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Chan OS, Wu P, Cowling B, Lee E, Yeung M, St-Hilaire S, Tun H, Wernli D, Lam W. Prescribing antibiotics prudently-A survey of policy implementation drivers among physicians and veterinarians. One Health 2024; 18:100752. [PMID: 38832078 PMCID: PMC11145358 DOI: 10.1016/j.onehlt.2024.100752] [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: 09/27/2023] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
Background As the antimicrobial resistance (AMR) problem accelerates, humans and animals are suffering from the consequences of infections with diminishing antimicrobial treatment options. Within the One Medicine and One Health mandate, which denotes a collaborative, multisectoral, and transdisciplinary approach to improve medicine and health across human and animal sectors, we investigate how human and veterinary medical practitioners apply their medical and policy knowledge in prescribing antimicrobials. Different regions and locations establish different intermediary policies and programs to support clinicians in that pursuit. In Hong Kong, there are locally adapted programs at governance and clinical levels in the human medical field. However, there is no locally adapted veterinary antibiotic prescription guideline or stewardship program, and veterinarians adopt overseas or international professions' antimicrobial use guidelines. Such a policy environment creates a natural experiment to compare local policy implementation conditions and clinicians' knowledge, perception, and practice. Method We construct the investigative survey tool by adaptation of Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, and Motivation-Behavior (COM-B) models. We identify, compare and contrast factors that influence clinicians' antimicrobial prescription behavior. The factors are considered both intrinsically, such as personal attributes, and extrinsically, such as societal and professional norms. Findings The absence of locally adopted antimicrobial guidelines influences AMR stewardship program implementation in local Hong Kong veterinary community. As medical allies, physicians and veterinarians share similar demographic influence, organization considerations and perception of public awareness. Both cohorts prescribe more prudently with more years-in-practice, time available to communicate with patients or caretakers, and public awareness and support.
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Affiliation(s)
- Olivia S.K. Chan
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Peng Wu
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ben Cowling
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Elaine Lee
- Agriculture, Fisheries and Conservation Department, 5/F, Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon, Hong Kong SAR, China
| | - Michelle Yeung
- Agriculture, Fisheries and Conservation Department, 5/F, Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon, Hong Kong SAR, China
| | - Sophie St-Hilaire
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Kowloon Tong, Hong Kong SAR, People's Republic of China
| | - Hein Tun
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Didier Wernli
- Global Studies Institute, University of Geneva, Sciences II, Quai Ernest-Ansermet 30, CH-1211 Genève, Switzerland
| | - Wendy Lam
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Taborda JCM, Guzmán JCM, Higuita-Gutiérrez LF. Understanding antibiotic knowledge, attitudes, and practices: a cross-sectional study in physicians from a Colombian region, 2023. BMC MEDICAL EDUCATION 2024; 24:380. [PMID: 38589913 PMCID: PMC11000393 DOI: 10.1186/s12909-024-05354-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Antibiotic resistance has been identified as a global health threat. Knowledge, attitudes, and inappropriate prescription practices of antibiotics by physicians play a crucial role in this problem. In Colombia, research addressing this issue is scarce. METHODS A cross-sectional study involving 258 physicians was conducted. A scale with questions on sociodemographic aspects, level of education, satisfaction with antibiotic education received, and knowledge, attitudes, and practices was administered. The scale was designed for each item to be analyzed individually or as a total score ranging from 0 to 100 (0 being the lowest and 100 the highest). RESULTS 31.5% of physicians rated the education received on antibiotics as fair to poor. The knowledge score was 80.1 (IQR 70.5-87.5); however, 25.2% agreed to some extent that amoxicillin is useful in treating most respiratory infections, and 15% agreed that antibiotics are effective in treating upper respiratory infections. Attitudes scored 80.2 (IQR 75.0-86.5), with 99% stating that bacterial resistance is a public health problem in Colombia, but only 56.9% considering it a problem affecting their daily practice. Practices scored 75.5 (IQR 68.8-81.2), and 71.7% affirmed that if they refuse to prescribe antibiotics to a patient who does not need them, the patient can easily obtain them from another physician. General practitioners were found to have lower scores in all three indices evaluated. CONCLUSION The study reveals enduring misconceptions and concerning practices in antibiotic prescription, particularly among general practitioners. Enhancing knowledge necessitates the implementation of continuous medical education programs that focus on updated antibiotic guidelines, and resistance patterns. Fostering positive attitudes requires a culture of trust and collaboration among healthcare professionals. Practical enhancements can be realized through the establishment of evidence-based prescribing guidelines and the integration of regular feedback mechanisms. Moreover, advocating for the inclusion of antimicrobial stewardship principles in medical curricula is crucial, emphasizing the significance of responsible antibiotic use early in medical education.
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Affiliation(s)
| | | | - Luis Felipe Higuita-Gutiérrez
- Facultad de medicina, Universidad Cooperativa de Colombia, Medellín, Colombia.
- Escuela de microbiología, Universidad de Antioquia, Medellín, Colombia.
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Sanchez GV, Kabbani S, Tsay SV, Bizune D, Hersh AL, Luciano A, Hicks LA. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2024; 30:951-962. [PMID: 37856146 DOI: 10.1089/tmj.2023.0229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Angelina Luciano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Hasegawa K, Matsumura Y, Mori T, Asakura T, Nakaminami H. Surveillance of antimicrobial awareness among patients visiting community pharmacies. J Infect Chemother 2024:S1341-321X(24)00076-X. [PMID: 38432558 DOI: 10.1016/j.jiac.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/17/2024] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Although antimicrobial resistance (AMR) measures have been progressing, cases of patients requesting their doctors to prescribe antimicrobial agents and patients mistakenly believing that these agents are effective against viruses occasionally occur. In the AMR action plan (2023-2027) in Japan, one of the primary goals are public awareness and education. However, public understanding of AMR and antimicrobial agents has been reported to be at an unsatisfactory level. Here, we conducted a surveillance of antimicrobial awareness among patients visiting community pharmacies. MATERIAL AND METHODS A questionnaire survey was conducted among patients visiting nine pharmacies in Hachioji, Tokyo, Japan. A total of 1887 active questionnaires were collected. The relationship between answers was analyzed using logistic regression analysis. RESULTS Of the patients, 72% were unaware of AMR, and 68% believed that antimicrobials are effective against viruses. In addition, 28% of the patients answered that they did not take antimicrobial agents as prescribed by their physicians. Seventeen percent of the patients had never received appropriate instruction of antimicrobial use from pharmacists. Analysis of the relationship between answers showed that patients with correct knowledge were 1.65 times more likely to take antimicrobial agents as prescribed by their physicians (P < 0.01). Furthermore, the factors that led to the inappropriate behaviors of patients were associated with preliminary antimicrobial prescriptions from physicians (odds ratio, 3.18; 95% CI, 2.12-4.76) (P < 0.01). CONCLUSION This study strongly suggests that physician and pharmacist interventions regarding the appropriate use of antimicrobial agents are important to improve awareness of antimicrobial agents.
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Affiliation(s)
- Kosuke Hasegawa
- Department of Clinical Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, 192-0392, Japan; MEDIX, Inc, 1-2-3 Motoyokoyamacho, Hachioji, Tokyo, 192-0063, Japan; Shinwa Pharmacy Shincho Store, 101 Iwasaki Building 7-12 Shincho, Hachioji, Tokyo, 192-0065, Japan
| | - Yuriko Matsumura
- MEDIX, Inc, 1-2-3 Motoyokoyamacho, Hachioji, Tokyo, 192-0063, Japan
| | - Tomoko Mori
- MEDIX, Inc, 1-2-3 Motoyokoyamacho, Hachioji, Tokyo, 192-0063, Japan
| | - Toshio Asakura
- MEDIX, Inc, 1-2-3 Motoyokoyamacho, Hachioji, Tokyo, 192-0063, Japan
| | - Hidemasa Nakaminami
- Department of Clinical Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo, 192-0392, Japan.
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Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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Derakhshan Z, Larijani B, Shamsi-Gooshki E, Salari P. Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis. Med J Islam Repub Iran 2023; 37:106. [PMID: 38021385 PMCID: PMC10657265 DOI: 10.47176/mjiri.37.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Indexed: 12/01/2023] Open
Abstract
Background Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis. Methods A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services. Results The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services. Conclusion A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.
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Affiliation(s)
- Zeinab Derakhshan
- Medical Ethics and History of Medicine Research Center, and Department of
Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism
Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Shamsi-Gooshki
- Medical Ethics and History of Medicine Research Center, and Department of
Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Pooneh Salari
- Medical Ethics and History of Medicine Research Center, Tehran University of
Medical Sciences, Tehran, Iran
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Stenlund S, Mâsse LC, Stenlund D, Sillanmäki L, Appelt KC, Koivumaa-Honkanen H, Rautava P, Suominen S, Patrick DM. Do Patients' Psychosocial Characteristics Impact Antibiotic Prescription Rates? Antibiotics (Basel) 2023; 12:1022. [PMID: 37370341 DOI: 10.3390/antibiotics12061022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Previous research suggests that the characteristics of both patients and physicians can contribute to the overuse of antibiotics. Until now, patients' psychosocial characteristics have not been widely explored as a potential contributor to the overuse of antibiotics. In this study, the relationship between a patient's psychosocial characteristics (self-reported in postal surveys in 2003) and the number of antibiotics they were prescribed (recorded in Finnish national registry data between 2004-2006) were analyzed for 19,300 working-aged Finns. Psychosocial characteristics included life satisfaction, a sense of coherence, perceived stress, hostility, and optimism. In a structural equation model, patients' adverse psychosocial characteristics were not related to increased antibiotic prescriptions in the subsequent three years. However, these characteristics were strongly associated with poor general health status, which in turn was associated with an increased number of subsequent antibiotic prescriptions. Furthermore, mediation analysis showed that individuals who used healthcare services more frequently also received more antibiotic prescriptions. The current study does not support the view that patients' adverse psychosocial characteristics are related to an increased number of antibiotic prescriptions. This could encourage physicians to actively discuss treatment options with their patients.
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Affiliation(s)
- Säde Stenlund
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
| | - Louise C Mâsse
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
| | - David Stenlund
- Department of Mathematics, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
- Faculty of Science and Engineering, Åbo Akademi University, 20500 Turku, Finland
| | - Lauri Sillanmäki
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
- Department of Public Health, University of Helsinki, 00014 Helsinki, Finland
| | - Kirstin C Appelt
- Sauder School of Business, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
| | - Heli Koivumaa-Honkanen
- Institute of Clinical Medicine (Psychiatry), University of Eastern Finland, 70029 Kuopio, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
| | - Sakari Suominen
- Department of Public Health, University of Turku, 20014 Turku, Finland
- Research Services, Turku University Hospital, 20520 Turku, Finland
- School of Health Sciences, University of Skövde, 54128 Skövde, Sweden
| | - David M Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
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8
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Chew C, Shih V, Han Z. Evaluation of antibiotic appropriateness at an outpatient oncology centre. J Oncol Pharm Pract 2023; 29:874-884. [PMID: 35306916 DOI: 10.1177/10781552221087604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Current evidence supporting antimicrobial stewardship programs focused largely in inpatient setting. With the shift in cancer management from inpatient to ambulatory setting, it is crucial to examine the prevalence and predictors of inappropriate antibiotics prescribing. This is a retrospective cross-sectional study conducted at the National Cancer Centre Singapore (NCCS). Patients at least 21 years, with an active or past cancer diagnosis and prescribed with at least one oral antibiotic by a NCCS physician from 1st July to 30th September 2019 were included. Antibiotic appropriateness was assessed using institutional antibiotic guidelines or published clinical practice guidelines. For cases where antibiotics appropriateness cannot be ascertained using these guidelines, an independent three-member expert panel was consulted. A total of 815 patients were screened; 411 (59.4% females) were included with mean age of 62.4 years. The top three cancer diagnoses were breast (26.5%), lung (15.6%) and head and neck (13.6%). More than half (58.6%) received appropriate antibiotic choice. Of which, 235 (97.5%), 238 (98.8%) and 194 (80.5%) received appropriate dose, frequency and duration respectively. The presence of non-oncologic immunosuppressive comorbidities (OR 4.890, 95% CI 1.556-15.369, p-value = 0.007), antibiotic allergy (OR 2.352, 95% CI 1.178-4.698, p-value = 0.015) and skin and soft tissue infections (OR 2.004, 95% CI 1.276-3.146, p-value = 0.003) were associated with a higher incidence of inappropriate antibiotic choice. This study highlighted that inappropriate antibiotic prescribing is prevalent in the ambulatory oncology setting. Predicators identified can aid in the design of targeted strategies to optimise antibiotic use in ambulatory oncology patients.
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Affiliation(s)
- Cindy Chew
- Department of Pharmacy, National Cancer Centre Singapore, Singapore
| | - Vivianne Shih
- Department of Pharmacy, National Cancer Centre Singapore, Singapore
| | - Zhe Han
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
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9
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Maarouf L, Amin M, Evans BA, Abouelfetouh A. Knowledge, attitudes and behaviour of Egyptians towards antibiotic use in the community: can we do better? Antimicrob Resist Infect Control 2023; 12:50. [PMID: 37226221 DOI: 10.1186/s13756-023-01249-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Infectious diseases are among the leading causes of death worldwide. This is concerning because of the increasing capacity of the pathogens to develop antibiotic resistance. Antibiotic overuse and misuse remain the main drivers of resistance development. In the USA and Europe, annual campaigns raise awareness of antibiotic misuse hazards and promote their judicial use. Similar efforts are lacking in Egypt. This study assessed the knowledge of the public in Alexandria, Egypt of antibiotic misuse risks and their habits towards antibiotic use, in addition to conducting a campaign to increase awareness of the safe use of antibiotics. METHODS A questionnaire assessing knowledge, attitudes and behaviour towards antibiotics was used to collect responses from study participants at various sports clubs in Alexandria in 2019. An awareness campaign to correct misconceptions and a post awareness survey followed. RESULTS Most of the participants were well-educated (85%), in their middle age (51%) and took antibiotics last year (80%). 22% would take an antibiotic for common cold. This dropped to 7% following the awareness. There was a 1.6 time increase in participants who would start an antibiotic on a healthcare professional's advice following the campaign. A 1.3 time increase in participants who would finish an antibiotic regimen was also observed. The campaign made all participants recognize that unwise antibiotic use is harmful to them or others; and 1.5 more participants would spread the word about antibiotic resistance. Despite learning of the risks of antibiotic use, there was no change in how often participants thought they should take antibiotics. CONCLUSIONS Although awareness of antibiotic resistance is rising, some wrong perceptions hold fast. This highlights the need for patient and healthcare-tailored awareness sessions as part of a structured and national public health program directed to the Egyptian population.
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Affiliation(s)
- Lina Maarouf
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, 1 Khartoum Sq, Azarita, Alexandria, 21521, Egypt
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mohamed Amin
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, Alamein International University, New Alamein City, 51718, Egypt
| | | | - Alaa Abouelfetouh
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, 1 Khartoum Sq, Azarita, Alexandria, 21521, Egypt.
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alamein International University, New Alamein City, 51718, Egypt.
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Carlsson F, Jacobsson G, Lampi E. Antibiotic prescription: Knowledge among physicians and nurses in western Sweden. Health Policy 2023; 130:104733. [PMID: 36791598 DOI: 10.1016/j.healthpol.2023.104733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 02/03/2022] [Accepted: 07/03/2022] [Indexed: 02/09/2023]
Abstract
Misuse and overuse of antibiotics are common in primary care. Guidelines for prescribing of antibiotics are often not followed We conducted a survey of 120 health centers in western Sweden to investigate to what extent physicians and nurses think they know and comply with the guidelines for prescribing of antibiotics. A large majority of the respondents answered that they know the guidelines well. However, many also believed that physicians/nurses in general know less about and are worse at following the guidelines than themselves, indicating optimism bias. According to the respondents the main reason for non-compliance with guidelines was patient expectations. The survey also showed that both physicians' and nurses' actual knowledge of when it is effective to prescribe antibiotics is incomplete. Interventions to reduce unnecessary antibiotic therapy in primary care should target the failing congruence between the perceived knowledge of guidelines for antibiotic therapy and actual knowledge.
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Affiliation(s)
- Fredrik Carlsson
- Department of Economics, University of Gothenburg, Vasagatan 1, Gothenburg S-405 30, Sweden
| | - Gunnar Jacobsson
- The Swedish Strategic Programme against Antibiotic Resistance, Region Västra Götaland, Sweden; Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elina Lampi
- Department of Economics, University of Gothenburg, Vasagatan 1, Gothenburg S-405 30, Sweden.
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11
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Huang Z, Tay E, Kuan WS, Tiah L, Weng Y, Tan HY, Seow E, Peng LL, Chow A. A multi-institutional exploration of emergency medicine physicians' attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study. Antimicrob Resist Infect Control 2023; 12:24. [PMID: 36991475 PMCID: PMC10057674 DOI: 10.1186/s13756-023-01230-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/20/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians' attitudes and behaviours in four EDs in Singapore. METHODS We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework. RESULTS We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor. CONCLUSIONS Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.
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Affiliation(s)
- Zhilian Huang
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge [OCEAN], Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- National Centre for Infectious Diseases, Singapore, Singapore
| | - Evonne Tay
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge [OCEAN], Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
- National Centre for Infectious Diseases, Singapore, Singapore
| | - Win Sen Kuan
- Department Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ling Tiah
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Yanyi Weng
- Department Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hann Yee Tan
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Li Lee Peng
- Department Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Angela Chow
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge [OCEAN], Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore.
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12
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Otake S, Kusama Y, Tsuzuki S, Myojin S, Kimura M, Kamiyoshi N, Takumi T, Ishida A, Kasai M. Comparing the effects of antimicrobial stewardship at primary emergency centers. Pediatr Int 2023; 65:e15614. [PMID: 37658628 DOI: 10.1111/ped.15614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 06/24/2023] [Accepted: 06/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge-based ASP publishing monthly newsletters reduces inappropriate prescription of oral third-generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential. METHODS We conducted a three-center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility-specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin-Kita Children's First-Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre- and post-intervention and compared using Poisson regression analysis. The difference-in-difference method was used to assess the effect of these interventions. RESULTS The numbers of patients pre- and post- intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62-0.82]; p < 0.001, RR 0.71, [95% CI: 0.62-0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88-1.13]; p = 0.963). CONCLUSION A facility-specific guideline was less effective than a nudge-based ASP for decreasing oral 3GC prescriptions in PECs.
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Affiliation(s)
- Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yoshiki Kusama
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shota Myojin
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Toru Takumi
- Hanshin-Kita Children's First-Aid Center, Itami, Hyogo, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
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13
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Martini N, Choong JW, Dela Cruz PD, Lau H, Lim H, Liu R, Lim AG, Marshall D. Assessing antibiotic prescribing in nurse practitioners: Applied cognitive task analysis. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2022; 4:100101. [PMID: 38745626 PMCID: PMC11080434 DOI: 10.1016/j.ijnsa.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/12/2022] [Accepted: 09/23/2022] [Indexed: 10/14/2022] Open
Abstract
Background Prescribing antibiotics is a demanding and complex task where decision-making skills are of critical importance to minimize the risk of antimicrobial resistance. Despite its importance, little is known about the decision-making skills and cognitive strategies new Nurse Practitioners (NPs) use when prescribing antibiotics. Objective To identify the cognitive demands of antibiotic prescribing complexity and to explore the cognitive strategies that new NPs in New Zealand use when prescribing antibiotics. Design A qualitative approach using Applied Cognitive Task Analysis (ACTA) methodology. Participants A purposive sample was recruited consisting of five NPs who had been registered within the last five years and were prescribing antibiotics as part of their scope of practice. Methods In-depth face-to-face interviews consisting of a task diagram interview and a knowledge audit were conducted and analyzed following the ACTA protocol. Results Four cognitive elements were identified from the data which showed the cognitive demands of prescribing antibiotics, and the cues and strategies NPs use for safe practice. These were: 1 prescribing in the face of uncertainty (complex patients and diagnostic uncertainty); 2 making clinical decisions with insufficient/poor guidance (lack of guidelines, conflicting information); 3 producing an individualized treatment plan in view of clinical and non-clinical patient factors (patient demand/expectation, inadequate patient education, risks versus benefits of antibiotic treatment); 4 ensuring treatment efficacy and continuity of care (ineffective treatment, patient care follow up). Conclusion The ACTA framework has given insight into the current antibiotic prescribing practice of new NPs, identifying areas where professional development courses and treatment resources can be targeted to support antibiotic prescribing. NPs are likely to benefit from resources that are freely available and reflect national or local antimicrobial data. Further work is also warranted to determine whether targeted education resources and clinical pathways will help with diagnostic uncertainty, and how this could be embedded into existing curricula.
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Affiliation(s)
- Nataly Martini
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Je Wei Choong
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Paula Donamae Dela Cruz
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Helen Lau
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Hanna Lim
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Roger Liu
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Anecita Gigi Lim
- School of Nursing, Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Dianne Marshall
- School of Nursing, Faculty of Medical and Health Sciences, School of Pharmacy, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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14
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Zheng K, Xie Y, Dan L, Mao M, Chen J, Li R, Wang X, Hesketh T. Effectiveness of Educational Interventions for Health Workers on Antibiotic Prescribing in Outpatient Settings in China: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11060791. [PMID: 35740197 PMCID: PMC9220158 DOI: 10.3390/antibiotics11060791] [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: 04/23/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 02/01/2023] Open
Abstract
Educational interventions are considered an important component of antibiotic stewardship, but their effect has not been systematically evaluated in outpatient settings in China. This research aims to evaluate the effectiveness of educational interventions for health workers on antibiotic prescribing rates in Chinese outpatient settings. Eight databases were searched for relevant randomized clinical trials, non-randomized trials, controlled before–after studies and interrupted time-series studies from January 2001 to July 2021. A total of 16 studies were included in the systematic review and 12 in the meta-analysis. The results showed that educational interventions overall reduced the antibiotic prescription rate significantly (relative risk, RR 0.72, 95% confidence interval, CI 0.61 to 0.84). Subgroup analysis demonstrated that certain features of education interventions had a significant effect on antibiotic prescription rate reduction: (1) combined with compulsory administrative regulations (RR With: 0.65 vs. Without: 0.78); (2) combined with financial incentives (RR With: 0.51 vs. Without: 0.77). Educational interventions can also significantly reduce antibiotic injection rates (RR 0.83, 95% CI 0.74 to 0.94) and the inappropriate use of antibiotics (RR 0.61, 95% CI 0.51 to 0.73). The limited number of high-quality studies limits the validity and reliability of the results. More high-quality educational interventions targeting the reduction of antibiotic prescribing rates are needed.
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Affiliation(s)
- Kunhua Zheng
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Ying Xie
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Lintao Dan
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Meixian Mao
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Jie Chen
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Ran Li
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
| | - Xuanding Wang
- Department of Antimicrobial Stewardship, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, China
- Correspondence:
| | - Therese Hesketh
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
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15
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Beilfuss S, Linde S, Norton B. Accountable care organizations and physician antibiotic prescribing behavior. Soc Sci Med 2022; 294:114707. [PMID: 35030393 DOI: 10.1016/j.socscimed.2022.114707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 12/30/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the Medicare ACO programs. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic prescribing. METHODS Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician antibiotic prescribing across these groups with adjustment for volume, patient, physician and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine, family or general practice, nurse practitioners, as well as general and orthopedic surgeons. RESULTS We find that ACO affiliation helps reduce antibiotic prescribing by 20.4 (95%CI = -26.65 to -14.16, p-value<0.001) prescriptions (about 19.5%) per year. We show that each additional hospital and practice affiliation increases prescriptions by 1.6 (95%CI = 1.27 to 1.95, p-value<0.001) and 1.7 (95%CI = 1.00 to 2.47, p-value<0.001), respectively. However, the use of electronic health records and high-quality medical training is associated with a decrease in antibiotic use of 7.9 (95%CI = -8.79 to -7.07, p-value<0.001) and 3.6 (95%CI = -4.47 to -2.73, p-value<0.001) claims, respectively. The treatment effects are found to vary with specialty, where internal medicine physicians experience an average decrease of 23.6 (95%CI = -29.98 to -17.20, p-value<0.001), family and general practice physicians a decrease of 22.1 (95%CI = -28.37 to -15.77, p-value<0.001), nurse practitioners a decrease of 7.1 (95%CI = -13.99 to -0.77, p-value = 0.028), general surgeons a decrease of 9.6 (95%CI = -16.02 to -3.25, p-value = 0.003), and orthopedic surgeons a reduction of 8.1 (95%CI = -14.84 to -1.42, p-value = 0.018) in their antibiotic prescribing per year. CONCLUSIONS In assessing the impact of Medicare ACO programs it is important to account for spillover effects. Our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.
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Affiliation(s)
- Svetlana Beilfuss
- Eastern Michigan University, Department of Economics, Address: 703 Pray, Harrold, Ypsilanti, MI, 48197, USA.
| | - Sebastian Linde
- Medical College of Wisconsin, Department of Medicine, Division of General Internal Medicine, Address: 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, United States; Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Brandon Norton
- Purdue University, Department of Economics, Krannert School of Management, Address: 403 West State Street, West Lafayette, IN, 47907-2056, United States.
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16
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Ten ways to make the most of World Antimicrobial Awareness Week. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e187. [PMID: 36425221 PMCID: PMC9679734 DOI: 10.1017/ash.2022.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/19/2022]
Abstract
One fundamental strategy to address the public health threat of antimicrobial resistance (AMR) is improved awareness among the public, prescribers, and policy makers with the aim of engaging these groups to act. World Antimicrobial Awareness Week is an opportunity for concerted and consistent communication regarding practical strategies to prevent and mitigate AMR. We highlight 10 ways for antimicrobial stewards to make the most of World Antimicrobial Awareness Week.
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17
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Basu S, Santra S, Bhatnagar N, Laul A. Outpatient antibiotic prescribing behavior and their psychosocial predictors among early-career clinicians in Delhi, India. INTERNATIONAL JOURNAL OF ACADEMIC MEDICINE 2022. [DOI: 10.4103/ijam.ijam_156_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Campioli CC, Castillo Almeida NE, O'Horo JC, Wilson WR, Cano E, DeSimone DC, Baddour LM, SohailMD MR. Diagnosis, Management, and Outcomes of Brain Abscess due to Gram-Negative Versus Gram-Positive Bacteria: Brain abscess due to Gram-positive vs. Gram-negative bacteria. Int J Infect Dis 2021; 115:189-194. [PMID: 34902581 DOI: 10.1016/j.ijid.2021.12.322] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/09/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Differences in management and outcomes of brain abscesses due to Gram-positive (GPB) versus Gram-negative bacteria (GNB) are not well defined. METHODS Retrospectively reviewed adult patients with brain abscesses due to monomicrobial infection from 2009 through 2020. RESULTS 177 had a monomicrobial brain abscess; 143 (80.8%) caused by GPB and 34 (19.2%) by GNB. Patients with GNB had more history of head/neck surgery than those with GPB (58.8% vs. 36.4%; P= 0.02). Pathogens in the GNB group included Pseudomonas aeruginosa (29.4%), Klebsiella species (spp.; 20.6%), and Enterobacter spp. (20.6%); in the GPB group were Staphylococcus aureus (32.2%) and Streptococcus spp. (31.5%). Most patients had combined medical/surgical management (64.7% GNB vs. 63.6% GPB). Median duration of antibiotic therapy was 42 days, and there were no significant differences in infection relapse or 3-month survival rates. Patients with GNB were more likely to have therapeutic failure than did those with GPB (44.1% vs. 22.4%; P= 0.01). CONCLUSION Compared with brain abscesses caused by GPB, those due to GNB were more likely to have prior head and neck surgery. No statistically difference in outcomes was observed between groups; however, patients with GNB had a higher therapeutic failure rate than did those with GPB.
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Affiliation(s)
| | - Natalia E Castillo Almeida
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - John C O'Horo
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Walter R Wilson
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Edison Cano
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel C DeSimone
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Rizwan SohailMD
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
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19
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Henaine AM, Lahoud N, Abdo R, Shdeed R, Safwan J, Akel M, Fahs I, Zeenny R, Sacre H, Hallit S, Salameh P. Knowledge of Antibiotics Use among Lebanese Adults: A study on the influence of sociodemographic characteristics. Sultan Qaboos Univ Med J 2021; 21:442-449. [PMID: 34522411 PMCID: PMC8407903 DOI: 10.18295/squmj.4.2021.006] [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: 04/27/2020] [Revised: 08/26/2020] [Accepted: 11/10/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aimed to evaluate the association between sociodemographic characteristics and antibiotic knowledge in the Lebanese population. Methods A questionnaire-based survey was conducted in community pharmacies across all Lebanese governorates. Data were collected by well-trained pharmacists through face-to-face interviews from January until March 2017. The survey tool was adapted from a questionnaire developed by the World Health Organization. A knowledge index was computed for comparative purposes and a linear regression model was performed to assess factors associated with knowledge. Results A total of 623 participants were included in the analysis of this study (response rate: 90.6%). The mean antibiotic knowledge index was 12.5 ± 3.2 (minimum score: 3 and maximum score: 19). Higher knowledge score was inversely correlated with age (r = −0.118; P = 0.003), but no gender differences were reported (females: 12.6 versus males: 12.3; P = 0.191). However, statistically significant differences were found for residence type (P = 0.002), educational level (P <0.001) and total household income categories (P <0.001). The linear regression model showed a significant association between residence type and knowledge (urban versus rural: β = 0.793; P = 0.011). Furthermore, a higher knowledge index was significantly associated with a higher income combined with higher education (additive scale/β = 1.590; P = 0.025). Finally, interactions between income and age, gender and residence type were not significant. Conclusion Individuals residing in urban areas, with combined high income and educational levels, are more knowledgeable about antibiotics use and resistance compared to other groups. More studies are needed to assess the interaction of sociodemographic interactions with health literacy.
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Affiliation(s)
| | - Nathalie Lahoud
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon.,INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon
| | - Rachel Abdo
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon.,INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon
| | - Ruba Shdeed
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Jihan Safwan
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Marwan Akel
- INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon.,School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Iqbal Fahs
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rony Zeenny
- INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon.,Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hala Sacre
- INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon
| | - Souheil Hallit
- INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon.,Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon.,Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | - Pascale Salameh
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon.,INSPECT-LB Institut National de Santé Publique, Épidémiologie Clinique et Toxicologie-Liban, Beirut, Lebanon
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20
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Ozturk GZ, Toprak D, Sagsoz O, Ardic C. Knowledge, Attitude and Practice of Family Physicians on Antimicrobial Therapy for Acute Respiratory Tract Infections - A Study from Istanbul, Turkey. EURASIAN JOURNAL OF FAMILY MEDICINE 2021. [DOI: 10.33880/ejfm.2021100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim: We aimed to investigate the knowledge, attitude, practice of family physicians regarding an-timicrobial therapy in acute respiratory tract infections.
Methods: After receiving the ethics committee approval, the data were collected by online questionnaire from a phone application with 304 physicians. Questions about socio-demographic features and knowledge, attitude, and practices on antibiotics use were asked. Using SPSS, we did the statistical analyses with appropriate procedures.
Results: Among the participants, 127 (41.8%) were specialists, and 177 (58.2%) were gen-eral practitioners. The specialists gave correct answers about tonsillopharyngitis and bron-chiolitis significantly more often than the general practitioners did. The antibiotic choices for acute otitis media were not in compliance with the guidelines of the Centers for Disease Control, and between the groups, there was no significant difference in terms of initial antibiotic choice. The self-reported antibiotic prescription rate was 25%. In 10%, the most common perceived reason for inappropriate antibiotic prescription was pressure from patients.
Conclusion: There remains considerable misuse of antibiotics by primary care physicians for acute respiratory tract infections. Education of physicians and patients regarding acute respiratory tract infections may be needed to lower the rate of inappropriate antibiotic pre-scriptions.
Keywords: public health practice, practice patterns, primary healthcare
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Affiliation(s)
| | | | | | - Cuneyt Ardic
- Recep Tayyip Erdoğan University Faculty of Medicine
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21
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Kanjilal S, Oberst M, Boominathan S, Zhou H, Hooper DC, Sontag D. A decision algorithm to promote outpatient antimicrobial stewardship for uncomplicated urinary tract infection. Sci Transl Med 2021; 12:12/568/eaay5067. [PMID: 33148625 DOI: 10.1126/scitranslmed.aay5067] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 10/16/2020] [Indexed: 11/02/2022]
Abstract
Antibiotic resistance is a major cause of treatment failure and leads to increased use of broad-spectrum agents, which begets further resistance. This vicious cycle is epitomized by uncomplicated urinary tract infection (UTI), which affects one in two women during their life and is associated with increasing antibiotic resistance and high rates of prescription for broad-spectrum second-line agents. To address this, we developed machine learning models to predict antibiotic susceptibility using electronic health record data and built a decision algorithm for recommending the narrowest possible antibiotic to which a specimen is susceptible. When applied to a test cohort of 3629 patients presenting between 2014 and 2016, the algorithm achieved a 67% reduction in the use of second-line antibiotics relative to clinicians. At the same time, it reduced inappropriate antibiotic therapy, defined as the choice of a treatment to which a specimen is resistant, by 18% relative to clinicians. For specimens where clinicians chose a second-line drug but the algorithm chose a first-line drug, 92% (1066 of 1157) of decisions ended up being susceptible to the first-line drug. When clinicians chose an inappropriate first-line drug, the algorithm chose an appropriate first-line drug 47% (183 of 392) of the time. Our machine learning decision algorithm provides antibiotic stewardship for a common infectious syndrome by maximizing reductions in broad-spectrum antibiotic use while maintaining optimal treatment outcomes. Further work is necessary to improve generalizability by training models in more diverse populations.
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Affiliation(s)
- Sanjat Kanjilal
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, MA 02215, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael Oberst
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Sooraj Boominathan
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Helen Zhou
- Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA 15213, USA
| | - David C Hooper
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - David Sontag
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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22
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Stivers T, Timmermans S. Arriving at no: Patient pressure to prescribe antibiotics and physicians' responses. Soc Sci Med 2021; 290:114007. [PMID: 34006432 DOI: 10.1016/j.socscimed.2021.114007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
While the vast majority of Acute Respiratory Infections (ARIs) are viral, between a quarter and a third of adults presenting with ARIs are given an antibiotic, making antibiotic prescribing for ARIs a major contributor to the inappropriate prescribing problem. We argue that inappropriate prescribing persists because of the interplay between physicians and patients in the medical visit. Relying on a convenience sample of 68 video recordings of primary care medical visits drawn from corpora collected in 2003-2004 and 2015-2016 in the US, we show that although few patients are "demanding" or "requesting" antibiotics, many convey subtle forms of pressure through priming physicians for a bacterial diagnosis in their problem presentations; nudging towards a bacterial diagnosis during information gathering; and resisting non-antibiotic recommendations during the counseling phase. We find that patient priming, nudging, and resisting are effective strategies to influence clinical prescribing behavior. However, we also identify two ways that physicians can counter patient pressure by working to manage patient expectations through foreshadowing a non-antibiotic outcome and using persuasion when confronted with resistance. These, we show, are effective means of countering patient pressure. We argue for the dual importance of how physicians communicate and when they communicate.
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23
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Butler AM, Durkin MJ, Keller MR, Ma Y, Dharnidharka VR, Powderly WG, Olsen MA. Risk of antibiotic treatment failure in premenopausal women with uncomplicated urinary tract infection. Pharmacoepidemiol Drug Saf 2021; 30:1360-1370. [PMID: 33783918 DOI: 10.1002/pds.5237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Acute uncomplicated urinary tract infections (UTIs) are among the most common indications for antibiotic prescriptions in otherwise healthy women. We compared the risk of treatment failure of antibiotic regimens for outpatient treatment of UTI in real-world practice. METHODS We identified non-pregnant, premenopausal women diagnosed with uncomplicated, lower tract UTI and prescribed an oral antibiotic with activity against common uropathogens. We used propensity score-weighted Kaplan-Meier functions to estimate 30-day risks and risk differences (RD) for pyelonephritis and UTI-related antibiotic prescription switch. RESULTS Of 1 140 602 patients, the distribution of index prescriptions was 44% fluoroquinolones (non-first-line), 28% trimethoprim-sulfamethoxazole (TMP/SMX) (first-line), 24% nitrofurantoin (first-line), 3% narrow-spectrum β-lactams (non-first-line), 1% broad-spectrum β-lactams (non-first-line), and 1% amoxicillin/ampicillin (non-recommended). Compared to the risk of pyelonephritis for nitrofurantoin (0.3%), risks were higher for TMP/SMX (RD, 0.2%; 95% CI, 0.2%-0.2%) and broad-spectrum β-lactams (RD, 0.2%; 95% CI, 0.1%-0.4%). Compared to the risk of prescription switch for nitrofurantoin (12.7%), the risk was higher for TMP/SMX (RD 1.6%; 95% CI 1.3%-1.7%) but similar for broad-spectrum β-lactams (RD -0.7%; 95% CI -1.4%-0.1%) and narrow-spectrum β-lactams (RD -0.3%; 95% CI -0.8%-0.2%). Subgroup analyses suggest TMP/SMX treatment failure may be due in part to increasing uropathogen resistance over time. CONCLUSIONS The risk of treatment failure differed by antibiotic agent, with higher risk associated with TMP/SMX versus nitrofurantoin, and lower or similar risk associated with broad- versus narrow-spectrum β-lactams. Given serious safety warnings for fluoroquinolones, these results suggest that nitrofurantoin may be preferable as the first-line agent for outpatient treatment of uncomplicated UTI.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yinjiao Ma
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Pediatric Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
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Finding the path of least resistance: Locally adapting the MITIGATE toolkit in emergency departments and urgent care centers. Infect Control Hosp Epidemiol 2021; 42:1376-1378. [PMID: 33602365 DOI: 10.1017/ice.2020.1394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The MITIGATE toolkit was developed to assist urgent care and emergency departments in the development of antimicrobial stewardship programs. At the University of Washington, we adopted the MITIGATE toolkit in 10 urgent care centers, 9 primary care clinics, and 1 emergency department. We encountered and overcame challenges: a complex data build, choosing feasible outcomes to measure, issues with accurate coding, and maintaining positive stewardship relationships. Herein, we discuss solutions to challenges we encountered to provide guidance for those considering using this toolkit.
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25
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Abstract
Acute respiratory tract infections (ARTIs) are typically viral; however, in the USA, approximately one-third of adults and 52% of children with ARTIs receive an antibiotic, making antibiotic prescribing for ARTIs a major contributor to the problem of inappropriate prescribing. Relying on a synthesis of work across pediatric and adult primary care, this article shows some of the main ways that patients and parents pressure physicians for antibiotics, whether intentionally or unintentionally, and how physicians combat that pressure. All data are from video recordings of community-based clinical encounters allowing us to see what is happening "on the ground." Strategies that physicians actually use are documented; however, untutored physicians do not rely on these reliably or strategically, leaving substantial room for the deployment of a three-pronged communication strategy that can reduce patient pressure and inappropriate antibiotic prescribing.
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Affiliation(s)
- Tanya Stivers
- Department of Sociology, UCLA, Los Angeles, CA, USA.
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26
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Lampi E, Carlsson F, Sundvall PD, Torres MJ, Ulleryd P, Åhrén C, Jacobsson G. Interventions for prudent antibiotic use in primary healthcare: an econometric analysis. BMC Health Serv Res 2020; 20:895. [PMID: 32967662 PMCID: PMC7510320 DOI: 10.1186/s12913-020-05732-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/11/2020] [Indexed: 01/21/2023] Open
Abstract
Background Rational antibiotic prescribing is crucial to combat antibiotic resistance. Optimal strategies to improve antibiotic use are not known. Strama, the Swedish strategic program against antibiotic resistance, has been successful in reducing antibiotic prescription rates. This study investigates whether two specific interventions directed toward healthcare centers, an informational visit and a self-evaluation meeting, played a role in observed reduction in rates of antibiotic prescriptions in primary healthcare. Methods The study was a retrospective, observational, empirical analysis exploiting the variation in the timing of the interventions and considering past prescriptions through use of estimations from dynamic panel data models. Primary healthcare data from 2011 to 2014 were examined. Data were from public and private primary healthcare centers in western Sweden. The key variables were prescription of antibiotics and indicator variables for the two interventions. Results The first intervention, an educational information intervention, decreased the number of prescriptions among public healthcare centers, but this effect was only temporary. We found no proof that the second intervention, a self-evaluation meeting at the healthcare center, had an impact on the reduction of prescriptions. Conclusions Single educational interventions aimed at influencing rates of antibiotic prescriptions have limited impact. A multifaceted approach is needed in efforts to reduce the use of antibiotics in primary health care.
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Affiliation(s)
- Elina Lampi
- Department of Economics, University of Gothenburg, Vasagatan 1, SE-411 24, Gothenburg, Sweden.,Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden
| | - Fredrik Carlsson
- Department of Economics, University of Gothenburg, Vasagatan 1, SE-411 24, Gothenburg, Sweden.,Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden
| | - Pär-Daniel Sundvall
- Region Västra Götaland, Research and Development Primary Health Care, Research and Development Centre Södra Älvsborg, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden.,Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Gothenburg, Sweden
| | - Marcela Jaime Torres
- School of Management and Business, Research Nucleus on Environmental and Natural Resource Economics (NENRE), Universidad de Concepción, Victoria 471, Barrio Universitario, Concepción, Chile
| | - Peter Ulleryd
- Department of Communicable Disease Control and Prevention, Region Västra Götaland, Kaserntorget 11B, SE-411 18, Gothenburg, Sweden.,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden
| | - Christina Åhrén
- Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden.,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden.,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 9 A-B, SE-413 90, Gothenburg, Sweden
| | - Gunnar Jacobsson
- Center for Antibiotic Resistance Research (CARe), University of Gothenburg, Guldhedsgatan 10, 405 30, Gothenburg, SE, Sweden. .,Swedish Strategic Program against Antimicrobial Resistance (Strama), Region Västra Götaland, Bergslagsgatan 2, SE-411 04, Gothenburg, Sweden. .,Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 9 A-B, SE-413 90, Gothenburg, Sweden. .,Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, SE-541 42, Skövde, Sweden.
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Wattengel BA, DiTursi S, Schroeck JL, Sellick JA, Mergenhagen KA. Outpatient antimicrobial stewardship: Targets for urinary tract infections. Am J Infect Control 2020; 48:1009-1012. [PMID: 31955854 DOI: 10.1016/j.ajic.2019.12.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are common. Outpatient antimicrobial stewardship programs are emerging and a focused approach to UTIs is needed to help guide programs. METHODS Data were collected by retrospective chart review of outpatients using encounters from January 2005 to March 2018. Antibiotic therapy was indicated if at least one UTI symptom was present. Antibiotic therapy was appropriate if consistent with guidelines and culture results. Factors that differed significantly (P <.05) between the comparator groups were built into a multivariable logistic regression model to determine factors associated with inappropriate prescribing. RESULTS A total of 607 outpatients were included, of which approximately 68% were treated inappropriately. Inappropriate regimens consisted of 50.9% (n = 309) incorrect durations, 35.1% (n = 213) incorrect choice of antibiotic, and 12.4% (n = 75) incorrect doses. Ten percent of patients developed a reinfection within 30 days. Recurrence of UTI with the same pathogen within 30 days occurred in 5.1%. Catheter use and advanced age are both risk factors for recurrence and inappropriate treatment. CONCLUSIONS Outpatient antibiotic prescribing for UTIs is suboptimal. Stewardship programs should focus on patients with catheters and of advanced age as they are often inappropriately treated.
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28
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Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ Open 2020; 10:e034983. [PMID: 32665343 PMCID: PMC7365421 DOI: 10.1136/bmjopen-2019-034983] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship is needed to improve prescribing and address the threat of antibiotic resistance. A better understanding of primary care physicians (PCPs) attitudes towards antibiotic prescribing and outpatient antibiotic stewardship is needed to identify barriers to stewardship implementation and help tailor stewardship strategies. The aim of this study was to assess PCPs current attitudes towards antibiotic resistance, inappropriate antibiotic prescribing and the feasibility of outpatient stewardship efforts. DESIGN Eight focus groups with PCPs were conducted by an independent moderator using a moderator guide. Focus groups were audio recorded, transcribed and coded for major themes using deductive and inductive content analysis methods. SETTING Focus groups were conducted in four US cities: Philadelphia, Birmingham, Chicago and Los Angeles. PARTICIPANTS Two focus groups were conducted in each city-one with family medicine and internal medicine physicians and one with paediatricians. A total of 26 family medicine/internal medicine physicians and 26 paediatricians participated. RESULTS Participants acknowledged that resistance is an important public health issue, but not as important as other pressing problems (eg, obesity, opioids). Many considered resistance to be more of a hospital issue. While participants recognised inappropriate prescribing as a problem in outpatient settings, many felt that the key drivers were non-primary care settings (eg, urgent care clinics, retail clinics) and patient demand. Participants reacted positively to stewardship efforts aimed at educating patients and clinicians. They questioned the validity of antibiotic prescribing metrics. This scepticism was due to a number of factors, including the feasibility of capturing prescribing quality, a belief that physicians will 'game the system' to improve their measures, and dissatisfaction and distrust of quality measurement in general. CONCLUSIONS Stakeholders will need to consider physician attitudes and beliefs about antibiotic stewardship when implementing interventions aimed at improving prescribing.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea M Garcia
- Health & Science, American Medical Association, Chicago, Illinois, USA
| | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
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29
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Zetts RM, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary Care Physicians' Attitudes and Perceptions Towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey. Open Forum Infect Dis 2020; 7:ofaa244. [PMID: 32782909 PMCID: PMC7406830 DOI: 10.1093/ofid/ofaa244] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/11/2020] [Indexed: 01/08/2023] Open
Abstract
Background Outpatient antibiotic stewardship is needed to reduce inappropriate prescribing and minimize the development of resistant bacteria. We assessed primary care physicians’ perceptions of antibiotic resistance, antibiotic use, and the need for stewardship activities. Methods We conducted a national online survey of 1550 internal, family, and pediatric medicine physicians in the United States recruited from an opt-in panel of healthcare professionals. Descriptive statistics were generated for respondent demographics and question responses. Responses were also stratified by geographic region and medical specialty, with a χ 2 test used to assess for differences. Results More respondents agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) than in their practice (37%). In addition, 60% agreed that they prescribed antibiotics more appropriately than their peers. Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. Approximately half (47%) believed they would need a lot of help to implement stewardship. Respondents indicated that they were likely to implement antibiotic stewardship efforts in response to feedback or incentives provided by payers or health departments. Conclusions Primary care physicians generally did not recognize antibiotic resistance and inappropriate prescribing as issues in their practice. This poses a challenge for the success of outpatient stewardship. Healthcare stakeholders will need to explore opportunities for feedback and incentive activities to encourage stewardship uptake.
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Affiliation(s)
- Rachel M Zetts
- The Pew Charitable Trusts, Washington, District of Columbia, USA
| | | | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- The Pew Charitable Trusts, Washington, District of Columbia, USA
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30
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Donovan BM, Abreo A, Ding T, Gebretsadik T, Turi KN, Yu C, Ding J, Dupont WD, Stone CA, Hartert TV, Wu P. Dose, Timing, and Type of Infant Antibiotic Use and the Risk of Childhood Asthma. Clin Infect Dis 2020; 70:1658-1665. [PMID: 31149702 PMCID: PMC7145998 DOI: 10.1093/cid/ciz448] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/29/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Aspects of infant antibiotic exposure and its association with asthma development have been variably explored. We aimed to evaluate comprehensively and simultaneously the impact of dose, timing, and type of infant antibiotic use on the risk of childhood asthma. METHODS Singleton, term-birth, non-low-birth-weight, and otherwise healthy children enrolled in the Tennessee Medicaid Program were included. Infant antibiotic use and childhood asthma diagnosis were ascertained from prescription fills and healthcare encounter claims. We examined the association using multivariable logistic regression models. RESULTS Among 152 622 children, 79% had at least 1 antibiotic prescription fill during infancy. Infant antibiotic use was associated with increased odds of childhood asthma in a dose-dependent manner, with a 20% increase in odds (adjusted odds ratio [aOR], 1.20 [95% confidence interval {CI}, 1.19-1.20]) for each additional antibiotic prescription filled. This significant dose-dependent relationship persisted after additionally controlling for timing and type of the antibiotics. Infants who had broad-spectrum-only antibiotic fills had increased odds of developing asthma compared with infants who had narrow-spectrum-only fills (aOR, 1.10 [95% CI, 1.05-1.19]). There was no significant association between timing, formulation, anaerobic coverage, and class of antibiotics and childhood asthma. CONCLUSIONS We found a consistent dose-dependent association between antibiotic prescription fills during infancy and subsequent development of childhood asthma. Our study adds important insights into specific aspects of infant antibiotic exposure. Clinical decision making regarding antibiotic stewardship and prevention of adverse effects should be critically assessed prior to use during infancy.
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Affiliation(s)
- Brittney M Donovan
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Abreo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tan Ding
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tebeb Gebretsadik
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kedir N Turi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Juan Ding
- Department of School of Mathematics and Statistics, Guangxi Normal University, Guilin, China
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cosby A Stone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tina V Hartert
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pingsheng Wu
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
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Risk Factors for Unnecessary Antibiotic Prescribing for Acute Respiratory Tract Infections in Primary Care. Mayo Clin Proc Innov Qual Outcomes 2020; 4:31-39. [PMID: 32055769 PMCID: PMC7011009 DOI: 10.1016/j.mayocpiqo.2019.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/17/2019] [Accepted: 09/20/2019] [Indexed: 12/22/2022] Open
Abstract
Objective To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency–based primary care offices. Patients and Methods A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency–based primary care office practices. Patients with an office visit at either of 2 IM residency–based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included. Results During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident–associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing. Conclusion For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.
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Key Words
- AHN, Allegheny Health Network
- ARI, acute respiratory tract infection
- ASP, antimicrobial stewardship program
- EHR, electronic health record
- ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification
- ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- IM, internal medicine
- OR, odds ratio
- URI, upper respiratory tract infection
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Gu Y, Fujitomo Y, Soeda H, Nakahama C, Hasegawa N, Maesaki S, Maeda M, Matsumoto T, Miyairi I, Ohmagari N. A nationwide questionnaire survey of clinic doctors on antimicrobial stewardship in Japan. J Infect Chemother 2019; 26:149-156. [PMID: 31879188 DOI: 10.1016/j.jiac.2019.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/05/2019] [Accepted: 12/03/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Clinics are high prescribers of antimicrobials in Japan, but the present situation and the attitude of clinic doctors toward prescribing them remain unclear. OBJECTIVE To investigate the present situation at clinics and clinic doctors' attitude toward antimicrobial stewardship. STUDY DESIGN A questionnaire survey of clinic doctors. METHODS A questionnaire targeting doctors was sent to 1500 clinics that were randomly selected from across the country. RESULTS Among 274 respondents (response rate, 18.3%), 269 provided consent and their responses were analyzed. Awareness of the National Action Plan on Antimicrobial Resistance and the Manual of Antimicrobial Stewardship was low, but awareness of antimicrobial stewardship was high. A certain proportion of doctors prescribed antimicrobials for the common cold and acute bronchitis, and macrolides were the most commonly prescribed group of antimicrobials. Such prescription was not based solely on the doctors' knowledge but was also influenced by complex factors such as the doctor-patient relationship. CONCLUSION Various measures such as improving doctor-patient communication and improving clinic doctors' knowledge are necessary to promote antimicrobial stewardship in the outpatient setting.
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Affiliation(s)
- Yoshiaki Gu
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan.
| | - Yumiko Fujitomo
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Hiroshi Soeda
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Department of Pharmacy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Chikara Nakahama
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Nakahama Clinic, Japan
| | - Naoki Hasegawa
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Shigefumi Maesaki
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Department of Infectious Disease and Infection Control, Saitama Medical University, Saitama, Japan
| | - Masayuki Maeda
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Division of Infection Control Sciences, Department of Clinical Pharmacy, School of Pharmacy, Showa University, Tokyo, Japan
| | - Tetsuya Matsumoto
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Department of Infectious Diseases, International University of Health and Welfare, Chiba, Japan
| | - Isao Miyairi
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Norio Ohmagari
- The Research Committee of the Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases on Antimicrobial Stewardship in Clinics, Japan; AMR Clinical Reference Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
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Seipel MBA, Prohaska ES, Ruisinger JF, Melton BL. Patient Knowledge and Experiences With Antibiotic Use and Delayed Antibiotic Prescribing in the Outpatient Setting. J Pharm Pract 2019; 34:618-624. [DOI: 10.1177/0897190019889427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Most antibiotic prescriptions originate in the outpatient setting and an estimated 30% are unnecessary. Pharmacists are well positioned to positively impact antibiotic prescribing habits; the role of the community pharmacist in outpatient antibiotic stewardship programs is not well defined. Objectives: The objectives of this study were to (1) assess the knowledge of the general public regarding appropriate antibiotic use, and (2) assess the experiences of the general public regarding delayed antibiotic prescriptions. Methods: A cross-sectional survey was administered at community pharmacies in Kansas from September 2018 to January 2019. Eligible individuals were older than 18 years and self-reported their ability to speak and read English. The 22-item survey collected demographics, knowledge regarding appropriate antibiotic use, and participant understanding and experiences of delayed antibiotic prescribing. Descriptive statistics assessed demographics and chi-square compared responses between demographics. Results: Of 347 surveys completed, respondents were mainly Caucasian (91.6%), female (58.2%), and aged 60 years or older (59.1%). Those with high school education or below were more likely to believe antibiotics kill viruses (43.1% vs 20.9%, respectively; p < 0.01) and that antibiotics work on most coughs and colds (31.4% vs 16.2%, respectively; p = 0.01). Delayed antibiotic prescriptions were more frequently offered to those who had received an antibiotic prescription in the last year compared to those who had not (36.1% vs 15%, p < 0.001). Conclusion: Gaps in patient knowledge about appropriate antibiotic use and delayed prescribing present an opportunity for community pharmacists to educate patients and become involved in outpatient antibiotic stewardship.
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Affiliation(s)
| | | | - Janelle F. Ruisinger
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, Lawrence, KS, USA
| | - Brittany L. Melton
- Department of Pharmacy Practice, University of Kansas School of Pharmacy, Lawrence, KS, USA
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Wee LE, Tan AL, Wijaya L, Chlebicki MP, Thumboo J, Tan BH. Timeliness of Infectious Diseases Referral and Inappropriate Antibiotic Usage Post-Referral in an Asian Tertiary Hospital. Trop Med Infect Dis 2019; 4:tropicalmed4040137. [PMID: 31752072 PMCID: PMC6958425 DOI: 10.3390/tropicalmed4040137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/16/2022] Open
Abstract
Infectious diseases (ID) specialists advise on complicated infections and are advocates for the interventions of antibiotic stewardship programs (ASP). Early referral to ID specialists has been shown to improve patient outcomes; however, not all referrals to ID specialists are made in a timely fashion. A retrospective cross-sectional study of all referrals to ID specialists in a Singaporean tertiary hospital was conducted from January 2016 to January 2018. The following quality indicators were examined: early referral to ID specialists (within 48 h of admission) and ASP intervention for inappropriate antibiotic usage, even after referral to ID specialists. Chi-square was used for univariate analysis and logistic regression for multivariate analysis. A total of 6490 referrals over the 2-year period were analysed; of those, 36.7% (2384/6490) were from surgical disciplines, 47.0% (3050/6490) were from medical disciplines, 14.2% (922/6490) from haematology/oncology and 2.1% (134/6490) were made to the transplant ID service. Haematology/oncology patients and older patients (aged ≥ 60 years) had lower odds of early referral to ID specialists but higher odds of subsequent ASP intervention for inappropriate antibiotic usage, despite prior referral to an ID specialist. Elderly patients and haematology/oncology patients can be referred to ID specialists earlier and their antimicrobial regimens further optimised, perhaps by fostering closer cooperation between ID specialists and primary physicians.
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Affiliation(s)
- Liang En Wee
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
- Correspondence: ; Tel.: +65-9677-7651
| | - Aidan Lyanzhiang Tan
- Preventive Medicine Residency, National University Health System, 1E Kent Ridge Rd, Singapore 119228, Singapore;
| | - Limin Wijaya
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
| | - Maciej Piotr Chlebicki
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
| | - Julian Thumboo
- Department of Rheumatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore;
- Health Services Research Unit, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
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Lovegrove MC, Geller AI, Fleming-Dutra KE, Shehab N, Sapiano MR, Budnitz DS. US Emergency Department Visits for Adverse Drug Events From Antibiotics in Children, 2011-2015. J Pediatric Infect Dis Soc 2019; 8:384-391. [PMID: 30137509 PMCID: PMC6467735 DOI: 10.1093/jpids/piy066] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 07/06/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Antibiotics are among the most commonly prescribed medications for children; however, at least one-third of pediatric antibiotic prescriptions are unnecessary. National data on short-term antibiotic-related harms could inform efforts to reduce overprescribing and to supplement interventions that focus on the long-term benefits of reducing antibiotic resistance. METHODS Frequencies and rates of emergency department (ED) visits for antibiotic adverse drug events (ADEs) in children were estimated using adverse event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project and retail pharmacy dispensing data from QuintilesIMS (2011-2015). RESULTS On the basis of 6542 surveillance cases, an estimated 69464 ED visits (95% confidence interval, 53488-85441) were made annually for antibiotic ADEs among children aged ≤19 years from 2011 to 2015, which accounts for 46.2% of ED visits for ADEs that results from systemic medication. Two-fifths (40.7%) of ED visits for antibiotic ADEs involved a child aged ≤2 years, and 86.1% involved an allergic reaction. Amoxicillin was the most commonly implicated antibiotic among children aged ≤9 years. When we accounted for dispensed prescriptions, the rates of ED visits for antibiotic ADEs declined with increasing age for all antibiotics except sulfamethoxazole-trimethoprim. Amoxicillin had the highest rate of ED visits for antibiotic ADEs among children aged ≤2 years, whereas sulfamethoxazole-trimethoprim resulted in the highest rate among children aged 10 to 19 years (29.9 and 24.2 ED visits per 10000 dispensed prescriptions, respectively). CONCLUSIONS Antibiotic ADEs lead to many ED visits, particularly among young children. Communicating the risks of antibiotic ADEs could help reduce unnecessary prescribing. Prevention efforts could target pediatric patients who are at the greatest risk of harm.
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Affiliation(s)
- Maribeth C. Lovegrove
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Andrew I. Geller
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Katherine E. Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Mathew R.P. Sapiano
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Daniel S. Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Harris A, Chandramohan S, Awali RA, Grewal M, Tillotson G, Chopra T. Physicians' attitude and knowledge regarding antibiotic use and resistance in ambulatory settings. Am J Infect Control 2019; 47:864-868. [PMID: 30926215 DOI: 10.1016/j.ajic.2019.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND The aim of this survey was to assess the attitudes of physicians toward antibiotic prescribing and explore their knowledge about antimicrobial resistance (AMR) in ambulatory care settings. METHODS We conducted a cross-sectional survey that was administered to physicians who work primarily in ambulatory care settings in the United States. The survey was self-administered, voluntary, and anonymous, and was delivered through electronic mail and online forums using a 35-item questionnaire. RESULTS The survey was completed by 323 physicians. Ninety-nine percent of respondents agreed that AMR is a national problem, but only 63% agreed that AMR is a local problem within their own facilities. Ninety-four percent of the respondents reported that each antibiotic prescription can impact AMR; however, 23% still believed that aggressive prescribing is necessary to avoid clinical failures. Factor perceived to have a low to moderate impact on the physicians' choice of antibiotic was the presence of prescription guidelines (54%). Top measures reported to be effective in reducing the emergence of AMR were institution specific guidelines (94%), institution specific antibiogram (92%), educating health care providers (87%), and regular audits and feedback on antibiotic prescribing (86%). CONCLUSIONS AMR awareness campaigns and antibiotic stewardships incorporating interactive education and feedback, along with input of local experts, are critically needed to address the problem of AMR in both inpatient and ambulatory settings.
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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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Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections. Antibiotics (Basel) 2019; 8:antibiotics8020084. [PMID: 31248119 PMCID: PMC6627108 DOI: 10.3390/antibiotics8020084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/26/2022] Open
Abstract
Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.
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Willis Z, Carpenter DM, Sayner R, Sleath BL. Discussions About Antibiotics During Adolescent Asthma Visits: Implications for Providers. Clin Pediatr (Phila) 2019; 58:564-570. [PMID: 30782003 DOI: 10.1177/0009922819829033] [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] [Indexed: 11/17/2022]
Abstract
Children with asthma are exposed to antibiotics more frequently than their peers. The quality of provider-patient discussion about antibiotics is unknown. In this secondary data analysis, we reviewed existing transcripts of audiotaped adolescent asthma visits using a standardized coding sheet to analyze the quality of communication about antibiotics. Of 539 transcripts, we identified 12 discussions about antibiotics. No patient or parent requested antibiotics. In most cases, discussion was limited to assessment of drug allergies and preferred formulation. In 5 cases (42%), the prescribed antibiotic was not named. We propose a set of communication elements that should be included whenever antibiotics are prescribed, classified into ( a) Essential, such as the drug name and dosing schedule; ( b) Encouraged, such as expected response to therapy; or ( c) Situational, such as discussion of alternatives to antibiotics. Future research should further explore the quality of antibiotic-related conversations among different groups of providers and patients.
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Affiliation(s)
| | | | - Robyn Sayner
- 1 University of North Carolina at Chapel Hill, NC, USA
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40
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Şarklı FD, Baydar Artantaş A, Uğurlu M. Why Do Patients Want Antibiotics and Why Do Physcians Prescribe Antibiotics?: A Cross-Sectional Study In Primary Health Care. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.542209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Dehn Lunn A. Reducing inappropriate antibiotic prescribing in upper respiratory tract infection in a primary care setting in Kolkata, India. BMJ Open Qual 2018; 7:e000217. [PMID: 30555928 PMCID: PMC6267302 DOI: 10.1136/bmjoq-2017-000217] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 12/30/2022] Open
Abstract
Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation’s primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4 months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8 weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4 weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4 months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.
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Abstract
The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
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Poole NM. Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key. Curr Probl Pediatr Adolesc Health Care 2018; 48:306-317. [PMID: 30389361 DOI: 10.1016/j.cppeds.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50-65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.
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Affiliation(s)
- Nicole M Poole
- Seattle Children's Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
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From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting. Curr Probl Pediatr Adolesc Health Care 2018; 48:289-305. [PMID: 30322711 DOI: 10.1016/j.cppeds.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.
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Antibiotic prescribing for acute respiratory infections in New York City: A model for collaboration. Infect Control Hosp Epidemiol 2018; 39:1360-1366. [PMID: 30226119 DOI: 10.1017/ice.2018.227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the status of antibiotic prescribing in the ambulatory setting for adult patients with acute respiratory infections (ARIs) and to identify opportunities and barriers for outpatient antibiotic stewardship programs (ASPs). DESIGN Mixed methods including point prevalence using chart reviews, surveys, and collaborative learning. SETTING Hospital-owned clinics in the New York City area.Participants/PatientsIn total, 31 hospital-owned clinics from 9 hospitals and health systems participated in the study to assess ARI prescribing practices for patients >18 years old.InterventionsEach clinic performed a survey of current stewardship practices, retrospective chart reviews of prescribing in 30 randomly selected ARI patients from October 2015 to March 2016, and surveys of provider characteristics and knowledge. Clinics participated in collaborative learning with peers and experts in antibiotic stewardship and collected data from June 2016 to August 2016. Sites received data reports by individual clinic, aggregated by hospital, and were compared among participating clinics. RESULTS Few sites had outpatient stewardship activities. The retrospective review of 1,004 ARI patients revealed that 37.3% of ARI patients received antibiotics, with significant variation in prescribing practices among sites (17.4%-71.0%; P<.001). Macrolides were the most commonly prescribed antibiotics. Most of the 302 respondents recognized the need for tools to assist in prescribing. CONCLUSIONS This collaborative study establishes a baseline assessment of the status of outpatient ASPs in New York City. It provides hospitals, health systems, and individual clinics with specific data to inform their development of stewardship interventions targeting ARIs.
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Hopman NEM, Hulscher MEJL, Graveland H, Speksnijder DC, Wagenaar JA, Broens EM. Factors influencing antimicrobial prescribing by Dutch companion animal veterinarians: A qualitative study. Prev Vet Med 2018; 158:106-113. [PMID: 30220383 DOI: 10.1016/j.prevetmed.2018.07.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/12/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
Use of antimicrobials selects for antimicrobial resistance, and this poses a threat for both human and animal health. Although previous studies show that total antimicrobial use in Dutch companion animal clinics is relatively low and decreasing, the majority of antimicrobials prescribed are categorised as critically important for human medicine by the World Health Organization (WHO). Large differences in use between clinics are also observed. Identification of factors that influence the prescribing behaviour of veterinarians is needed to tailor future interventions aimed at promoting prudent use of antimicrobials in companion animals. The aim of this study was to explore factors influencing the antimicrobial prescribing behaviour of companion animal veterinarians in the Netherlands. Face-to-face, semi-structured interviews were used to interview 18 Dutch companion animal veterinarians. Interviews were held until theoretical data saturation was reached. An interview guide was used to structure the interviews, and ATLAS.ti 7.5 was used to manage and analyse the qualitative data. An iterative approach was applied to develop a conceptual model of factors that influence antimicrobial prescribing behaviour. The conceptual model shows four major categories of factors that influence the antimicrobial prescribing behaviour: veterinarian-related factors, patient-related (i.e. owner- and pet-related) factors, treatment-related factors (i.e. alternative treatment options and antimicrobial-related factors) and contextual factors (i.e. professional interactions, further diagnostics and environmental factors). All four major categories of influencing factors should be addressed to improve awareness on antimicrobial prescribing behaviour and to develop an antimicrobial stewardship programme for companion animal clinics.
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Affiliation(s)
- Nonke E M Hopman
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands.
| | - Marlies E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein 21, 6525 EZ Nijmegen, The Netherlands.
| | - Haitske Graveland
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands.
| | - David C Speksnijder
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands.
| | - Jaap A Wagenaar
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands; Wageningen Bioveterinary Research, Houtribweg 39, 8221 RA Lelystad, The Netherlands.
| | - Els M Broens
- Department of Infectious Diseases and Immunology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, 3584 CL Utrecht, The Netherlands.
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National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015. J Gen Intern Med 2018; 33:1060-1068. [PMID: 29679226 PMCID: PMC6025673 DOI: 10.1007/s11606-018-4430-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 02/07/2018] [Accepted: 03/20/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention. OBJECTIVE Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs. DESIGN Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015. PATIENTS Antibiotic-treated adults (≥ 20 years) seeking ED care. MAIN MEASURES Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics. KEY RESULTS Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group. CONCLUSIONS Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.
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Yates TD, Davis ME, Taylor YJ, Davidson L, Connor CD, Buehler K, Spencer MD. Not a magic pill: a qualitative exploration of provider perspectives on antibiotic prescribing in the outpatient setting. BMC FAMILY PRACTICE 2018; 19:96. [PMID: 29933762 PMCID: PMC6015451 DOI: 10.1186/s12875-018-0788-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/31/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Inappropriate prescribing of antibiotics poses an urgent public health threat. Limited research has examined factors associated with antibiotic prescribing practices in outpatient settings. The goals of this study were to explore elements influencing provider decisions to prescribe antibiotics, identify provider recommendations for interventions to reduce inappropriate antibiotic use, and inform the clinical management of patients in the outpatient environment for infections that do not require antibiotics. METHODS This was a qualitative study using semi-structured interviews with key informants. Seventeen outpatient providers (10 medical doctors and 7 advanced care practitioners) within a large healthcare system in Charlotte, North Carolina, participated. Interviews were audio recorded, transcribed, and analyzed for themes. RESULTS Primary barriers to reducing inappropriate antibiotic prescribing included patient education and expectations, system-level factors, and time constraints. Providers indicated they would be interested in having system-wide, evidence-based guidelines to inform their prescribing decisions and that they would also be receptive to efforts to improve their awareness of their own prescribing practices. Results further suggested that providers experience a high demand for antibiotic prescriptions; consequently, patient education around appropriate use would be beneficial. CONCLUSIONS Findings suggest that antibiotic prescribing in the outpatient setting is influenced by many pressures, including patient demand and patient satisfaction. Training on appropriate antibiotic prescribing, guideline-based decision support, feedback on prescribing practices, and patient education are recommended interventions to improve levels of appropriate prescribing.
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Affiliation(s)
- Traci D Yates
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA.
| | - Marion E Davis
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Lisa Davidson
- Division of Infectious Disease, Atrium Health, Charlotte, NC, USA
| | - Crystal D Connor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Katherine Buehler
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Melanie D Spencer
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
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Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics 2018; 141:peds.2017-4124. [PMID: 29793986 DOI: 10.1542/peds.2017-4124] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Brian A Smith
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
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Cohen SM, Lee HJ, Roy N, Misono S. Pharmacologic management of voice disorders by general medicine providers and otolaryngologists. Laryngoscope 2017; 128:682-689. [PMID: 28944537 DOI: 10.1002/lary.26875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVES 1) To compare laryngeal diagnoses from general medical providers (GMP) to otolaryngologists following GMP-based medication trial, and 2) to evaluate associations between GMP medication trials and pharmacologic treatment by otolaryngologists. METHODS Retrospective cohort analysis using large, national administrative U.S. claims database. Patients with laryngeal/voice disorders as per the International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2010, to December 31, 2012, seen by a GMP and then an otolaryngologist between 2 weeks to 3 months after the GMP visit, were included. Patient demographics, comorbid conditions, medication use, and initial GMP and otolaryngology laryngeal diagnoses were collected. Logistic regression was performed to evaluate the association between GMP and otolaryngologist medication trials. RESULTS A total of 12,475 unique laryngeal/voice-disordered patients met inclusion criteria. At the initial GMP visit, 15.3% received an antibiotic, 14.0% a proton pump inhibitor (PPI), and 7.7% an oral steroid. After the otolaryngology visit, increased diagnoses of vocal fold paralysis/paresis, benign vocal fold/laryngeal pathology, chronic laryngitis, and multiple diagnoses occurred. The adjusted odds for an otolaryngologist prescribing an antibiotic, PPI, or oral steroid, respectively, given that a GMP prescribed an antibiotic, PPI, or oral steroid, was roughly two to three times higher that of a GMP not prescribing the given medication. CONCLUSION Patients with structural and neuromuscular laryngeal disorders were treated with medications by GMPs, and similar mediations often were repeated after otolaryngology evaluation. These findings suggest potential areas of unnecessary pharmacologic treatment of laryngeal/voice-disordered patients. LEVEL OF EVIDENCE 2b. Laryngoscope, 128:682-689, 2018.
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Affiliation(s)
- Seth M Cohen
- Duke Voice Care Center, Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Nelson Roy
- Department of Communication Sciences and Disorders, Division of Otolaryngology-Head & Neck Surgery (Adjunct), University of Utah, Salt Lake City, Utah
| | - Stephanie Misono
- Lions Voice Clinic, Department of Otolaryngology/Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
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