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Lewnard JA, Charani E, Gleason A, Hsu LY, Khan WA, Karkey A, Chandler CIR, Mashe T, Khan EA, Bulabula ANH, Donado-Godoy P, Laxminarayan R. Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis. Lancet 2024; 403:2439-2454. [PMID: 38797180 DOI: 10.1016/s0140-6736(24)00862-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/18/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024]
Abstract
National action plans enumerate many interventions as potential strategies to reduce the burden of bacterial antimicrobial resistance (AMR). However, knowledge of the benefits achievable by specific approaches is needed to inform policy making, especially in low-income and middle-income countries (LMICs) with substantial AMR burden and low health-care system capacity. In a modelling analysis, we estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337 000 (95% CI 250 200-465 200) AMR-associated deaths annually. Ensuring universal access to high-quality water, sanitation, and hygiene services would prevent 247 800 (160 000-337 800) AMR-associated deaths and paediatric vaccines 181 500 (153 400-206 800) AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. These estimates translate to prevention of 7·8% (5·6-11·0) of all AMR-associated mortality in LMICs by infection prevention and control, 5·7% (3·7-8·0) by water, sanitation, and hygiene, and 4·2% (3·4-5·1) by vaccination interventions. Despite the continuing need for research and innovation to overcome limitations of existing approaches, our findings indicate that reducing global AMR burden by 10% by the year 2030 is achievable with existing interventions. Our results should guide investments in public health interventions with the greatest potential to reduce AMR burden.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
| | - Esmita Charani
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alec Gleason
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Wasif Ali Khan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Clare I R Chandler
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Tapfumanei Mashe
- One Health Office, Ministry of Health and Child Care, Harare, Zimbabwe; Health System Strengthening Unit, WHO, Harare, Zimbabwe
| | - Ejaz Ahmed Khan
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa International Hospital, Islamabad, Pakistan
| | - Andre N H Bulabula
- Division of Disease Control and Prevention, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Pilar Donado-Godoy
- AMR Global Health Research Unit, Colombian Integrated Program of Antimicrobial Resistance Surveillance, Corporación Colombiana de Investigación Agropecuaria, Cundinamarca, Colombia
| | - Ramanan Laxminarayan
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA.
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Alejandro AL, Leo WWC, Bruce M. Opportunities to Improve Awareness of Antimicrobial Resistance Through Social Marketing: A Systematic Review of Interventions Targeting Parents and Children. HEALTH COMMUNICATION 2023; 38:3376-3392. [PMID: 36437539 DOI: 10.1080/10410236.2022.2149132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Lack of knowledge from parents concerning the appropriate use of antimicrobials leads to poor treatment choices and mismanagement of antimicrobials for their children. Social marketing (SM) strategies have the potential to help parents access useful information on the appropriate use of antimicrobials. Still, its application in interventions targeting antimicrobial/antibiotic resistance awareness is minimal. This study explores the use of SM in antimicrobial/antibiotic awareness campaigns (AACs) to identify opportunities for SM approaches in developing future communication interventions targeting parents and children. We conduct a systematic review of interventions targeting parents and children between 2000 and 2022. Articles meeting the selection criteria were assessed against social marketing benchmark criteria (SMBC). We identified 6978 original records, 16 of which were included in the final review. None of the articles explicitly identified SM as part of their interventions. Twelve interventions (75%) included 1 to 4 (out of 8) benchmark criteria, while four (25%) had 5-8 benchmarks in their interventions. Of the interventions with less than four benchmark criteria, six studies (50%) reported a positive effect direction outcome, and six studies (50%) reported negative/no change direction on the outcome of interests. Meanwhile, all interventions with five or more SMBC resulted in a positive effect direction in their outcomes. In this review, the use of SM has shown promising results, indicating opportunities for future antimicrobial resistance (AMR) interventions that incorporate social marketing benchmark criteria to improve intervention outcomes.
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Affiliation(s)
- Aaron Lapuz Alejandro
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University
- Department of Nursing, Fiona Stanley Hospital
| | | | - Mieghan Bruce
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University
- School of Veterinary Medicine, Murdoch University
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Fulone I, Cadogan C, Barberato-Filho S, Bergamaschi CC, Mazzei LG, Lopes LP, Silva MT, Lopes LC. Pharmaceutical policies: effects of policies regulating drug marketing. Cochrane Database Syst Rev 2023; 6:CD013780. [PMID: 37288951 PMCID: PMC10250001 DOI: 10.1002/14651858.cd013780.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities. OBJECTIVES To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs. SEARCH METHODS We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023. SELECTION CRITERIA We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author. We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance. MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria. AUTHORS' CONCLUSIONS We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.
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Affiliation(s)
- Izabela Fulone
- Pharmaceutical Science Graduate Course, University of Sorocaba, São Paulo, Brazil
| | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | | | | | | | - Luis Phillipe Lopes
- Pharmaceutical Science Graduate Course, University of Sorocaba, São Paulo, Brazil
| | | | - Luciane C Lopes
- Pharmaceutical Science Graduate Course, University of Sorocaba, São Paulo, Brazil
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Brigadoi G, Rossin S, Visentin D, Barbieri E, Giaquinto C, Da Dalt L, Donà D. The impact of Antimicrobial Stewardship Programmes in paediatric emergency departments and primary care: a systematic review. Ther Adv Infect Dis 2023; 10:20499361221141771. [PMID: 36654872 PMCID: PMC9841878 DOI: 10.1177/20499361221141771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 11/07/2022] [Indexed: 01/14/2023] Open
Abstract
Background Antibiotics remain the most prescribed medicine in children worldwide, but half of the prescriptions are unnecessary or inappropriate, leading to an increase in antibiotic resistance. This study aims to systemically review the effects of different Antimicrobial Stewardship Programmes (ASPs) on reducing the rates of both antibiotic prescriptions and changes in antimicrobial resistance, and on the economic impact in paediatric emergency departments (PED) and primary care settings. Materials and methods Embase, MEDLINE, and Cochrane Library were systematically searched, combining Medical Subject Heading and free-text terms for 'children' and 'antimicrobial' and 'stewardship'. The search strategy involved restrictions on dates (from 1 January 2007 to 30 December 2020) but not on language. Randomized controlled trials, controlled and non-controlled before and after studies, controlled and non-controlled interrupted time series, and cohort studies were included for review. The review protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews: Registration Number CRD42021270630. Results Of the 47,158 articles that remained after removing duplicates, 59 were eligible for inclusion. Most of the studies were published after 2015 (37/59, 62.7%) and in high-income countries (51/59, 86.4%). Almost half of the studies described the implementation of an ASP in the primary care setting (28/59, 47.5%), while 15 manuscripts described the implementation of ASPs in EDs (15/59, 25.4%). More than half of the studies (43/59, 72.9%) described the implementation of multiple interventions, whereas few studies considered the implementation of a single intervention. Antibiotic prescriptions and compliance with guidelines were the most frequent outcomes (47/59, 79.7% and 20/59, 33.9%, respectively). Most of the articles reported an improvement in these outcomes after implementing an ASP. Meanwhile, only very few studies focused on health care costs (6/59, 10.2%) and antimicrobial resistance (3/59 5.1%). Conclusion The implementation of ASPs has been proven to be feasible and valuable, even in challenging settings such as Emergency Departments and Primary care.
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Affiliation(s)
- Giulia Brigadoi
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Sara Rossin
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Davide Visentin
- Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Liviana Da Dalt
- Paediatric Emergency Department, Department of Woman’s and Children’s Health, University of Padua, Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department of Woman’s and Children’s Health, University of Padua, Via Giustiani 3, 35141 Padua, Italy
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Improvements in appropriate ambulatory antibiotic prescribing using a bundled antibiotic stewardship intervention in general pediatrics practices. Infect Control Hosp Epidemiol 2022; 43:1894-1900. [PMID: 35098913 DOI: 10.1017/ice.2021.534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To improve appropriate antibiotic prescribing for children in Tennessee. DESIGN We performed a before-and-after intervention study with 3 comparison periods: period 1 (P1, baseline) May 2018-September 2019; period 2 (P2, intervention before the COVID-19 pandemic) November 11, 2019-March 20, 2020; and period 3 (P3, intervention during the coronavirus disease 2019 [COVID-19] pandemic) March 21, 2020-November 10, 2020. We additionally surveyed participating providers to assess acceptance of the intervention. SETTING Community general pediatrics practices. PARTICIPANTS In total, 81 general pediatricians, family medicine physicians, and nurse practitioners in 5 general pediatrics practices participated in this study. INTERVENTIONS Each practice identified a practice and operations champion for the project. Practices chose 2-4 implementation strategies previously shown to be effective at reducing outpatient antibiotic use to implement in their practice throughout the study intervention period. Study personnel also held quarterly meetings with all providers to review deidentified peer comparison feedback both across practices enrolled in the study and at the provider level within each practice. RESULTS We detected improvements in guideline-concordant antibiotic use in the pre-COVID-19 intervention period, and they were sustained in the study period during the pandemic (P3): otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%). CONCLUSIONS Bundled implementation strategies led to significant increases in guideline-concordant antibiotic prescribing for all diagnoses. Survey results demonstrate that the bundled implementation strategies were well-accepted by providers.
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Prevention of antimicrobial prescribing among infants following maternal vaccination against respiratory syncytial virus. Proc Natl Acad Sci U S A 2022; 119:e2112410119. [PMID: 35286196 PMCID: PMC8944586 DOI: 10.1073/pnas.2112410119] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Strategies to reduce consumption of antimicrobial drugs are needed to contain the growing burden of antimicrobial resistance. Respiratory syncytial virus (RSV) is a prominent cause of upper and lower respiratory tract infections, as a single agent and in conjunction with bacterial pathogens, and may thus contribute to the burden of both inappropriately treated viral infections and appropriately treated polymicrobial infections involving bacteria. In a double-blind, randomized, placebo-controlled trial, administering an RSV vaccine to pregnant mothers reduced antimicrobial prescribing among their infants by 12.9% over the first 3 mo of life. Our findings implicate RSV as an important contributor to antimicrobial exposure among infants and demonstrate that this exposure is preventable by use of effective maternal vaccines against RSV. Reductions in antimicrobial consumption are needed to mitigate the burden of antimicrobial resistance. Vaccines may have an important role to play in reducing antimicrobial consumption by preventing infections for which treatment is often prescribed, whether appropriately or inappropriately. However, limited understanding of the volume of antimicrobial treatment attributable to specific pathogens—and to viruses, in particular—presently hinders efforts to prioritize vaccines with the greatest potential to reduce antimicrobial consumption. In a double-blind trial undertaken across 11 countries, infants born to mothers who were randomized to receive an experimental vaccine against respiratory syncytial virus (RSV) experienced 12.9% (95% CI: 1.3 to 23.1%) lower incidence of antimicrobial prescribing over the first 3 mo of life than infants whose mothers were randomized to receive placebo. Vaccine efficacy against antimicrobial prescriptions associated with acute lower respiratory tract infections (LRTIs) was 16.9% (95% CI: 1.4 to 29.4%). Over the first 3 mo of life, maternal vaccination prevented 3.6 antimicrobial prescription courses for every 100 infants born in high-income countries and 5.1 courses per 100 infants in low- and middle-income countries, representing 20.2 and 10.9% of all antimicrobial prescribing in these settings, respectively. While LRTI episodes accounted for 69 to 73% of all antimicrobial prescribing prevented by maternal vaccination, striking vaccine efficacy (71.3% [95% CI: 28.1 to 88.6%]) was also observed against acute otitis media–associated antimicrobial prescription among infants in high-income countries. Our findings implicate RSV as a cause of substantial volumes of antimicrobial prescribing among young infants and demonstrate the potential for prevention of such prescribing through use of maternal vaccines against RSV.
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Hardefeldt LY, Hur B, Richards S, Scarborough R, Browning GF, Billman-Jacobe H, Gilkerson JR, Ierardo J, Awad M, Chay R, Bailey KE. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac015. [PMID: 35233530 PMCID: PMC8874133 DOI: 10.1093/jacamr/dlac015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/02/2022] [Indexed: 11/28/2022] Open
Abstract
Background Antimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens. Objectives To implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing. Methods In October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing. Results The overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics. Conclusions These AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.
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Affiliation(s)
- L. Y. Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
- Corresponding author. E-mail:
| | - B. Hur
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - S. Richards
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - R. Scarborough
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - G. F. Browning
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - H. Billman-Jacobe
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - J. R. Gilkerson
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
| | - J. Ierardo
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - M. Awad
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - R. Chay
- Greencross Vets Pty Ltd, Brisbane, Queensland, Australia
| | - K. E. Bailey
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Grattan St, Carlton, Victoria, Australia
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Lewnard JA, King LM, Fleming-Dutra KE, Link-Gelles R, Van Beneden CA. Incidence of Pharyngitis, Sinusitis, Acute Otitis Media, and Outpatient Antibiotic Prescribing Preventable by Vaccination Against Group A Streptococcus in the United States. Clin Infect Dis 2021; 73:e47-e58. [PMID: 32374829 DOI: 10.1093/cid/ciaa529] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/30/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Group A Streptococcus (GAS) is a leading cause of acute respiratory conditions that frequently result in antibiotic prescribing. Vaccines against GAS are currently in development. METHODS We estimated the incidence rates of healthcare visits and antibiotic prescribing for pharyngitis, sinusitis, and acute otitis media (AOM) in the United States using nationally representative surveys of outpatient care provision, supplemented by insurance claims data. We estimated the proportion of these episodes attributable to GAS and to GAS emm types included in a proposed 30-valent vaccine. We used these outputs to estimate the incidence rates of outpatient visits and antibiotic prescribing preventable by GAS vaccines with various efficacy profiles under infant and school-age dosing schedules. RESULTS GAS pharyngitis causes 19.1 (95% confidence interval [CI], 17.3-21.1) outpatient visits and 10.2 (95% CI, 9.0-11.5) antibiotic prescriptions per 1000 US persons aged 0-64 years, annually. GAS pharyngitis causes 93.2 (95% CI, 82.3-105.3) visits and 53.2 (95% CI, 45.2-62.5) antibiotic prescriptions per 1000 children ages 3-9 years, annually, representing 5.9% (95% CI, 5.1-7.0%) of all outpatient antibiotic prescribing in this age group. Collectively, GAS-attributable pharyngitis, sinusitis, and AOM cause 26.9 (95% CI, 23.9-30.8) outpatient visits and 16.1 (95% CI, 14.0-18.7) antibiotic prescriptions per 1000 population, annually. A 30-valent GAS vaccine meeting the World Health Organization's 80% efficacy target could prevent 5.4% (95% CI, 4.6-6.4%) of outpatient antibiotic prescriptions among children aged 3-9 years. If vaccine prevention of GAS pharyngitis made the routine antibiotic treatment of pharyngitis unnecessary, up to 17.1% (95% CI, 15.0-19.6%) of outpatient antibiotic prescriptions among children aged 3-9 years could be prevented. CONCLUSIONS An efficacious GAS vaccine could prevent substantial incidences of pharyngitis infections and associated antibiotic prescribing in the United States.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California, USA.,Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, California, USA.,Center for Computational Biology, School of Engineering, University of California, Berkeley, California, USA
| | - Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ruth Link-Gelles
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Chris A Van Beneden
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Aksoy M, Isli F, Kadi E, Varimli D, Gursoz H, Tolunay T, Kara A, Unal S, Alp Mese E. Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level. Pharmacoepidemiol Drug Saf 2021; 30:1242-1249. [PMID: 34155708 DOI: 10.1002/pds.5311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics. METHODS Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics. RESULTS A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years. CONCLUSIONS Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.
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Affiliation(s)
- Mesil Aksoy
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Fatma Isli
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Esma Kadi
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Didem Varimli
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Hakki Gursoz
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Tolga Tolunay
- Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Ates Kara
- Hacettepe University, Ankara, Turkey
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10
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Bulabula ANH, Dramowski A, Mehtar S. Antibiotic use in pregnancy: knowledge, attitudes and practices among pregnant women in Cape Town, South Africa. J Antimicrob Chemother 2021; 75:473-481. [PMID: 31637418 DOI: 10.1093/jac/dkz427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To establish the knowledge, attitudes and practices (KAP) regarding antibiotic use and self-medication among pregnant women. METHODS We conducted a KAP survey of 301 pregnant women hospitalized at a tertiary hospital obstetric service in Cape Town, South Africa in November and December 2017, using an interviewer-administered 12 item questionnaire. We stratified analysis of attitudes and practices by participants' mean knowledge score (K-score) group (<6 versus ≥6 out of 7 questions). Multivariate models were built to identify independent predictors of antibiotic self-medication and K-score. RESULTS The mean age of pregnant women was 29 (SD 6.1) years, 44/247 (17.8%) were nulliparous, 69/247 (27.9%) were HIV-infected, 228/247 (92.3%) had completed secondary school and 78/247 (31.6%) reported a monthly household income in the lowest category of ≤50-100 US dollars (USD). The mean K-score was 6.1 (SD 1.02) out of 7 questions. Sixteen percent of the cohort reported antibiotic self-medication, with higher rates among pregnant women with K-score <6 [18/48 (37.5%) versus 32/253 (12.6%); P<0.001]. The monthly household income category of >500 USD (the highest category) was the only predictor of antibiotic self-medication behaviour [adjusted OR=6.4 (95% CI 1.2-35.2), P=0.03]. CONCLUSIONS Higher antibiotic knowledge scores are associated with lower rates of antibiotic self-medication, whereas higher household income is correlated with increasing self-medication behaviours. Education of pregnant women regarding the potential dangers of antibiotic self-medication and stricter enforcement of existing South African antibiotic prescribing and dispensing regulations are needed.
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Affiliation(s)
- Andre N H Bulabula
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Infection Control Africa Network-ICAN, Cape Town, South Africa
| | - Angela Dramowski
- Infection Control Africa Network-ICAN, Cape Town, South Africa.,Paediatric Infectious Diseases, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Shaheen Mehtar
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Infection Control Africa Network-ICAN, Cape Town, South Africa
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11
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Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid. Infect Control Hosp Epidemiol 2021; 43:582-588. [PMID: 33975663 DOI: 10.1017/ice.2021.177] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS Population-based sample of pediatric Medicaid patients and providers. METHODS Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.
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12
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Hempel EV, Duca N, Kipp R, van Harskamp J, Caputo G. Preparing for the New Joint Commission Requirements: a Model for Tracking Outcomes of an Ambulatory Antibiotic Stewardship Program in Primary Care. J Gen Intern Med 2021; 36:762-766. [PMID: 33420558 PMCID: PMC7947146 DOI: 10.1007/s11606-020-06365-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 11/25/2020] [Indexed: 11/28/2022]
Abstract
Since 2007, inpatient antibiotic stewardship programs have been required for all Joint Commission-accredited hospitals in the USA. Given the frequency of ambulatory antibiotic prescribing, in June 2019, the Joint Commission released new standards for antibiotic stewardship programs in ambulatory healthcare. This report identified five elements of performance (EPs): (1) Identify an antimicrobial stewardship leader, (2) establish an annual antimicrobial stewardship goal, (3) implement evidence-based practice guidelines related to the antimicrobial stewardship goal, (4) provide clinical staff with educational resources related to the antimicrobial stewardship goal, and (5) collect, analyze, and report data related to the antimicrobial stewardship goal. We provide eight practical tips for implementing the EPs for antimicrobial stewardship: (1) Identify a collaborative leadership team, (2) partner with informatics, (3) identify national prescribing patterns, (4) perform a needs assessment based on local prescribing patterns, (5) review guidelines for diagnosis and treatment of the selected condition, (6) identify systems-level interventions to help support providers in making appropriate treatment decisions, (7) prioritize individual EPs for your institution, and (8) re-assess local data to identify areas of strength and deficiency in local practice.
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Affiliation(s)
- Eliana V Hempel
- Penn State College of Medicine, Hershey, PA, USA. .,Division of General Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA.
| | - Nicholas Duca
- Penn State College of Medicine, Hershey, PA, USA.,Division of General Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Ryan Kipp
- Penn State College of Medicine, Hershey, PA, USA
| | | | - Gregory Caputo
- Penn State College of Medicine, Hershey, PA, USA.,Division of General Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
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13
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Grammatico‐Guillon L, Jafarzadeh SR, Laurent E, Shea K, Pasco J, Astagneau P, Adams W, Pelton S. Gradual decline in outpatient antibiotic prescriptions in paediatrics: A data warehouse-based 11-year cohort study. Acta Paediatr 2021; 110:611-617. [PMID: 32573837 DOI: 10.1111/apa.15439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/26/2022]
Abstract
AIM To describe trends in antibiotic (AB) prescriptions in children in primary care over 11 years, using a large data warehouse. METHODS A retrospective cohort study assessed outpatient AB prescriptions 2007-2017, using the Massachusetts Health Disparities Repository. The evolution of paediatric outpatient AB prescriptions was assessed using time-series analyses through annual per cent change (APC) for the population and for children with or without comorbid condition. RESULTS About 25 000 children were followed in primary care with 31 248 AB prescriptions reported in the data warehouse. The youngest children had more AB prescriptions. Penicillins were prescribed most frequently (46%), then macrolides (28%). One third of children had comorbid conditions, receiving significantly more antibiotics (30.3 vs 21.0 AB/100 child-years, relative risk: 1.43, 95% CI: 1.40, 1.46). Overall AB prescription decreased over the period (APC = -5.34%, 95% CI: -7.10, -3.54), with similar trends for penicillins (APC = -5.49; 95% CI: -8.27, -2.62) and macrolides (APC = -6.46; 95% CI: -8.37, -4.58); antibiotic prescribing declined more in children with comorbid conditions. CONCLUSION Outpatient AB prescribing decline was gradual and consistent in paediatrics over the period. Prescription differences persisted between age groups, conditions and indication. The availability of routine care data through data warehouse fosters the surveillance automation, providing inexpensive fast tools to design appropriate antimicrobial stewardship.
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Affiliation(s)
- Leslie Grammatico‐Guillon
- Medical School and School of Public Health Boston University Boston MA USA
- Public Health, Epidemiology Unit (EpiDcliC) Teaching Hospital of Tours University of Tours Tours France
| | - S. Reza Jafarzadeh
- Clinical Epidemiology Research and Training Unit Boston University School of Medicine Boston MA USA
| | - Emeline Laurent
- Public Health, Epidemiology Unit (EpiDcliC) Teaching Hospital of Tours University of Tours Tours France
- Research unit EA 7505 "Education Ethique et Santé" University of Tours Tours France
| | - Kimberly Shea
- Medical School and School of Public Health Boston University Boston MA USA
| | - Jeremy Pasco
- Research unit EA 7505 "Education Ethique et Santé" University of Tours Tours France
- Public Health Clinical Data Centre Teaching Hospital of Tours Tours France
| | - Pascal Astagneau
- Reference Centre for Prevention of Healthcare‐Associated Infections Faculty of Medicine, APHP University Hospital and Department of Public Health Sorbonne University Paris France
| | - William Adams
- Service of Bioinformatics Boston University Medical School Boston MA USA
| | - Stephen Pelton
- Medical School and School of Public Health Boston University Boston MA USA
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14
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Marusinec R, Kurowski KM, Amato HK, Saraiva-Garcia C, Loayza F, Salinas L, Trueba G, Graham JP. Caretaker knowledge, attitudes, and practices (KAP) and carriage of extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) in children in Quito, Ecuador. Antimicrob Resist Infect Control 2021; 10:2. [PMID: 33407927 PMCID: PMC7789729 DOI: 10.1186/s13756-020-00867-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background The rapid spread of extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) is an urgent global health threat. We examined child caretaker knowledge, attitudes, and practices (KAP) towards proper antimicrobial agent use and whether certain KAP were associated with ESBL-EC colonization of their children. Methods Child caretakers living in semi-rural neighborhoods in peri-urban Quito, Ecuador were visited and surveyed about their KAP towards antibiotics. Fecal samples from one child (less than 5 years of age) per household were collected at two time points between July 2018 and May 2019 and screened for ESBL-EC. A repeated measures analysis with logistic regression was used to assess the relationship between KAP levels and child colonization with ESBL-EC. Results We analyzed 740 stool samples from 444 children living in households representing a range of environmental conditions. Of 374 children who provided fecal samples at the first household visit, 44 children were colonized with ESBL-EC (11.8%) and 161 were colonized with multidrug-resistant E. coli (43%). The prevalences of ESBL-EC and multidrug-resistant E. coli were similar at the second visit (11.2% and 41.3%, respectively; N = 366). Only 8% of caretakers knew that antibiotics killed bacteria but not viruses, and over a third reported that they “always” give their children antibiotics when the child’s throat hurts (35%). Few associations were observed between KAP variables and ESBL-EC carriage among children. The odds of ESBL-EC carriage were 2.17 times greater (95% CI: 1.18–3.99) among children whose caregivers incorrectly stated that antibiotics do not kill bacteria compared to children whose caregivers correctly stated that antibiotics kill bacteria. Children from households where the caretaker answered the question “When your child’s throat hurts, do you give them antibiotics?” with “sometimes” had lower odds of ESBL-EC carriage than those with a caretaker response of “never” (OR 0.48, 95% CI 0.27–0.87). Conclusion Caregivers in our study population generally demonstrated low knowledge regarding appropriate use of antibiotics. Our findings suggest that misinformation about the types of infections (i.e. bacterial or viral) antibiotics should be used for may be associated with elevated odds of carriage of ESBL-EC. Understanding that using antibiotics is appropriate to treat infections some of the time may reduce the odds of ESBL-EC carriage. Overall, however, KAP measures of appropriate use of antibiotics were not strongly associated with ESBL-EC carriage. Other individual- and community-level environmental factors may overshadow the effect of KAP on ESBL-EC colonization. Intervention studies are needed to assess the true effect of improving KAP on laboratory-confirmed carriage of antimicrobial resistant bacteria, and should consider community-level studies for more effective management.
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Affiliation(s)
- Rachel Marusinec
- Berkeley School of Public Health, University of California, Berkeley, CA, USA
| | - Kathleen M Kurowski
- Berkeley School of Public Health, University of California, Berkeley, CA, USA
| | - Heather K Amato
- Berkeley School of Public Health, University of California, Berkeley, CA, USA
| | - Carlos Saraiva-Garcia
- Microbiology Institute, Colegio de Ciencias Biologicas Y Ambientales, Universidad San Francisco de Quito, Quito, Ecuador
| | - Fernanda Loayza
- Microbiology Institute, Colegio de Ciencias Biologicas Y Ambientales, Universidad San Francisco de Quito, Quito, Ecuador
| | - Liseth Salinas
- Microbiology Institute, Colegio de Ciencias Biologicas Y Ambientales, Universidad San Francisco de Quito, Quito, Ecuador
| | - Gabriel Trueba
- Microbiology Institute, Colegio de Ciencias Biologicas Y Ambientales, Universidad San Francisco de Quito, Quito, Ecuador
| | - Jay P Graham
- Berkeley School of Public Health, University of California, Berkeley, CA, USA.
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15
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Lin L, Alam P, Fearon E, Hargreaves JR. Public target interventions to reduce the inappropriate use of medicines or medical procedures: a systematic review. Implement Sci 2020; 15:90. [PMID: 33081791 PMCID: PMC7574316 DOI: 10.1186/s13012-020-01018-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/06/2020] [Indexed: 01/08/2023] Open
Abstract
Background An epidemic of health disorders can be triggered by a collective manifestation of inappropriate behaviors, usually systematically fueled by non-medical factors at the individual and/or societal levels. This study aimed to (1) landscape and assess the evidence on interventions that reduce inappropriate demand of medical resources (medicines or procedures) by triggering behavioral change among healthcare consumers, (2) map out intervention components that have been tried and tested, and (3) identify the “active ingredients” of behavior change interventions that were proven to be effective in containing epidemics of inappropriate use of medical resources. Methods For this systematic review, we searched MEDLINE, EMBASE, the Cochrane Library, and PsychINFO from the databases’ inceptions to May 2019, without language restrictions, for behavioral intervention studies. Interventions had to be empirically evaluated with a control group that demonstrated whether the effects of the campaign extended beyond trends occurring in the absence of the intervention. Outcomes of interest were reductions in inappropriate or non-essential use of medicines and/or medical procedures for clinical conditions that do not require them. Two reviewers independently screened titles, abstracts, and full text for inclusion and extracted data on study characteristics (e.g., study design), intervention development, implementation strategies, and effect size. Data extraction sheets were based on the checklist from the Cochrane Handbook for Systematic Reviews. Results Forty-three studies were included. The behavior change technique taxonomy v1 (BCTTv1), which contains 93 behavioral change techniques (BCTs), was used to characterize components of the interventions reported in the included studies. Of the 93 BCTs, 15 (16%) were identified within the descriptions of the selected studies targeting healthcare consumers. Interventions consisting of education messages, recommended behavior alternatives, and a supporting environment that incentivizes or encourages the adoption of a new behavior were more likely to be successful. Conclusions There is a continued tendency in research reporting that mainly stresses the effectiveness of interventions rather than the process of identifying and developing key components and the parameters within which they operate. Reporting “negative results” is likely as critical as reporting “active ingredients” and positive findings for implementation science. This review calls for a standardized approach to report intervention studies. Trial registration PROSPERO registration number CRD42019139537
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Affiliation(s)
- Leesa Lin
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Prima Alam
- London School of Hygiene & Tropical Medicine, London, UK
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16
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Aubin Ndjadi WK, Olivier M, Gray A-Wakamb K, Mick Ya-Pongombo S, André Kabamba M, Albert Mwembo-A-Nkoy T, Dieudonné Tshikwej N, Stanis Okitotsho W, Oscar Numbi L. General practitioners’ knowledge, attitudes and practices on antibiotic prescribing for acute respiratory infections in children in Lubumbashi, Democratic Republic of Congo. JOURNAL OF PULMONOLOGY AND RESPIRATORY RESEARCH 2020. [DOI: 10.29328/journal.jprr.1001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective: To assess the knowledge, attitudes and practices declared among general practitioners (GPs) concerning the use of antibiotics for the treatment of ARI in children under 5 years in Lubumbashi. Methods: A cross-sectional survey was conducted to assess the level of knowledge, attitude and practices concerning antibiotic prescribing among 67 GPs working in the pediatric setting in various health structures in Lubumbashi city, in the Democratic Republic of Congo. Data were collected from April 1st to June 30th, 2020. Results: GPs had limited knowledge about antibiotic prescriptions (mean of 46% correct answers to 8 questions). Although they are generally concerned about antibiotic resistance (mean ± SD = 0.50 ± 0.68), and are unwilling to submit to pressure to prescribe antibiotics to meet patient demands and expectations (mean ± SD = –1.78 ± 0.31) and the requirements to prescribe antibiotics for fear of losing patients (mean ± SD = –1.67 ± 0.47), there was a lack of motivation to change prescribing practices (mean ± SD = −0.37 ± 0.94) and strong agreement that they themselves should take responsibility for tackling antibiotic resistance (mean ± SD = 1.24 ± 0.74). Multiple linear regression results showed that higher knowledge scores were associated with less avoidance of responsibility when prescribing antibiotics (β = 0.919; p = 0.000). Conclusion: To curb the over-prescription of antibiotics, it is not enough to improve knowledge in itself. The lack of motivation of physicians to change must be addressed through a systematic approach. These data show the need for interventions that support the rational prescribing of antibiotics.
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17
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Avent ML, Cosgrove SE, Price-Haywood EG, van Driel ML. Antimicrobial stewardship in the primary care setting: from dream to reality? BMC FAMILY PRACTICE 2020; 21:134. [PMID: 32641063 PMCID: PMC7346425 DOI: 10.1186/s12875-020-01191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.
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Affiliation(s)
- M L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, Australia.
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Australia.
| | - S E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E G Price-Haywood
- Ochsner Health System, Center for Outcomes and Health Services Research, New Orleans, Louisiana, USA
- Ochnser Clinical School, The University of Queensland, New Orleans, Louisiana, USA
| | - M L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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18
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Fletcher-Miles H, Gammon J, Williams S, Hunt J. A scoping review to assess the impact of public education campaigns to affect behavior change pertaining to antimicrobial resistance. Am J Infect Control 2020; 48:433-442. [PMID: 31444097 DOI: 10.1016/j.ajic.2019.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Years of global antibiotic misuse has led to the progression of antimicrobial resistance (AMR), posing a direct threat to public health. To impact AMR and maintain antimicrobial viability, educational interventions toward fostering positive AMR behavior change have been employed with some success. METHODS This scoping review sought to identify research-supporting use of public educational AMR campaigns, and their efficacy toward informing positive AMR behaviors to inform current debate. To enable credible and reflexive examination of a wide variety of literature, Arksey and O'Malley's (2005) methodological framework was used. RESULTS Three primary themes were identified: (1) behavior change and theoretical underpinnings, (2) intervention paradigm, and (3) educational engagement. From 94 abstracts identified, 31 articles were chosen for review. More attention is required to identify elements of intervention design that inform and sustain behavior change, and the impact of how an intervention is delivered and targeted is needed to limit assumptions of population homogeneity, which potentially limits intervention efficacy. Moreover, research on the impact of hospital-based inpatient interventions is needed. CONCLUSIONS The existing body of research fails to provide robust evidence to support sound evidential interventions supported by theoretical justifications. Furthermore, interventions to ensure long-term sustained behavior change are unclear and not addressed.
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Affiliation(s)
| | - John Gammon
- College of Human and Health Sciences, Swansea University, Wales, United Kingdom
| | - Sharon Williams
- College of Human and Health Sciences, Swansea University, Wales, United Kingdom
| | - Julian Hunt
- College of Human and Health Sciences, Swansea University, Wales, United Kingdom
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19
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Satterfield J, Miesner AR, Percival KM. The role of education in antimicrobial stewardship. J Hosp Infect 2020; 105:130-141. [PMID: 32243953 DOI: 10.1016/j.jhin.2020.03.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/23/2020] [Indexed: 02/03/2023]
Abstract
The role of antimicrobial stewardship programmes (ASPs) has expanded in health systems. ASP interventions often contain an educational component; however, current guidelines suggest that educational interventions should not be used alone but to support other stewardship interventions. Such interventions are most commonly directed towards prescribers (often general practice physicians) with few studies offering education towards other healthcare providers such as pharmacists, nurses, or even members of the stewardship team. Educational interventions are offered most frequently, but not exclusively, with concomitant stewardship interventions such as prospective audit and feedback. Such strategies appear to positively impact prescribing behaviours, but it is not possible to isolate the effect of education from other interventions. Common educational methods include one-time seminars and online e-learning modules, but unique strategies such as social media platforms, educational video games and problem-based learning modules have also been employed. Education directed towards patients often occurs in conjunction with education of local prescribers and wider community-based efforts to impact prescribing. Such studies evaluating patient education often include passive educational leaflets and focus most often on appropriate treatment of upper respiratory tract infections. Educational interventions appear to be an integral component of other interventions of ASPs; however, there is a paucity of evidence to support use as a stand-alone intervention outside of regional public health interventions. Future studies should focus on efficacy of educational interventions including providing education to non-prescribers and disease states beyond upper respiratory tract infections to demonstrate a broader role for education in ASP activities.
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Affiliation(s)
- J Satterfield
- University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - A R Miesner
- Drake University College of Pharmacy & Health Sciences, Department of Clinical Sciences, Des Moines, IA, USA.
| | - K M Percival
- University of Iowa Hospitals and Clinics, Department of Pharmaceutical Care, Iowa City, IA, USA
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20
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Colijn C, Corander J, Croucher NJ. Designing ecologically optimized pneumococcal vaccines using population genomics. Nat Microbiol 2020; 5:473-485. [PMID: 32015499 PMCID: PMC7614922 DOI: 10.1038/s41564-019-0651-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022]
Abstract
Streptococcus pneumoniae (the pneumococcus) is a common nasopharyngeal commensal that can cause invasive pneumococcal disease (IPD). Each component of current protein-polysaccharide conjugate vaccines (PCVs) generally induces immunity specific to one of the approximately 100 pneumococcal serotypes, and typically eliminates it from carriage and IPD through herd immunity. Overall carriage rates remain stable owing to replacement by non-PCV serotypes. Consequently, the net change in IPD incidence is determined by the relative invasiveness of the pre- and post-PCV-carried pneumococcal populations. In the present study, we identified PCVs expected to minimize the post-vaccine IPD burden by applying Bayesian optimization to an ecological model of serotype replacement that integrated epidemiological and genomic data. We compared optimal formulations for reducing infant-only or population-wide IPD, and identified potential benefits to including non-conserved pneumococcal carrier proteins. Vaccines were also devised to minimize IPD resistant to antibiotic treatment, despite the ecological model assuming that resistance levels in the carried population would be preserved. We found that expanding infant-administered PCV valency is likely to result in diminishing returns, and that complementary pairs of infant- and adult-administered vaccines could be a superior strategy. PCV performance was highly dependent on the circulating pneumococcal population, further highlighting the advantages of a diversity of anti-pneumococcal vaccination strategies.
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Affiliation(s)
- Caroline Colijn
- Department of Mathematics, Simon Fraser University, Burnaby, BC, Canada.
- Department of Mathematics, Imperial College London, London, UK.
| | - Jukka Corander
- Department of Biostatistics, University of Oslo, Oslo, Norway
- Helsinki Institute of Information Technology, Department of Mathematics and Statistics, University of Helsinki, Helsinki, Finland
- Parasites & Microbes, Wellcome Sanger Institute, Wellcome Genome Campus, Cambridge, UK
| | - Nicholas J Croucher
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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21
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Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
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Affiliation(s)
- D. Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
| | - E. Barbieri
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
| | - M. Daverio
- Pediatric intensive care unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - R. Lundin
- Fondazione Penta ONLUS, Padua, Italy
| | - C. Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Fondazione Penta ONLUS, Padua, Italy
| | - T. Zaoutis
- Fondazione Penta ONLUS, Padua, Italy
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - M. Sharland
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
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Impact of Education and Peer Comparison on Antibiotic Prescribing for Pediatric Respiratory Tract Infections. Pediatr Qual Saf 2019; 4:e195. [PMID: 31572896 PMCID: PMC6708653 DOI: 10.1097/pq9.0000000000000195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/19/2019] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Inappropriate prescribing of broad-spectrum antibiotics is a significant modifiable risk factor for the development of antibiotic resistance. The objective was to improve guideline-concordant care for 3 common acute respiratory tract infections (ARTIs) and to reduce broad-spectrum antibiotic prescribing in ambulatory pediatric patients. Methods: Quality measures were developed for 3 ARTIs: viral upper respiratory infection (URI), acute bacterial sinusitis (ABS), and acute otitis media (AOM). Among 22 pediatric clinics, a collaborative of 10 was identified for intervention using baseline data for each ARTI, and 3 plan-do-study-act cycles were planned and completed. Outcomes included guideline-concordant antibiotic utilization and broad-spectrum antibiotic prescribing percentage (BSAP%). Comparison in number of diagnoses for the ARTI measures and total antibiotic prescribing over time served as balancing measures. Results: Collaborative clinics had baseline medians for appropriate or first-line treatment of 70% for URI, 53% for ABS, and 36% for AOM. To reach targets for URI, ABS, and AOM required 6, 14, and 18 months, respectively. At 42 months, performance for all 3 ARTIs remained ≥90%. BSAP% decreased from a baseline of 57% to 34% at 24 months. There was a limited effect from financial incentives but a significant decrease was noted in total antibiotic utilization. Diagnosis shifting may have occurred for URI and ABS while the rates for diagnoses for AOM declined over time. Conclusions: Through education and peer comparison feedback, guideline-concordant care for 3 ARTIs in collaborative clinics improved and remained beyond above targets and was accompanied by reductions in BSAP% and total antibiotic prescribing.
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Communication interventions to promote the public's awareness of antibiotics: a systematic review. BMC Public Health 2019; 19:899. [PMID: 31286948 PMCID: PMC6615171 DOI: 10.1186/s12889-019-7258-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 06/28/2019] [Indexed: 12/03/2022] Open
Abstract
Background Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public. Methods We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes. Results Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful. Conclusions Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term. Electronic supplementary material The online version of this article (10.1186/s12889-019-7258-3) contains supplementary material, which is available to authorized users.
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Rowe TA, Linder JA. Novel approaches to decrease inappropriate ambulatory antibiotic use. Expert Rev Anti Infect Ther 2019; 17:511-521. [DOI: 10.1080/14787210.2019.1635455] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Theresa A. Rowe
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A. Linder
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
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Rogers Van Katwyk S, Grimshaw JM, Nkangu M, Nagi R, Mendelson M, Taljaard M, Hoffman SJ. Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map. PLoS Med 2019; 16:e1002819. [PMID: 31185011 PMCID: PMC6559631 DOI: 10.1371/journal.pmed.1002819] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 05/03/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans. METHODS AND FINDINGS Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review. CONCLUSIONS To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published. PROTOCOL REGISTRATION PROSPERO CRD42017067514.
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Affiliation(s)
- Susan Rogers Van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Miriam Nkangu
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ranjana Nagi
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven J. Hoffman
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, and McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Affiliation(s)
- Lauri A Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop A-31 Atlanta, GA 30329, USA
| | - Laura M King
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop A-31 Atlanta, GA 30329, USA
| | - Katherine E Fleming-Dutra
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop A-31 Atlanta, GA 30329, USA
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Finkelstein JA, Raebel MA, Nordin JD, Lakoma M, Young JG. Trends in Outpatient Antibiotic Use in 3 Health Plans. Pediatrics 2019; 143:e20181259. [PMID: 30559122 PMCID: PMC6317571 DOI: 10.1542/peds.2018-1259] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.
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Affiliation(s)
- Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts;
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Marsha A Raebel
- Kaiser Permanente Colorado Institute for Health Research, Denver, Colorado
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado; and
| | | | - Matthew Lakoma
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jessica G Young
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Keller SC, Tamma PD, Cosgrove SE, Miller MA, Sateia H, Szymczak J, Gurses AP, Linder JA. Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review. J Am Board Fam Med 2018; 31:417-430. [PMID: 29743225 PMCID: PMC6013839 DOI: 10.3122/jabfm.2018.03.170225] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/28/2017] [Accepted: 01/04/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. METHODS We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. RESULTS Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. CONCLUSIONS A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.
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Affiliation(s)
- Sara C Keller
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL).
| | - Pranita D Tamma
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Sara E Cosgrove
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Melissa A Miller
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Heather Sateia
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Julie Szymczak
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Ayse P Gurses
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
| | - Jeffrey A Linder
- From Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD (SCK, PDT, SEC); Division of Healthcare-Associated Infections, Agency for Healthcare Research and Quality, Rockville (MAM); Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore (HS); University of Pennsylvania Perelman School of Medicine, Philadelphia (JS); Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore (SCK, SEC, APG); Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL (JAL)
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Saha SK, Hawes L, Mazza D. Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists. BMJ Open 2018; 8:e020583. [PMID: 29654036 PMCID: PMC5898351 DOI: 10.1136/bmjopen-2017-020583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist-GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. METHODS AND ANALYSIS A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. ETHICS AND DISSEMINATION No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017078478.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Lesley Hawes
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
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Schrier L, Hadjipanayis A, del Torso S, Stiris T, Emonts M, Dornbusch HJ. European Antibiotic Awareness Day 2017: training the next generation of health care professionals in antibiotic stewardship. Eur J Pediatr 2018; 177:279-283. [PMID: 29204852 PMCID: PMC5758684 DOI: 10.1007/s00431-017-3055-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/17/2017] [Accepted: 11/22/2017] [Indexed: 11/09/2022]
Abstract
Antimicrobial stewardship (AMS) aims to optimise treatment, minimise the risk of adverse effects and reduce health care costs. In addition, it is recognised as a key component to stop the current spread of antimicrobial resistance in Europe. Educational programmes are particularly important for the successful implementation of AMS. Training should start during medical school, continue during clinical training and be reinforced throughout postgraduate training. National core curricula for paediatric training should include passive and active training of competencies needed for AMS and future paediatricians should be skilled in taking leadership roles in AMS initiatives. Other core members of the paediatric AMS team should also receive training focused on the unique medical needs of the paediatric patient. CONCLUSION Ideally, all communities, hospitals and health regions in Europe should have AMS that serve all patient types, including children. We all have the responsibility to ensure that existing antibiotics remain effective. What is Known: • Antimicrobial stewardship (AMS) is a key component to stop the current spread of antimicrobial resistance • Educational programmes are particularly important for the successful implementation of AMS What is New: • All medical doctors in Europe who will be undertaking significant practice in child health should master the competencies needed to prescribe antibiotics to children rationally as described in the European Academy of Paediatrics (EAP) Curriculum for Common Trunk Training in Paediatrics • Interdisciplinary approaches of education need to be developed, as all hospitals and health regions in Europe ideally should have AMS programmes that serve all patient types, including children.
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Affiliation(s)
- Lenneke Schrier
- European Academy of Paediatrics, Brussels, Belgium
- Willem-Alexancer Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Adamos Hadjipanayis
- European Academy of Paediatrics, Brussels, Belgium
- Paediatric Department, Larnaca General Hospital, Larnaca, Cyprus
- European University Medical School, Nicosia, Cyprus
| | - Stefano del Torso
- European Academy of Paediatrics, Brussels, Belgium
- Pediatra di Famiglia, Padua, Italy
| | - Tom Stiris
- European Academy of Paediatrics, Brussels, Belgium
- Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
| | - Marieke Emonts
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Department of Paediatric Immunology and Infectious Diseases, Newcastle upon Tyne, UK
- Hospital Foundation Trust, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Hans Juergen Dornbusch
- European Academy of Paediatrics, Brussels, Belgium
- Medical University of Graz, Graz, Austria
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Geographic Variability in Diagnosis and Antibiotic Prescribing for Acute Respiratory Tract Infections. Infect Dis Ther 2017; 7:171-174. [PMID: 29273976 PMCID: PMC5840100 DOI: 10.1007/s40121-017-0181-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Indexed: 01/21/2023] Open
Abstract
Introduction Antibiotic prescribing rates vary substantially across regions in the USA. Whether these differences are driven primarily by a greater tendency to treat certain infections (i.e., overtreatment) in certain regions or differences in the tendency to diagnose certain infections (i.e., overdiagnosis) is poorly understood. Methods We examined data from 2012 to 2013 using the National Ambulatory Medical Care Survey, which is a nationally representative sample of visits to office-based physicians. For each of nine geographic regions, we examined the relationship between the visit rate/1000 population for respiratory diagnoses for which antibiotics were prescribed to the visit rate/1000 population for selected respiratory diagnoses where antibiotic therapy may be warranted. Results The visit rate for all respiratory conditions resulting in an antibiotic prescription was lowest (109/1000 population) in the Pacific Region and highest (176/1000, 95% CI 138–213) in the East South Central Region. The diagnosis rate for selected respiratory conditions where antibiotic therapy may be warranted was also lowest (119/1000, 95% CI 91–147) in the Pacific Region and highest (189/1000, 95% CI 153–225) in the East South Central Region. Conclusion Antibiotic prescribing rates for respiratory conditions vary by region and are strongly associated with the rate with which selected respiratory conditions are diagnosed.
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Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003) 2017; 57:464-473. [DOI: 10.1016/j.japh.2017.03.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 01/10/2023]
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Martínez-González NA, Coenen S, Plate A, Colliers A, Rosemann T, Senn O, Neuner-Jehle S. The impact of interventions to improve the quality of prescribing and use of antibiotics in primary care patients with respiratory tract infections: a systematic review protocol. BMJ Open 2017; 7:e016253. [PMID: 28611111 PMCID: PMC5726136 DOI: 10.1136/bmjopen-2017-016253] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/02/2017] [Accepted: 05/11/2017] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) are the most common reason for primary care (PC) consultations and for antibiotic prescribing and use. The majority of RTIs have a viral aetiology however, and antibiotic consumption is ineffective and unnecessary. Inappropriate antibiotic use contributes greatly to antibiotic resistance (ABR) leading to complications, increased adverse events, reconsultations and costs. Improving antibiotic consumption is thus crucial to containing ABR, which has become an urgent priority worldwide. We will systematically review the evidence about interventions aimed at improving the quality of antibiotic prescribing and use for acute RTI. METHODS AND ANALYSIS We will include primary peer-reviewed and grey literature of studies conducted on in-hours and out-of-hours PC patients (adults and children): (1) randomised controlled trials (RCTs), quasi-RCTs and/or cluster-RCTs evaluating the effectiveness, feasibility and acceptability of patient-targeted and clinician-targeted interventions and (2) RCTs and other study designs evaluating the effectiveness of public campaigns and regulatory interventions. We will search MEDLINE (EBSCOHost), EMBASE (Elsevier), the Cochrane Library (Wiley), CINHAL (EBSCOHost), PsychINFO (EBSCOHost), Web of Science, LILACS (Latin American and Caribbean Literature on Health Sciences), TRIP (Turning Research Into Practice) and opensgrey.eu without language restriction. We will also search the reference lists of included studies and relevant reviews. Primary outcomes include the rates of (guideline-recommended) antibiotics prescribed and/or used. Secondary outcomes include immediate or delayed use of antibiotics, and feasibility and acceptability outcomes. We will assess study eligibility and risk of bias, and will extract data. Data permitting, we will perform meta-analyses. ETHICS AND DISSEMINATION This is a systematic review protocol and so formal ethical approval is not required. We will not collect confidential, personal or primary data. The findings of this review will be disseminated at national and international scientific meetings. TRIAL REGISTRATION NUMBER PROSPERO trial (CRD42017035305).
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Affiliation(s)
| | - Samuel Coenen
- Department of Primary and Interdisciplinary Care (ELIZA), Centre for General Practice, University of Antwerp - Campus Drie Eiken, Wilrijk, Belgium
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Annelies Colliers
- Department of Primary and Interdisciplinary Care (ELIZA), Centre for General Practice, University of Antwerp - Campus Drie Eiken, Wilrijk, Belgium
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Almalki ZS, Yue X, Xia Y, Wigle PR, Guo JJ. Utilization, Spending, and Price Trends for Quinolones in the US Medicaid Programs: 25 Years' Experience 1991-2015. PHARMACOECONOMICS - OPEN 2017; 1:123-131. [PMID: 29442334 PMCID: PMC5691846 DOI: 10.1007/s41669-016-0007-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Given that the quinolones is one of the antibacterial classes most frequently used to treat patients with bacterial infections in the United States, any change in prescribing patterns of quinolones will impact Medicaid medical expenditures. OBJECTIVES This study was undertaken to examine trends in utilization, reimbursement, and prices of quinolone antibacterials for the US Medicaid population. METHODS The publicly available Medicaid State Drug Utilization outpatient pharmacy files were used for this study. Quarterly and annual prescription counts and reimbursement amounts were calculated for each of the quinolones reimbursed by Medicaid from quarter 1, 1991 through quarter 2, 2015. Average per-prescription reimbursement, as a proxy for drug price, was calculated as the drug reimbursement divided by the number of prescriptions. RESULTS The total annual number of quinolone prescriptions increased 402%, from 247,395 in the first quarter of 1991 to 1.2 million in the second quarter of 2015, peaking at 1.3 million in the first quarter of 2005. Similarly, the total reimbursement for quinolone agents increased by 245.5% over the same period. More than 80% of quinolone prescriptions reimbursed by Medicaid were for the second-generation agent, ciprofloxacin, and the third-generation agent, levofloxacin. The average payment per prescription for quinolones increased from US$43.8 in the first quarter of 1991 to US$87.6 in the second quarter of 2015. CONCLUSIONS A substantial rise in Medicaid expenditures on quinolones was observed during the 25-year study period, which was mainly because of rising utilization. Therefore, there is a need for additional research that has access to clinically relevant data with which to measure the rate of inappropriate quinolone use among the Medicaid population and associated clinical outcomes and healthcare costs.
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Affiliation(s)
- Ziyad S Almalki
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, 45267, USA.
| | - Xiaomeng Yue
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, 45267, USA
| | - Ying Xia
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, 45267, USA
| | - Patricia R Wigle
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, 45267, USA
| | - Jeff Jianfei Guo
- James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, 45267, USA
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Youngster I, Avorn J, Belleudi V, Cantarutti A, Díez-Domingo J, Kirchmayer U, Park BJ, Peiró S, Sanfélix-Gimeno G, Schröder H, Schüssel K, Shin JY, Shin SM, Simonsen GS, Blix HS, Tong A, Trifirò G, Ziv-Baran T, Kim SC. Antibiotic Use in Children - A Cross-National Analysis of 6 Countries. J Pediatr 2017; 182:239-244.e1. [PMID: 28012694 DOI: 10.1016/j.jpeds.2016.11.027] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/13/2016] [Accepted: 11/07/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To describe the rates of pediatric antibiotic use across 6 countries on 3 continents. STUDY DESIGN Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries. RESULTS A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population. CONCLUSIONS We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.
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Affiliation(s)
- Ilan Youngster
- Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Anna Cantarutti
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Javier Díez-Domingo
- Health Services Research Unit, Center for Public Health Research, Valencia, Spain
| | - Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Byung-Joo Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Salvador Peiró
- Health Services Research Unit, Center for Public Health Research, Valencia, Spain
| | | | - Helmut Schröder
- Wissenschaftliches Institut der AOK WIdO (Scientific Institute of the AOK), Berlin, Germany
| | - Katrin Schüssel
- Wissenschaftliches Institut der AOK WIdO (Scientific Institute of the AOK), Berlin, Germany
| | - Ju-Young Shin
- Korea Institute of Drug Safety and Risk Management, Seoul, Republic of Korea
| | - Sun Mi Shin
- Korea Institute of Drug Safety and Risk Management, Seoul, Republic of Korea
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Hege Salvesen Blix
- Department of Pharmacoepidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Angela Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gianluca Trifirò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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Kleinman K, Huang SS. Calculating Power by Bootstrap, with an Application to Cluster-Randomized Trials. EGEMS 2017; 4:1202. [PMID: 28303254 PMCID: PMC5340517 DOI: 10.13063/2327-9214.1202] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: A key requirement for a useful power calculation is that the calculation mimic the data analysis that will be performed on the actual data, once that data is observed. Close approximations may be difficult to achieve using analytic solutions, however, and thus Monte Carlo approaches, including both simulation and bootstrap resampling, are often attractive. One setting in which this is particularly true is cluster-randomized trial designs. However, Monte Carlo approaches are useful in many additional settings as well. Calculating power for cluster-randomized trials using analytic or simulation-based methods is frequently unsatisfactory due to the complexity of the data analysis methods to be employed and to the sparseness of data to inform the choice of important parameters in these methods. Methods: We propose that among Monte Carlo methods, bootstrap approaches are most likely to generate data similar to the observed data. In bootstrap approaches, real data are resampled to build complete data sets based on real data that resemble the data for the intended analyses. In contrast, simulation methods would use the real data to estimate parameters for the data, and would then simulate data using these parameters. We describe means of implementing bootstrap power calculation. Results: We demonstrate bootstrap power calculation for a cluster-randomized trial with a censored survival outcome and a baseline observation period. Conclusions: Bootstrap power calculation is a natural application of resampling methods. It provides a relatively simple solution to power calculation that is likely to be more accurate than analytic solutions or simulation-based calculations, in the sense that the bootstrap approach does not rely on the assumptions inherent in analytic calculations. This method of calculation has several important strengths. Notably, it is simple to achieve great fidelity to the proposed data analysis method and there is no requirement for parameter estimates, or estimates of their variability, from outside settings. So, for example, for cluster-randomized trials, power calculations need not depend on intracluster correlation coefficient estimates from outside studies. In contrast, bootstrap power calculation requires initial data that resemble data that are to be used in the planned study. We are not aware of bootstrap power calculation being previously proposed or explored for cluster-randomized trials, but it can also be applied for other study designs. We show with a simulation study that bootstrap power calculation can replicate analytic power in cases where analytic power can be accurately calculated. We also demonstrate power calculations for correlated censored survival outcomes in a cluster-randomized trial setting, for which we are unaware of an analytic alternative. The method can easily be used when preliminary data are available, as is likely to be the case when research is performed in health delivery systems or other settings where electronic medical records can be obtained.
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Affiliation(s)
- Ken Kleinman
- Department of Biostatistics and Epidemiology, University of Massachusetts Amherst School of Public Health and Health Sciences; Department of Population Medicine, Harvard Medical School
| | - Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California Irvine School of Medicine
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Robert A, Nguyen Y, Bajolet O, Vuillemin B, Defoin B, Vernet-Garnier V, Drame M, Bani-Sadr F. Knowledge of antibiotics and antibiotic resistance in patients followed by family physicians. Med Mal Infect 2016; 47:142-151. [PMID: 27856082 DOI: 10.1016/j.medmal.2016.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 05/06/2016] [Accepted: 10/11/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We aimed to evaluate factors associated with knowledge of antibiotics and drug resistance. METHODS A questionnaire was handed out by 14 family physicians to their patients between December 20, 2014 and April 20, 2015 in Rethel (North-East of France). We conducted a cross-sectional study using a logistical regression model to assess factors associated with antibiotic knowledge. Three criteria were used to assess that knowledge. RESULTS Overall, 293 questionnaires were analysed; 48% of patients had received antibiotics in the previous 12 months. Only 44% and 26% gave a correct answer for the statements "Antibiotics are effective against bacteria and ineffective against viruses" and "Antibiotic resistance decreases if the antibiotic use decreases", respectively. Characteristics such as female sex, age>30 years, high level of education, high professional categories, and having received antibiotic information by the media were associated with high level of knowledge about antibiotics and/or antibiotic resistance. In contrast, having received antibiotic information from family physicians was not associated with good knowledge. CONCLUSION Although media awareness campaigns had an independent impact on a higher public knowledge of antibiotics, the overall public knowledge remains low. It would be necessary to strengthen antibiotic campaigns with clearer information on the relation between the excessive use of antibiotics and the increased risk of antibiotic resistance. Family physicians should be more involved to improve antibiotic knowledge among target groups such as men, young patients, and people from a poor social and cultural background.
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Affiliation(s)
- A Robert
- Unité des maladies infectieuses et tropicales, hôpital Robert-Debré, université de Reims Champagne-Ardenne, CHU de Reims, 51092 Reims, France
| | - Y Nguyen
- Unité des maladies infectieuses et tropicales, hôpital Robert-Debré, université de Reims Champagne-Ardenne, CHU de Reims, 51092 Reims, France; EA-4684/SFR CAP-SANTE, faculté de médecine, université de Reims Champagne-Ardenne, 51095 Reims, France
| | - O Bajolet
- Laboratoire de bactériologie-virologie-hygiène, CHU de Reims, 51092 Reims, France; UFR médecine SFR CAP Santé, EA 4687, université de Reims Champagne-Ardenne, 51095 Reims, France
| | - B Vuillemin
- Cabinet de médecine générale, 08190 Asfeld, France
| | - B Defoin
- UFR médecine Reims, département de médecine générale, université de Reims Champagne-Ardenne, 51095 Reims, France
| | - V Vernet-Garnier
- Laboratoire de bactériologie-virologie-hygiène, CHU de Reims, 51092 Reims, France; UFR médecine SFR CAP Santé, EA 4687, université de Reims Champagne-Ardenne, 51095 Reims, France
| | - M Drame
- EA 3797, faculté de médecine, université de Reims Champagne-Ardenne, 51095 Reims, France; Unité d'aide méthodologique, pôle recherche et innovations, hôpital Robert-Debré, CHU de Reims, 51092 Reims, France
| | - F Bani-Sadr
- Unité des maladies infectieuses et tropicales, hôpital Robert-Debré, université de Reims Champagne-Ardenne, CHU de Reims, 51092 Reims, France; EA-4684/SFR CAP-SANTE, faculté de médecine, université de Reims Champagne-Ardenne, 51095 Reims, France.
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Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016; 65:1-12. [PMID: 27832047 DOI: 10.15585/mmwr.rr6506a1] [Citation(s) in RCA: 358] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.
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Abstract
BACKGROUND Antibiotics are among the drugs most commonly prescribed to children in hospitals and communities. Unfortunately, a great number of these prescriptions are unnecessary or inappropriate. Antibiotic abuse and misuse have several negative consequences, including drug-related adverse events, the emergence of multidrug resistant bacterial pathogens, the development of Clostridium difficile infection, the negative impact on microbiota, and undertreatment risks. In this paper, the principle of and strategies for paediatric antimicrobial stewardship (AS) programs, the effects of AS interventions and the common barriers to development and implementation of AS programs are discussed. DISCUSSION Over the last few years, there have been significant shortages in the development and availability of new antibiotics; therefore, the implementation of strategies to preserve the activity of existing antimicrobial agents has become an urgent public health priority. AS is one such approach. The need for formal AS programs in paediatrics was officially recognized only recently, considering the widespread use of antibiotics in children and the different antimicrobial resistance patterns that these subjects exhibit in comparison to adult and elderly patients. However, not all problems related to the implementation of AS programs among paediatric patients are solved. The most important remaining problems involve educating paediatricians, creating a multidisciplinary interprofessional AS team able to prepare guidelines, monitoring antibiotic prescriptions and defining corrective measures, and the availability of administrative consensuses with adequate financial support. Additionally, the problem of optimizing the duration of AS programs remains unsolved. Further studies are needed to solve the above mentioned problems. CONCLUSIONS In paediatric patients, as in adults, the successful implementation of AS strategies has had a significant impact on reducing targeted- and nontargeted-antimicrobial use by improving the quality of care for hospitalized patients and preventing the emergence of resistance. Considering that rationalization of antibiotic misuse and abuse is the basis for reducing emergence of bacterial resistance and several clinical problems, all efforts must be made to develop multidisciplinary paediatric AS programs in hospital and community settings.
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Affiliation(s)
- Nicola Principi
- Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milan, 20122 Italy
| | - Susanna Esposito
- Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milan, 20122 Italy
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Barlam TF, Soria-Saucedo R, Cabral HJ, Kazis LE. Unnecessary Antibiotics for Acute Respiratory Tract Infections: Association With Care Setting and Patient Demographics. Open Forum Infect Dis 2016; 3:ofw045. [PMID: 27006968 PMCID: PMC4800455 DOI: 10.1093/ofid/ofw045] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 02/18/2016] [Indexed: 01/20/2023] Open
Abstract
Background. Up to 40% of antibiotics are prescribed unnecessarily for acute respiratory tract infections (ARTIs). We sought to define factors associated with antibiotic overprescribing of ARTIs to inform efforts to improve practice. Methods. We conducted a retrospective analysis of ARTI visits between 2006 and 2010 from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Those surveys provide a representative sample of US visits to community-based physicians and to hospital-based emergency departments (EDs) and outpatient practices. Patient factors (age, sex, race, underlying lung disease, tobacco use, insurance), physician specialty, practice demographics (percentage poverty, median household income, percentage with a Bachelor's Degree, urban-rural status, geographic region), and care setting (ED, hospital, or community-based practice) were evaluated as predictors of antibiotic overprescribing for ARTIs. Results. Hospital and community-practice visits had more antibiotic overprescribing than ED visits (odds ratio [OR] = 1.64 and 95% confidence interval [CI], 1.27-2.12 and OR = 1.59 and 95% CI, 1.26-2.01, respectively). Care setting had significant interactions with geographic region and urban and rural location. The quartile with the lowest percentage of college-educated residents had significantly greater overprescribing (adjusted OR = 1.41; 95% CI, 1.07-1.86) than the highest quartile. Current tobacco users were overprescribed more often than nonsmokers (OR = 1.71; 95% CI, 1.38-2.12). Patient age, insurance, and provider specialty were other significant predictors. Conclusions. Tobacco use and a lower grouped rate of college education were associated with overprescribing and may reflect poor health literacy. A focus on educating the patient may be an effective approach to stewardship.
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Affiliation(s)
| | - Rene Soria-Saucedo
- Department of Health Policy and Management; Center for the Assessment of Pharmaceutical Practices
| | - Howard J Cabral
- Department of Biostatistics , Boston University School of Public Health , Massachusetts
| | - Lewis E Kazis
- Department of Health Policy and Management; Center for the Assessment of Pharmaceutical Practices
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Dar OA, Hasan R, Schlundt J, Harbarth S, Caleo G, Dar FK, Littmann J, Rweyemamu M, Buckley EJ, Shahid M, Kock R, Li HL, Giha H, Khan M, So AD, Bindayna KM, Kessel A, Pedersen HB, Permanand G, Zumla A, Røttingen JA, Heymann DL. Exploring the evidence base for national and regional policy interventions to combat resistance. Lancet 2016; 387:285-95. [PMID: 26603921 DOI: 10.1016/s0140-6736(15)00520-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to inform effective policy interventions across countries with different income levels and the human health and animal sectors. We examine three policy domains-responsible use, surveillance, and infection prevention and control-and consider which will be the most effective at national and regional levels. Many complexities exist in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, we make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks, of cost-effectiveness and generalisability. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. We also advocate a One Health approach that will enable the development of sensitive policies, accommodating the needs of each sector involved, and addressing concerns of specific countries and regions.
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Affiliation(s)
- Osman A Dar
- Public Health England, London, UK; Chatham House Centre on Global Health Security, London, UK.
| | | | - Jørgen Schlundt
- School of Chemical & Biomedical Engineering, Nanyang Technological University, Singapore
| | - Stephan Harbarth
- University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | | | | | - Mark Rweyemamu
- Southern African Centre for Infectious Disease Surveillance, Sokoine University of Agriculture, Morogoro, Tanzania
| | | | - Mohammed Shahid
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
| | | | - Henry Lishi Li
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Mishal Khan
- London School of Hygiene & Tropical Medicine, London, UK; Research Alliance for Advocacy and Development, Karachi, Pakistan
| | - Anthony D So
- Sanford School of Public Policy and Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Anthony Kessel
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Alimuddin Zumla
- University College London, London, UK; National Institute for Health Research Biomedical Research Centre, University College Hospitals NHS Trust, London, UK
| | - John-Arne Røttingen
- Norwegian Institute of Public Health, Oslo, Norway; Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - David L Heymann
- Public Health England, London, UK; Chatham House Centre on Global Health Security, London, UK; London School of Hygiene & Tropical Medicine, London, UK
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Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015; 36:142-52. [PMID: 25632996 DOI: 10.1017/ice.2014.41] [Citation(s) in RCA: 188] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs. DESIGN Systematic review METHODS Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type. RESULTS We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited. CONCLUSIONS Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.
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Vaz LE, Kleinman KP, Lakoma MD, Dutta-Linn MM, Nahill C, Hellinger J, Finkelstein JA. Prevalence of Parental Misconceptions About Antibiotic Use. Pediatrics 2015; 136:221-31. [PMID: 26195539 PMCID: PMC4516948 DOI: 10.1542/peds.2015-0883] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Differences in antibiotic knowledge and attitudes between parents of Medicaid-insured and commercially insured children have been previously reported. It is unknown whether understanding has improved and whether previously identified differences persist. METHODS A total of 1500 Massachusetts parents with a child <6 years old insured by a Medicaid managed care or commercial health plan were surveyed in spring 2013. We examined antibiotic-related knowledge and attitudes by using χ(2) tests. Multivariable modeling was used to assess current sociodemographic predictors of knowledge and evaluate changes in predictors from a similar survey in 2000. RESULTS Medicaid-insured parents in 2013 (n = 345) were younger, were less likely to be white, and had less education than those commercially insured (n = 353), P < .01. Fewer Medicaid-insured parents answered questions correctly except for one related to bronchitis, for which there was no difference (15% Medicaid vs 16% commercial, P < .66). More parents understood that green nasal discharge did not require antibiotics in 2013 compared with 2000, but this increase was smaller among Medicaid-insured (32% vs 22% P = .02) than commercially insured (49% vs 23%, P < .01) parents. Medicaid-insured parents were more likely to request unnecessary antibiotics in 2013 (P < .01). Multivariable models for predictors of knowledge or attitudes demonstrated complex relationships between insurance status and sociodemographic variables. CONCLUSIONS Misconceptions about antibiotic use persist and continue to be more prevalent among parents of Medicaid-insured children. Improvement in understanding has been more pronounced in more advantaged populations. Tailored efforts for socioeconomically disadvantaged populations remain warranted to decrease parental drivers of unnecessary antibiotic prescribing.
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Affiliation(s)
- Louise Elaine Vaz
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon;
| | - Kenneth P Kleinman
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Matthew D Lakoma
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - M Maya Dutta-Linn
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - James Hellinger
- Neighborhood Health Plan, Boston, Massachusetts; Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts; and
| | - Jonathan A Finkelstein
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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45
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Hernandez-Santiago V, Marwick CA, Patton A, Davey PG, Donnan PT, Guthrie B. Time series analysis of the impact of an intervention in Tayside, Scotland to reduce primary care broad-spectrum antimicrobial use. J Antimicrob Chemother 2015; 70:2397-404. [PMID: 25953807 DOI: 10.1093/jac/dkv095] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/19/2015] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Concern about Clostridium difficile infection (CDI) and resistance has driven interventions internationally to reduce broad-spectrum antimicrobial use. An intervention combining guidelines, education and feedback was implemented in Tayside, Scotland in 2009 aiming to reduce primary care prescribing of co-amoxiclav, cephalosporins, fluoroquinolones and clindamycin ('4C antimicrobials'). Our aim was to assess the impact of this real-world intervention on antimicrobial prescribing rates. METHODS We used interrupted time series with segmented regression analysis to examine associations between the intervention and changes in antimicrobial prescribing (quarterly rates of patients exposed to 4C antimicrobials, non-4C antimicrobials and any antimicrobial in 2005-12). RESULTS The intervention was associated with a highly significant and sustained decrease in 4C antimicrobial prescribing, by 33.5% (95% CI -26.1 to -40.9), 42.2% (95% CI -34.2 to -50.2) and 55.5% (95% CI -45.9 to -65.1) at 6, 12 and 24 months after intervention, respectively. The effect was seen across all age groups, with the largest reductions in people aged 65 years and over (58.4% reduction at 24 months, 95% CI -46.7 to -70.1) and care home residents (65.6% reduction at 24 months, 95% CI -51.8 to -79.4). There were balancing increases in doxycycline, nitrofurantoin and trimethoprim prescribing as well as a reduction in macrolide prescribing. Total antimicrobial exposure did not change. CONCLUSIONS A real-world intervention to reduce primary care prescribing of antimicrobials associated with CDI led to large, sustained reductions in the targeted prescribing, largely due to substitution with guideline-recommended antimicrobials rather than by avoiding antimicrobial use altogether. Further research is needed to examine the impact on antimicrobial resistance.
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Affiliation(s)
- Virginia Hernandez-Santiago
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Charis A Marwick
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Andrea Patton
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Peter G Davey
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Peter T Donnan
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Bruce Guthrie
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
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46
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Educational effectiveness, target, and content for prudent antibiotic use. BIOMED RESEARCH INTERNATIONAL 2015; 2015:214021. [PMID: 25945327 PMCID: PMC4402196 DOI: 10.1155/2015/214021] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 03/20/2015] [Indexed: 11/18/2022]
Abstract
Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.
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47
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Wang S, Pulcini C, Rabaud C, Boivin JM, Birgé J. Inventory of antibiotic stewardship programs in general practice in France and abroad. Med Mal Infect 2015; 45:111-23. [DOI: 10.1016/j.medmal.2015.01.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/18/2014] [Accepted: 01/28/2015] [Indexed: 12/18/2022]
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48
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Roque F, Herdeiro MT, Soares S, Teixeira Rodrigues A, Breitenfeld L, Figueiras A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014; 14:1276. [PMID: 25511932 PMCID: PMC4302109 DOI: 10.1186/1471-2458-14-1276] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings. Methods We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011. Results We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively. Conclusion The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Maria Teresa Herdeiro
- Centre for Cell Biology, University of Aveiro (Centro de Biologia Celular - CBC/UA); Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
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49
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Lalana-Josa P, Laclaustra-Mendizábal B, Aza-Pascual-Salcedo MM, Carcas-de-Benavides C, Lallana-Álvarez MJ, Pina-Gadea MB. [Does the prescribing of antibiotics in paediatrics improve after a multidisciplinary intervention?]. Enferm Infecc Microbiol Clin 2014; 33:78-83. [PMID: 25124487 DOI: 10.1016/j.eimc.2014.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/03/2014] [Accepted: 05/29/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Antibiotics overuse is linked to elevated antimicrobial resistance. In Aragon, Spain, the highest antibiotic prescription rates occur among children from 1 to 4 years old. The rate of use in this age group is over 60%. AIM To evaluate the effect of multi-faceted intervention on Primary Care paediatricians to reduce antibiotic use and to improve antibiotic prescribing for paediatric outpatients. METHODS Outpatient antimicrobial prescribing was analysed before and after an intervention in paediatricians. The intervention included a clinical education session about diagnosis and treatment in the most prevalent paediatric infectious diseases, a clinical interview and communication skills, a workshop on rapid Streptococcus antigen detection test and patient information leaflets and useful internet websites for parents. The control group included paediatricians without this educational intervention on antibiotics. RESULTS Antibiotic prescribing decreased from 19.17 defined daily doses per 1000 inhabitants/day (DID) to 14.36 DID among intervention paediatricians vs 19.84 DID to 16.02 DID in controls. The decreasing was higher in the intervention group, but the effect was not statistically significant. Macrolides and broad-spectrum penicillins prescribing decreased in both groups. CONCLUSION Antibiotic prescribing decreased, but there were no statistically significant differences between the two groups. The high satisfaction of paediatricians in the intervention group makes it necessary to continue with these kinds of strategies to improve antibiotic use in outpatients.
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Affiliation(s)
- Pilar Lalana-Josa
- Centro de Salud Oliver, Sector Zaragoza III, Servicio Aragonés de Salud, Zaragoza, España.
| | | | | | | | - M Jesús Lallana-Álvarez
- Dirección de Atención Primaria, Sector Zaragoza III, Servcio Aragonés de Salud, Zaragoza, España
| | - M Belén Pina-Gadea
- Dirección de Atención Primaria, Sector Zaragoza II, Servicio Aragonés de Salud, Zaragoza, España
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50
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Stockwell MS, Catallozzi M, Larson E, Rodriguez C, Subramony A, Andres Martinez R, Martinez E, Barrett A, Meyer D. Effect of a URI-related educational intervention in early head start on ED visits. Pediatrics 2014; 133:e1233-40. [PMID: 24709931 PMCID: PMC4006431 DOI: 10.1542/peds.2013-2350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness of an educational intervention to decrease pediatric emergency department (PED) visits and adverse care practices for upper respiratory infections (URI) among predominantly Latino Early Head Start (EHS) families. METHODS Four EHS sites in New York City were randomized. Families at intervention sites received 3 1.5-hour education modules in their EHS parent-child group focusing on URIs, over-the-counter medications, and medication management. Standard curriculum families received the standard EHS curriculum, which did not include URI education. During weekly telephone calls for 5 months, families reported URI in family members, care sought, and medications given. Pre- and post-intervention knowledge-attitude surveys were also conducted. Outcomes were compared between groups. RESULTS There were 154 families who participated (76 intervention, 78 standard curriculum) including 197 children <4 years old. Families were primarily Latino and Spanish-speaking. Intervention families were significantly less likely to visit the PED when their young child (age 6 to <48 months) was ill (8.2% vs 15.7%; P = .025). The difference remained significant on the family level (P = .03). These families were also less likely to use an inappropriate over-the-counter medication for their <2-year-old child (odds ratio, 0.29; 95% confidence interval, 0.09-0.95; 12.2% vs 32.4%, P = .034) and/or incorrect dosing tool for their <4-year-old child (odds ratio, 0.24; 95% confidence interval, 0.08-0.74; 9.8% vs 31.1%; P < .01). The mean difference in Knowledge-Attitude scores for intervention families was higher. CONCLUSIONS A URI health literacy-related educational intervention embedded into EHS decreased PED visits and adverse care practices.
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Affiliation(s)
- Melissa S. Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics,,Department of Population and Family Health and,New York-Presbyterian Hospital, New York, New York
| | - Marina Catallozzi
- Division of Child and Adolescent Health, Department of Pediatrics,,Department of Population and Family Health and,New York-Presbyterian Hospital, New York, New York
| | - Elaine Larson
- Department of Epidemiology, Mailman School of Public Health, and,School of Nursing, Columbia University, New York, New York; and
| | | | - Anupama Subramony
- Division of Child and Adolescent Health, Department of Pediatrics,,New York-Presbyterian Hospital, New York, New York
| | | | - Emelin Martinez
- Division of Child and Adolescent Health, Department of Pediatrics
| | - Angela Barrett
- Division of Child and Adolescent Health, Department of Pediatrics
| | - Dodi Meyer
- Division of Child and Adolescent Health, Department of Pediatrics,,New York-Presbyterian Hospital, New York, New York
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