (10.9% vs 100.0%; P < .0001). CONCLUSIONS Respiratory viral panel testing was associated with more appropriate oseltamivir use in children hospitalized with ARI. Physicians started antibiotics more often in children with a negative RVP test result and occasionally discontinued antibiotics in children diagnosed with a viral pathogen. These results suggest that RVP testing may enhance physician decision-making when prescribing antimicrobials in children hospitalized with ARI.
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Affiliation(s)
- Russell J McCulloh
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - Kimberle Chapin
- Department of Pathology, Rhode Island Hospital/Brown University, Providence
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Safdar N, Tape TG, Fox BC, Svenson JE, Wigton RS. Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians. Health (London) 2014. [DOI: 10.4236/health.2014.68099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Evans CT, Rogers TJ, Chin A, Johnson S, Smith B, Weaver FM, Burns SP. Antibiotic prescribing trends in the emergency department for veterans with spinal cord injury and disorder 2002-2007. J Spinal Cord Med 2013; 36:492-8. [PMID: 23941797 PMCID: PMC3739899 DOI: 10.1179/2045772312y.0000000076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE Clinical guidelines exist to promote antibiotic stewardship, particularly in ambulatory care settings such as the emergency department (ED). However, there is limited evidence on prescribing practice for persons with spinal cord injury and disorder (SCI/D). The goal of this study was to assess trends in antibiotic prescribing in the ED setting for persons with SCI/D. DESIGN A retrospective dynamic cohort study design. SETTING ED visits that did not result in same day hospitalization over 6 years (fiscal year (FY) 2002-FY2007) in Department of Veterans Affairs (VA) facilities Participants Veterans with SCI/D. OUTCOME MEASURES VA clinical and administrative databases were used to identify the cohort and to obtain demographics, diagnoses, and medications. The rate of antibiotic prescribing for ED visits was defined as the number of antibiotics/total ED visits. RESULTS Veterans with SCI/D had 21 934 ED visits and 5887 antibiotics prescribed over the study period (rate of 268.4 prescriptions/1000 visits). The antibiotic prescribing rate increased from 238.8/1000 visits in FY2002 to 310.8/1000 visits in FY2007 (P < 0.0001). This increase in the rate of prescribing was seen across all patient demographics and factors assessed. CONCLUSION Although clinical guidelines for judicious use of antibiotics in persons with SCI/D have been disseminated to providers, antibiotic prescribing in an ED setting is high and continuing to rise in this population.
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Affiliation(s)
- Charlesnika T. Evans
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care; Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI); and Institute for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Correspondence to: Charlesnika T. Evans, MPH, PhD, Edward J. Hines, Jr. VA Hospital (151H), 5th Avenue and Roosevelt Rd, P.O. Box 5000, Room D302, Hines, IL 60141, USA.
| | - Thea J. Rogers
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care; and Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI)
| | - Amy Chin
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care; and Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI)
| | - Stuart Johnson
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Bridget Smith
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care; and Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI); and Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Frances M. Weaver
- Department of Veterans Affairs (VA), Center for Management of Complex Chronic Care; and Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI); and Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Stephen P. Burns
- Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI); and VA Puget Sound Health Care System and University of Washington, Seattle, WA, USA
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Xu KT, Roberts D, Sulapas I, Martinez O, Berk J, Baldwin J. Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments. BMC Emerg Med 2013; 13:7. [PMID: 23594440 PMCID: PMC3637124 DOI: 10.1186/1471-227x-13-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 03/27/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Unnecessary use of resources for common illnesses has substantial effect on patient care and costs. Evidence-based guidelines do not recommend antibiotics or imaging for uncomplicated upper respiratory infections (URIs). The objective of the current study was to examine medical care providers' compliance with guidelines in treating uncomplicated URIs in emergency departments (EDs) in the US. METHODS Nationally representative data from the NHAMCS 2007 and 2008 were used. Uncomplicated URIs were identified through ICD-9 codes of nasopharyngitis, laryngitis, bronchitis, URI not otherwise specified and influenza involving upper respiratory tract. Exclusion criteria were concurrent comorbidities, follow-up visits, and age < 18 or >64 years. Most frequently prescribed classes of antibiotics were identified. Multivariate analyses were conducted to identify the factors associated with the prescribing of antibiotics and use of imaging studies. RESULTS In 2007 and 2008, there were 2.2 million adult uncomplicated URI visits without any other concurrent diagnoses in EDs in the US. Approximately 52% were given antibiotic prescriptions, over one-third of which were macrolides, and nearly half of the visits performed imaging studies. About 51% had a diagnosis of bronchitis, 35% URI NOS, 9% nasopharyngitis, laryngitis or influenza, and 4% multiple URI diagnoses. The diagnosis of bronchitis, fever at presentation, older ages, male gender, longer waiting time, and metropolitan areas were associated with a greater likelihood of prescribing antibiotics or imaging studies, controlling for confounding factors. CONCLUSION Despite the recommendations and campaign efforts by the CDC and many medical associations, the prescribing of antibiotics in treating uncomplicated URIs in the EDs remains prevalent. Furthermore, overutilization of imaging studies is prevalent. Changes at levels of health care system and hospitals are needed to avoid unnecessary resource utilization. In addition, further patient education about antibiotic use in the community may greatly facilitate the transition out of an antibiotic-dependent consumer culture.
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Affiliation(s)
- K Tom Xu
- Department of Family & Community Medicine, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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Lopez-Vazquez P, Vazquez-Lago JM, Figueiras A. Misprescription of antibiotics in primary care: a critical systematic review of its determinants. J Eval Clin Pract 2012; 18:473-84. [PMID: 21210896 DOI: 10.1111/j.1365-2753.2010.01610.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics. METHODS A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only. RESULTS A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics. CONCLUSIONS Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.
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Affiliation(s)
- Paula Lopez-Vazquez
- Galician Ministry of Health, Spain and PhD Candidate, Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Spain
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Kroening-Roche JC, Soroudi A, Castillo EM, Vilke GM. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med 2012; 43:221-7. [PMID: 22341759 DOI: 10.1016/j.jemermed.2011.06.143] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 04/14/2011] [Accepted: 06/05/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the overuse of antibiotics and underuse of bronchodilators for treatment of acute bronchitis is well known, few studies have analyzed these trends in the emergency department (ED). STUDY OBJECTIVES To characterize the antibiotic and bronchodilator prescribing practices of physicians at two academic EDs in the diagnosis of acute bronchitis, and to identify factors that may or may not be associated with these practices. METHODS A computer database was searched retrospectively for all patients with an ED discharge diagnosis of acute bronchitis, and analyzed, looking at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and several other related factors including age, gender, chief complaint, duration of cough, and comorbid conditions. RESULTS During the study period, there were 836 cases of acute bronchitis in adults. Of these, 622 (74.0%) were prescribed antibiotics. Of those prescribed antibiotics, 480 (77.2%) were prescribed broad-spectrum antibiotics. Using multivariate analysis (odds ratio, 95% confidence interval), antibiotics were prescribed significantly more often in patients aged 50 years or older (1.7, 1.2-2.5) and in smokers (1.5, 1.0-2.2). Of patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. CONCLUSION Antibiotics are over-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibiotics prescribed. Age ≥50 years and smoking are associated with higher antibiotic prescribing rates.
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Affiliation(s)
- Jason C Kroening-Roche
- University of California (UC) San Diego School of Medicine, San Diego, California 92102, USA
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Aspinall SL, Good CB, Metlay JP, Mor MK, Fine MJ. Antibiotic prescribing for presumed nonbacterial acute respiratory tract infections. Am J Emerg Med 2009; 27:544-51. [DOI: 10.1016/j.ajem.2008.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 03/31/2008] [Accepted: 04/10/2008] [Indexed: 10/20/2022] Open
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El Sayed MF, Tamim H, Jamal D, Mumtaz G, Melki I, Yunis K. Prospective study on antibiotics misuse among infants with upper respiratory infections. Eur J Pediatr 2009; 168:667-72. [PMID: 18762979 DOI: 10.1007/s00431-008-0815-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 07/23/2008] [Accepted: 08/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The judicious prescription of antibiotics has become a central focus of professional and public health measures to combat the spread of resistant organisms. MATERIALS AND METHODS A one-year multi-center prospective follow-up study of 1,320 healthy infants was conducted. The study aim was to determine the prevalence and identify the predictors of antibiotics misuse in viral respiratory illnesses among healthy infants in the first year of life. Infants born between August 2001 and February 2002 were recruited through the clinics and dispensaries of 117 pediatricians located in the Greater Beirut area of Lebanon. On each routine visit from birth until one year of life, pediatricians reported any episodes of upper respiratory tract infection (URTI; common cold) and bronchiolitis, as well as the treatment type, duration, and dose. Predictors that were considered included infant, maternal, and pediatrician characteristics. RESULTS Of the 1,320 recruited infants, 770 (58.3%) had common cold or acute bronchiolitis on at least one occasion during the study period. Pediatricians prescribed antibiotics at least once in 21.4% of cases diagnosed as the common cold and 45.5% of cases of acute bronchiolitis. Logistic regression analysis revealed that antibiotics misuse was more common among infants born to mothers with lower educational levels (odds ratio [OR] = 1.6; 95% confidence interval [CI]: 1.1-2.3). Furthermore, pediatricians tend to prescribe antibiotics in dispensaries more often than in private clinics (OR = 1.4; 95% CI: 1.0-2.3). CONCLUSION This study shows a substantial quantity of antibiotics prescriptions for common cold and acute bronchiolitis in our population. Our findings suggest that lower maternal education and pediatricians working in dispensaries (versus private clinics) are associated with increased antibiotics misuse.
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Affiliation(s)
- Manal F El Sayed
- Department of Pediatrics, Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El Solh, Beirut, 11072020, Lebanon
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Lizogub VG, Riley DS, Heger M. Efficacy of a pelargonium sidoides preparation in patients with the common cold: a randomized, double blind, placebo-controlled clinical trial. Explore (NY) 2008; 3:573-84. [PMID: 18005909 DOI: 10.1016/j.explore.2007.09.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The common cold is a viral infection with symptoms such as sneezing, sore throat, and running nose. It is one of the most prevalent illnesses in the world, and although commonly caused by rhinoviruses, antibiotics are often prescribed unnecessarily. Therefore, it is of utmost importance to evaluate alternative treatments such as herbal medications, whose efficacy and safety is proven by pharmacological and clinical studies. OBJECTIVE The aim of the present study was to evaluate the efficacy of a liquid herbal drug preparation from the roots of Pelargonium sidoides compared with placebo in adult patients with the common cold. DESIGN The study was designed as a multicenter, prospective, randomized, double blind, parallel group, placebo-controlled phase III clinical trial with an adaptive group-sequential design. SETTING The study took place in eight outpatient departments affiliated with hospitals. PATIENTS One hundred three male and female adult patients with at least two major and one minor or with one major and three minor cold symptoms (maximum symptom score of 40 points), present for 24 to 48 hours, and who gave provision of informed consent were randomized to receive either 30 drops (1.5 mL) of the liquid herbal drug preparation EPs or placebo three times a day. INTERVENTION Patients received randomized treatment for a maximum period of 10 days. MEASUREMENTS The primary outcome criterion was the sum of symptom intensity differences (SSID) of the cold intensity score (CIS) from day one to day five. The CIS consists of the following 10 cold symptoms: nasal drainage, sore throat, nasal congestion, sneezing, scratchy throat, hoarseness, cough, headache, muscle aches, and fever. RESULTS From baseline to day five, the mean SSID improved by 14.6 +/- 5.3 points in the EPs group compared with 7.6 +/- 7.5 points in the placebo group. This difference was statistically significant (P < .0001). The mean CIS decreased by 10.4 +/- 3.0 points and 5.6 +/- 4.3 points in EPs and placebo-treated patients, respectively. After 10 days, 78.8% versus 31.4% in the EPs versus placebo group were clinically cured (CIS equals zero points or complete resolution of all but a maximum of one cold symptom; P < .0001). The mean duration of inability to work was significantly lower in the EPs treatment group (6.9 +/- 1.8 days) than in the placebo group (8.2 +/- 2.1 days; P = .0003). Treatment outcome (rates of complete recovery or major improvement from disease [integrative medicine outcomes scale]) was assessed better in the EPs treatment group than in the placebo group by both the investigator and the patient on day five (P < .0001). Adverse events occurred in three of 103 patients (2.9%), with two of 52 (3.8%) and one of 51 (2.0%) patients in the EPs and placebo group, respectively. All adverse events were assessed as nonserious. At the end of treatment, all patients (100%) in the active treatment group judged the subjective tolerability of EPs as good or very good. CONCLUSIONS EPs represents an effective treatment of the common cold. It significantly reduces the severity of symptoms and shortens the duration of the common cold compared with placebo. The herbal drug is well tolerated.
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Affiliation(s)
- Viktor G Lizogub
- Faculty Therapy No. 2, National Medical University, Kiev, Ukraine.
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Cosby JL, Francis N, Butler CC. The role of evidence in the decline of antibiotic use for common respiratory infections in primary care. THE LANCET. INFECTIOUS DISEASES 2007; 7:749-56. [PMID: 17961860 DOI: 10.1016/s1473-3099(07)70263-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Antibiotic prescribing in primary care for common respiratory infections increased steadily until the mid 1990s, when the trend reversed noticeably. During the subsequent decade, antibiotic prescribing reduced by up to one-third in some countries. Explanations for this reduction have focused on a decline in the incidence and severity of common respiratory infections, and on the resulting decrease in the number of patients seeking consultation. We argue that evidence from primary-care research had a central role in changing the practice of antibiotic prescribing, and discuss the concern that has arisen among some physicians around this issue. Targeted reductions in antibiotic prescribing constitute a balancing act between individual and societal concerns, pitting the expected gains in preserving the usefulness of an antibiotic against any given reduction in use. There may be unintended consequences for decreasing antibiotic use beyond a certain point without adequate supporting evidence. A new approach to antibiotic prescribing requires comprehensive research to answer why change is necessary, and how that change can be safely implemented. Future policies must move beyond a "one size fits all" mindset if public and provider behaviours are expected to become more congruent with the growing research evidence.
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Affiliation(s)
- Jarold L Cosby
- Applied Health Sciences, Brock University, St Catharines, ON, Canada.
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Tomii K, Matsumura Y, Maeda K, Kobayashi Y, Takano Y, Tasaka Y. Minimal use of antibiotics for acute respiratory tract infections: validity and patient satisfaction. Intern Med 2007; 46:267-72. [PMID: 17379992 DOI: 10.2169/internalmedicine.46.6200] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antibiotics have been overused for acute respiratory tract infections (ARTIs) and the recent guidelines have emphasized limiting their use. OBJECTIVE To clarify the exact rate of antibiotic use and patient outcomes and satisfaction, under strict adherence to the guideline proposed by the American College of Physicians. DESIGN Prospective cohort observational study. SETTING Primary care clinics in Japan. PATIENTS 783 patients diagnosed with ARTIs from October 2004 to April 2005, aged 15-64 and without any underlying disease. MEASUREMENTS Scores of symptoms and patient satisfaction at the 5th, 8th and 15th day of their initial visit, when treatment had been initiated according to that strategy. RESULTS In 691 non-influenza patients, comprising 554 (80%) cases of nonspecific upper respiratory tract infection (A), 11 (2%) of acute rhinosinusitis (B), 90 (13%) of acute pharyngitis (C) and 36 (5%) of acute bronchitis (D); the rates of antibiotic use were 5% [0.2%; (A), 9%; (B), 36%; (C), 3%; (D)] initially and 2% [2%; (A), 0%; (B), 1%; (C), 3%; (D)] subsequently. For the remaining 92 influenza patients, no antibiotics were prescribed, though oseltamivir was prescribed in 89 (97%). Within 7 days, more than 90% of all patients felt improved and expressed their satisfaction with the treatment. Furthermore, no patients needed emergency room visits or hospital admission. LIMITATIONS Only patients who gave informed consent were enrolled. CONCLUSIONS Adhering to the guideline, antibiotic use could be limited to only 5-7% of non-influenza ARTIs-mainly acute pharyngitis-without any problems and with a high degree of patient satisfaction.
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Affiliation(s)
- Keisuke Tomii
- Department of Pulmonary Medicine, Kobe City General Hospital.
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