Long-term effects of an educational seminar on antibiotic prescribing by GPs: a randomised controlled trial

Reporting of costs and economic impacts in randomized trials of de-implementation interventions for low-value care: a systematic scoping review

BACKGROUND

De-implementation of low-value care can increase health care sustainability. We evaluated the reporting of direct costs of de-implementation and subsequent change (increase or decrease) in health care costs in randomized trials of de-implementation research.

METHODS

We searched MEDLINE and Scopus databases without any language restrictions up to May 2021. We conducted study screening and data extraction independently and in duplicate. We extracted information related to study characteristics, types and characteristics of interventions, de-implementation costs, and impacts on health care costs. We assessed risk of bias using a modified Cochrane risk-of-bias tool.

RESULTS

We screened 10,733 articles, with 227 studies meeting the inclusion criteria, of which 50 included information on direct cost of de-implementation or impact of de-implementation on health care costs. Studies were mostly conducted in North America (36%) or Europe (32%) and in the primary care context (70%). The most common practice of interest was reduction in the use of antibiotics or other medications (74%). Most studies used education strategies (meetings, materials) (64%). Studies used either a single strategy (52%) or were multifaceted (48%). Of the 227 eligible studies, 18 (8%) reported on direct costs of the used de-implementation strategy; of which, 13 reported total costs, and 12 reported per unit costs (7 reported both). The costs of de-implementation strategies varied considerably. Of the 227 eligible studies, 43 (19%) reported on impact of de-implementation on health care costs. Health care costs decreased in 27 studies (63%), increased in 2 (5%), and were unchanged in 14 (33%).

CONCLUSION

De-implementation randomized controlled trials typically did not report direct costs of the de-implementation strategies (92%) or the impacts of de-implementation on health care costs (81%). Lack of cost information may limit the value of de-implementation trials to decision-makers.

TRIAL REGISTRATION

OSF (Open Science Framework): https://osf.io/ueq32 .

Is Education Alone Enough to Sustain Improvements of Antimicrobial Stewardship in General Practice in Australia? Results of an Intervention Follow-Up Study

Sustained behaviour change and practice improvements for the optimal use of antimicrobials remains challenging in primary care. In 2018, a simple antimicrobial stewardship education programme involving guideline recommendations for common infections, antimicrobial audit reports, and local antibiograms resulted in significant improvements in guideline compliance and more appropriate antimicrobial prescribing by GPs. This observational follow-up study aims to examine the sustainability of the positive intervention effect after two years of implementation of the intervention. Practice-based data on all oral antimicrobial prescriptions issued by GPs were collected retrospectively to compare with intervention data and to measure the sustainability of the intervention effect. The data were analysed using a two-sample test of proportions. The primary outcomes included changes in the rate of prescription compliance with the Australian “Therapeutic Guidelines: Antibiotic” and the appropriateness of antimicrobial choice and duration of therapy. Overall, there was a significant decline in guideline compliance, from 58.5 to 36.5% (risk ratio (RR) (95% CI): 0.62 (0.52–0.74)), in the appropriateness of antimicrobial choice, from 92.8 to 72.8% (0.78 (0.73, 0.84)), and in the prescribed duration, from 87.7 to 53.3% (0.61 (0.54, 0.68)) in the intervention follow-up period. In respiratory infections and ear, nose, and throat infections, the rates of guideline compliance and appropriate choice and duration of antimicrobial prescription decreased significantly at p < 0.001. Appropriateness in the duration of antimicrobial therapy also significantly decreased for most antimicrobials. The evidence suggests that a simple and single-occasion antimicrobial stewardship education programme is probably not enough to sustain improvements in the optimal use of antimicrobials by GPs. Future research is needed to validate the results in multiple GP clinics and to examine the effect of sustained education programmes involving infection-specific and antimicrobial-targeted audits and feedback.

Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally: A Systematic Review and Meta-Analysis

IMPORTANCE

Antimicrobial resistance continues to spread rapidly at a global scale. Little evidence exists on the association of antimicrobial stewardship programs (ASPs) with the consumption of antibiotics across health care and income settings.

OBJECTIVE

To synthesize current evidence regarding the association between antimicrobial stewardship programs and the consumption of antibiotics globally.

DATA SOURCES

PubMed, Web of Science, and Scopus databases were searched from August 1, 2010, to Aug 1, 2020. Additional studies from the bibliography sections of previous systematic reviews were included.

STUDY SELECTION

Original studies of the association of ASPs with antimicrobial consumption across health care and income settings. Animal and environmental studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items in Systematic Reviews and Meta-Analyses guideline, the pooled association of targeted ASPs with antimicrobial consumption was measured using multilevel random-effects models. The Effective Public Health Practice Project quality assessment tool was used to assess study quality.

MAIN OUTCOMES AND MEASURES

The main outcome measures were proportion of patients receiving an antibiotic prescription and defined daily doses per 100 patient-days.

RESULTS

Overall, 52 studies (with 1 794 889 participants) measured the association between ASPs and antimicrobial consumption and were included, with 40 studies conducted in high-income countries and 12 in low- and middle-income countries (LMICs). ASPs were associated with a 10% (95% CI, 4%-15%) reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption (rate ratio, 0.72; 95% CI, 0.56-0.92). ASPs were also associated with a 21% (95% CI, 5%-36%) reduction in antibiotic consumption in pediatric hospitals and a 28% reduction in World Health Organization watch groups antibiotics (rate ratio, 0.72; 95% CI, 0.56-0.92).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, ASPs appeared to be effective in reducing antibiotic consumption in both hospital and nonhospital settings. Impact assessment of ASPs in resource-limited settings remains scarce; further research is needed on how to best achieve reductions in antibiotic use in LMICs.

Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact

Antibiotic resistance remains a crucial global public health problem with excessive and inappropriate antibiotic use representing an important driver of this issue. Strategies to improve antibiotic prescription and dispensing are required in primary health care settings. The main purpose of this review is to identify and synthesize available evidence on the economic impact of educational interventions to reduce prescription and dispensing of antibiotics among primary health care professionals. Information about the clinical impact resulting from the implementation of interventions was also gathered. PubMed, Scopus, Web of Science and EMBASE were the scientific databases used to search and identify relevant studies. Of the thirty-three selected articles, most consisted of a simple intervention, such as a guideline implementation, while the others involved multifaceted interventions, and differed regarding study populations, designs and settings. Main findings were grouped either into clinical or cost outcomes. Twenty of the thirty-three articles included studies reporting a reduction in outcome costs, namely in antibiotic cost and associated prescription costs, in part due to an overall improvement in the appropriateness of antibiotic use. The findings of this study show that the implementation of educational interventions is a cost-effective strategy to reduce antibiotic prescription and dispensing among primary healthcare providers.

Cost-effectiveness and Economic Benefit of Continuous Professional Development for Drug Prescribing: A Systematic Review

Importance

The economic impact of continuous professional development (CPD) education is incompletely understood.

Objective

To systematically identify and synthesize published research examining the costs associated with physician CPD for drug prescribing.

Evidence Review

MEDLINE, Embase, PsycInfo, and the Cochrane Database were searched from inception to April 23, 2020, for comparative studies that evaluated the cost of CPD focused on drug prescribing. Two reviewers independently screened all articles for inclusion and reviewed all included articles to extract data on participants, educational interventions, study designs, and outcomes (costs and effectiveness). Results were synthesized for educational costs, health care costs, and cost-effectiveness.

Findings

Of 3338 articles screened, 38 were included in this analysis. These studies included at least 15 659 health care professionals and 1 963 197 patients. Twelve studies reported on educational costs, ranging from $281 to $183 554 (median, $15 664). When economic outcomes were evaluated, 31 of 33 studies (94%) comparing CPD with no intervention found that CPD was associated with reduced health care costs (drug costs), ranging from $4731 to $6 912 000 (median, $79 373). Four studies found reduced drug costs for 1-on-1 outreach compared with other CPD approaches. Regarding cost-effectiveness, among 5 studies that compared CPD with no intervention, the incremental cost-effectiveness ratio for a 10% improvement in prescribing ranged from $15 390 to $437 027 to train all program participants. Four comparisons of alternative CPD approaches found that 1-on-1 educational outreach was more effective but more expensive than group education or mailed materials (incremental cost-effectiveness ratio, $18-$4105 per physician trained).

Conclusions and Relevance

In this systematic review, CPD for drug prescribing was associated with reduced health care (drug) costs. The educational costs and cost-effectiveness of CPD varied widely. Several CPD instructional approaches (including educational outreach) were more effective but more costly than comparators.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

Antibiotic stewardship knowledge and belief differences among healthcare professionals in hospitals: A survey study

BACKGROUND

Collaborative practice in healthcare has been recommended to improve the quality of antimicrobial stewardship interventions, a behavioral change in antimicrobial use. Insufficient knowledge regarding antibiotic resistance, the fear of complications from infections, and how providers perceive antibiotic use and resistance are likely to influence prescribing behavior. This study's objective was to identify the knowledge and belief healthcare professionals' differences about antibiotic stewardship.

METHODS

This cross-sectional survey study of three hospitals in the East Java province, Indonesia utilized a 43-item questionnaire to assess antimicrobial stewardship knowledge and belief. There were 12 knowledge questions (total possible score: 12) and 31 belief questions (total possible score: 155). The Kuder Richardson 20 (KR-20) and Cronbach alpha values of the questionnaire were 0.54 and 0.92, respectively.

RESULTS

Out of the 257 respondents, 19% (48/257) had a low scores of knowledge, and 39% (101/257) had low scores on belief about antibiotic stewardship (101/257). Most midwives had a low scores on knowledge (25/61) and low scores on belief (46/61). Respondents with high scores on belief were 17% (10/59) physicians, 15% (4/27) pharmacists, 8% (5/65) nurses, and 3% (2/61) midwives.

CONCLUSION

Among healthcare professionals, knowledge and belief differences concerning antibiotic stewardship vary widely. These differences will affect their capability, behavior, and contribution to the healthcare team collaboration and performance. Further studies are needed to evaluate the correlation between the level of inter-professional collaboration and the quality of the antibiotic stewardship implementation.

A randomised controlled trial to reduce highest priority critically important antimicrobial prescription in companion animals

Robust evidence supporting strategies for companion animal antimicrobial stewardship is limited, despite frequent prescription of highest priority critically important antimicrobials (HPCIA). Here we describe a randomised controlled trial where electronic prescription data were utilised (August 2018-January 2019) to identify above average HPCIA-prescribing practices (n = 60), which were randomly assigned into a control group (CG) and two intervention groups. In March 2019, the light intervention group (LIG) and heavy intervention group (HIG) were notified of their above average status, and were provided with educational material (LIG, HIG), in-depth benchmarking (HIG), and follow-up meetings (HIG). Following notification, follow-up monitoring lasted for eight months (April-November 2019; post-intervention period) for all intervention groups, though HIG practices were able to access further support (i.e., follow-up meetings) for the first six of these months if requested. Post-intervention, in the HIG a 23.5% and 39.0% reduction in canine (0.5% of total consultations, 95% confidence interval, 0.4-0.6, P = 0.04) and feline (4.4%, 3.4-5.3, P < 0.001) HPCIA-prescribing consultations was observed, compared to the CG (dogs: 0.6%, 0.5-0.8; cats: 7.4%, 6.0-8.7). The LIG was associated with a 16.7% reduction in feline HPCIA prescription (6.1% of total consultations, 5.3-7.0, P = 0.03). Therefore, in this trial we have demonstrated effective strategies for reducing veterinary HPCIA prescription.

Effect of governmental strategies on antibiotic prescription in dentistry

Objective: To study the effect of governmental strategies, to constitute and publish recommendations on antibiotic usage in dentistry, on the antibiotic consumption.Material and methods: Descriptive statistics regarding antibiotic prescription between 2009 and 2017 was retrieved from two national registers, the Swedish Prescribed Drug Register and the Dental Health register, both administered by the National Board of Health and Welfare. Age standardization was applied to alleviate the comparison between gender, different regions and years.Results: The number of dispatched prescriptions of antibiotics from dentists was reduced with 31% during the study period. 10% of the visits to a dentist generated an antibiotic prescription corresponding to 7% of the total number of antibiotic prescriptions. A decline in prescription was observed after publication of national recommendations for antibiotics prophylaxis in 2012 and antibiotic treatment in 2014. Unexplained geographical and gender differences in the rates of prescription were seen.Conclusions: Data indicates a correlation between introduction of governmental strategies to reduce antibiotic usage and declining antibiotic prescription. Although a marked reduction in prescription was observed, the results indicate that there is further potential for improvement of antibiotic stewardship in odontology.

Effectiveness of an intervention to improve antibiotic-prescribing behaviour in primary care: a controlled, interrupted time-series study

BACKGROUND

High rates of antibiotic misprescribing in primary care, with alarming clinical and economic consequences, highlight the urgent need for interventions to improve antibiotic prescribing in this setting.

OBJECTIVES

To assess the effectiveness on antibiotic prescribing quality indicators of a multifaceted intervention targeting health professionals' and patients' behaviour regarding antibiotic use.

METHODS

We conducted a pragmatic cluster-randomized controlled trial in the catchment area covered by Portugal's Central Regional Health Administration. The intervention consisted of a multidisciplinary, multifaceted programme involving physicians, pharmacists and patients, and comprising outreach visits for physicians and pharmacists, and educational materials for health professionals and patients. The following were assessed: relative ratios of prescription of penicillins sensitive to β-lactamase, penicillin combinations including β-lactamase inhibitors, third- and fourth-generation cephalosporins and fluoroquinolones; and the ratio of broad- to narrow-spectrum antibiotics. An interrupted time-series analysis for multiple-group comparisons was performed. The study protocol was registered on Clinical.trials.gov (NCT02173509).

RESULTS

The participation rate in the educational intervention was 64% (197/309 GPs) in a total of 25 counties. Statistically significant improvements were obtained, not only in the relative prescription of penicillins sensitive to β-lactamase (overall relative change of +896%) and penicillin combinations including β-lactamase inhibitors (-161%), but also in the ratio of broad- to narrow-spectrum antibiotics (-200%). Statistically significant results were also obtained for third- and fourth-generation cephalosporins, though only in the immediate term.

CONCLUSIONS

This study showed that quality indicators of antibiotic prescribing can be improved by tackling influences on behaviour including knowledge and attitudes surrounding physicians' clinical practice. Accordingly, these determinants must be considered when implementing interventions aimed at improving antibiotic prescribing.

The effectiveness of a simple antimicrobial stewardship intervention in general practice in Australia: a pilot study

BACKGROUND

Inappropriate and excessive antimicrobial prescribing can lead to antimicrobial resistance. Antimicrobial Stewardship (AMS) principles are not well established in general practice in Australia despite the relatively high rate of community antimicrobial prescribing. Few interventions have been implemented that have resulted in a significant reduction or improvement in antimicrobial prescribing by General Practitioners (GPs). This study was therefore conducted to assess the impact of a novel GP educational intervention on the appropriateness of antimicrobial prescriptions as well as GP compliance with antimicrobial prescription guidelines.

METHODS

In 2018, a simple GP educational intervention was rolled out in a large clinic with the aim of improving antimicrobial prescribing. It included face-to-face education sessions with GPs on AMS principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. An antibiotic appropriateness audit on prescribing practice before and after the educational intervention was conducted. Data were summarised using percentages and compared across time points using Chi-squared tests and Poisson regression (results reported as risk ratios (RR) with 95% confidence intervals (CI)).

RESULTS

Data from 376 and 369 prescriptions in July 2016 and July 2018, respectively, were extracted. There were significant improvements in appropriate antimicrobial selection (73.9% vs 92.8%, RR = 1.26; 95% CI = 1.18-1.34), appropriate duration (53.1% vs 87.7%, RR = 1.65; 95% CI = 1.49-1.83) and compliance with guidelines (42.2% vs 58.5%, RR = 1.39, 95% CI = 1.19-1.61) post- intervention. Documentation of antimicrobial duration directions, patient follow-up as well as patient weight significantly increased after the intervention (p < 0.001). There was significant reduction in; prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions (p < 0.001). Inappropriate antimicrobial prescriptions observed pre-intervention for medical termination of pregnancy ceased post-intervention.

CONCLUSIONS

Auditing GP antimicrobial prescriptions identified prescribing practices inconsistent with Australian guidelines. However, implementation of a simple education program led to significantly improved antimicrobial prescribing by GPs. These findings indicate the important role of AMS and continued antimicrobial education within general practice.

Communication training and the prescribing pattern of antibiotic prescription in primary health care

BACKGROUND

The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians.

METHODS

In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs.

RESULTS

Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

CONCLUSIONS

Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.

Long-term effect of a practice-based intervention (HAPPY AUDIT) aimed at reducing antibiotic prescribing in patients with respiratory tract infections

Objectives

Few studies have evaluated the long-term effects of educational interventions on antibiotic prescription and the results are controversial. This study was aimed at assessing the effect of a multifaceted practice-based intervention carried out 6 years earlier on current antibiotic prescription for respiratory tract infections (RTIs).

Methods

The 210 general practitioners (GPs) who completed the first two registrations in 2008 and 2009 were invited to participate in a third registration. The intervention held before the second registration consisted of discussion about the first registration of results, appropriate use of antibiotics for RTIs, patient brochures, a workshop and the provision of rapid tests. As in the previous registrations, GPs were instructed to complete a template for all the patients with RTIs during 15 working days in 2015. A new group of GPs from the same areas was also invited to participate and acted as controls. A multilevel logistic regression analysis was performed considering the prescription of antibiotics as the dependent variable.

Results

A total of 121 GPs included in the 2009 intervention (57.6%) and 117 control GPs registered 22 247 RTIs. On adjustment for covariables, compared with the antibiotic prescription observed just after the intervention, GPs assigned to intervention prescribed slightly more antibiotics 6 years later albeit without statistically significant differences (OR 1.08, 95% CI 0.89-1.31, P = 0.46), while GPs in the control group prescribed significantly more antibiotics (OR 2.74, 95% CI 2.09-3.59, P < 0.001).

Conclusions

This study shows that a single multifaceted intervention continues to reduce antibiotic prescribing 6 years later.

Reducing antibiotic prescribing for lower respiratory tract infections 6 years after a multifaceted intervention

AIMS

Few studies have evaluated the long-term impact of interventions on antibiotic prescription for lower respiratory tract infections (LRTI). This study was aimed at evaluating the use of antibiotics prescribed for LRTIs by general practitioners (GP) who underwent a multifaceted intervention carried out 6 years earlier.

METHODS

General practitioners who had completed two registrations in 2008 and 2009 were again invited to participate in a third audit-based study in 2015. A multifaceted intervention was held 1-3 months before the second registration. A new group of GPs with no previous training on the rational use of antibiotics were also invited to participate and acted as controls. Multilevel logistic regression was performed considering the prescription of antibiotics as the dependent variable.

RESULTS

A total of 121 GPs of the 210 who underwent the intervention (57.6%) and 117 control GPs registered 4333 episodes of LRTIs. On adjustment for covariables, compared with the antibiotic prescription for LRTIs observed just after the intervention, antibiotic prescription slightly increased 6 years later among GPs who had undergone the intervention (OR 1.17, 95% CI 0.95-1.43), while control GPs prescribed significantly more antibiotics (OR 2.31, 95% CI 1.62-3.29). However, withholding antibiotic prescribing with C-reactive protein (CRP) values <10 mg/L was more frequently observed just after the intervention compared 6 years later (12.7% vs 32.2%; P < 0.01).

CONCLUSIONS

Antibiotic prescribing for LRTIs remains low 6 years after an intervention, although GPs are less confident to withhold antibiotic therapy in patients with low CRP levels.

Attitude and perception of medical interns about antimicrobial resistance: a multi center cross-sectional study in Ethiopia

Background

Antibiotic resistance is a global burden and reduction of antimicrobial resistance requires change in antimicrobial prescribing behavior of health workers. The current study aimed to evaluate the attitude and perception of Ethiopian medical interns towards antimicrobials resistance.

Methods

A multi center cross-sectional institutional based survey was conducted from August 2016 to October 2016 among medical interns in Ethiopia. Data entered and analyzed using Statistical Package for Social Sciences program (SPSS) software version 21.0 for Windows. Descriptive statistics, chi-square test and binary logistic regression analysis were used and statistical significance was set at P-value < 0.05 as a cut of point.

Results

Out of the 278 questionnaires distributed, 270 were returned completed giving a response rate of 97.1%. Most of the participants 256 (94.8%) wants to receive further education about antimicrobial stewardship. Chi-square test showed a significant difference between institutions about interns' attitude and perception concerning over usage of antimicrobials in their institutions; description of correct antimicrobial coverage; handling patients who demands antimicrobial therapy that is not indicated and finding reliable sources of information to treat infections (P-value < 0.05). Attaching at internal medicine wards during the survey and receiving antimicrobial stewardship training during the past 6 months were found to improve their attitude significantly by 2.68 and 3.48 times respectively.

Conclusions

The current study demonstrates an enormous desire of medical interns for further education about antimicrobial stewardship. Hence, it is strongly recommended to provide a comprehensive, regular, standard and up to date educational training in all medical institutions for our future prescribers. Medical institutions and stakeholders are recommended to advocate curriculums and policies that build up antimicrobial stewardship programs.

From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting

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.

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review

INTRODUCTION

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation.

METHODS

We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment.

RESULTS

Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS.

CONCLUSIONS

A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS.

Reducing early career general practitioners' antibiotic prescribing for respiratory tract infections: a pragmatic prospective non-randomised controlled trial

BACKGROUND

Inappropriate antibiotic prescription and consequent antibacterial resistance is a major threat to healthcare.

OBJECTIVES

To evaluate the efficacy of a multifaceted intervention in reducing early career general practitioners' (GPs') antibiotic prescribing for upper respiratory tract infections (URTIs) and acute bronchitis/bronchiolitis.

METHODS

A pragmatic non-randomized trial employing a non-equivalent control group design nested within an existing cohort study of GP registrars' (trainees') clinical practice. The intervention included access to online modules (covering the rationale of current clinical guidelines recommending non-prescription of antibiotics for URTI and bronchitis/bronchiolitis, and communication skills in management of acute bronchitis) followed by a face-to-face educational session. The intervention was delivered to registrars (and their supervisors) in two of Australia's seventeen regional GP training providers (RTPs). Three other RTPs were the control group. Outcomes were proportion of registrars' URTI consultations and bronchitis/bronchiolitis consultations prescribed antibiotics. Intention-to-treat analyses employed logistic regression within a Generalised Estimating Equation framework, adjusted for relevant independent variables. The predictors of interest were time; treatment group; and an interaction term for time-by-treatment group. The P value associated with an interaction term determined statistically significant differences in antibiotic prescribing.

RESULTS

Analyses include data of 217 intervention RTPs' and 311 control RTPs' registrars. There was no significant reduction in antibiotic prescribing for URTIs. For bronchitis/bronchiolitis, a significant reduction (interaction P value = 0.024) remained true for analysis adjusted for independent variables (P value = 0.040). The adjusted absolute reduction in prescribing was 15.8% (95% CI: 4.2%-27.5%).

CONCLUSIONS

A multifaceted intervention reduced antibiotic prescribing for bronchitis/bronchiolitis but not URTIs.

The emergence and evolution of antimicrobial resistance: Impact on a global scale

The evolution of antimicrobial resistance is a multifaceted issue that is influenced by numerous factors. This growing healthcare problem has significantly impacted the public welfare and has substantially burdened the economic system on a global scale. In an effort to combat this rising problem, several strategies have been implemented in the recent years to stall the progression and decrease the emergence of antimicrobial resistance. The aim of this review article is to describe the various factors that have contributed to the current state of antimicrobial resistance and to evaluate potential strategies developed to reduce the burden of antimicrobial resistance.

Effects 4.5 years after an interactive GP educational seminar on antibiotic therapy for respiratory tract infections: a randomized controlled trial

BACKGROUND

The few studies assessing long-term effects of educational interventions on antibiotic prescription have produced conflicting results.

OBJECTIVES

Our aim was to assess the effects after 4.5 years of an interactive educational seminar designed for GPs and focused on antibiotic therapy in respiratory tract infections (RTIs). The seminar was expected to decrease antibiotic prescriptions for any diagnosis.

METHODS

We conducted a randomized controlled parallel-group trial in a Paris suburb (France), with GPs as the randomization unit and prescriptions as the analysis unit. The intervention occurred in September 2004 and the final assessment in March 2009. Among 203 randomized GPs, 168 completed the study, 70 in the intervention group and 98 in the control group. Intervention GPs were randomized to attending only a 2-day interactive educational seminar on evidence-based guidelines about managing RTIs or also 1 day of problem-solving training. The primary outcome was the percentage of change in the proportion of prescriptions containing an antibiotic for any diagnosis in 2009 versus 2004. An intention-to-treat sensitivity analysis was performed using multiple imputation.

RESULTS

After 4.5 years, absolute changes in the primary outcome measure were -1.1% (95% confidence interval: -2.2 to 0.0) in the intervention group and +1.4% (0.3-2.6) in the control group, yielding an adjusted between-group difference of -2.2% (-2.7 to -1.7; P < 0.001). Both intervention modalities had significant effects, and multiple imputation produced similar results.

CONCLUSIONS

A single, standardized and interactive educational seminar targeting GPs significantly decreased antibiotic use for RTIs after 4.5 years.

How can we improve antibiotic prescribing in primary care?

Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.

Educational effectiveness, target, and content for prudent antibiotic use

Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.

Antibiotic Resistance: What are the Opportunities for Primary Care in Alleviating the Crisis?

Numerous opportunities are available in primary care for alleviating the crisis of increasing antibiotic resistance. Preventing patients from developing an acute respiratory infection (ARI) will obviate any need for antibiotic use downstream. Hygiene measures such as physical barriers and hand hygiene, and possibly vaccination and exercise, may be effective. Also, a large range of complementary and alternative medicines (e.g. zinc, vitamin C and probiotics) are proposed for preventing and treating ARIs, but evidence for efficacy is scarce. General practitioners' (GPs) attitudes towards antibiotic prescribing are a major factor in the prescribing for ARIs. Professional interventions with educational components are effective, although they have modest effects, and are expensive. GPs' perceptions - that mistakenly assume as a default that patients want antibiotics for their ARIs - are often wrong. Shared decision making might be a solution, as it enables clinician and patient to participate jointly in making a health decision, having discussed the options together with the evidence for their harms as well as benefits. Furthermore, GPs' diagnostic uncertainty - often leading to an antibiotic prescription "just in case" - might be addressed by exploiting strategies such as safety-netting, e.g., establishing with the patient a priori clearly defined actions to take if the course of the illness deviates from the expected. None of these strategies or interventions on their own will greatly improve the use of antibiotics for ARIs. However, used in concert, combinations are likely to enable clinicians and health care systems to implement the strategies that will reduce antimicrobial resistance in the future.

[Prospective cross-sectional study of antibiotic prescriptions in a sample of French general practitioners]

OBJECTIVES

The aim of our study was to assess the quality of antibiotic prescriptions in a sample of general practitioners (GPs) receiving junior doctors in training, whatever the motive of the prescription.

METHODS

We performed a prospective observational study of all antibiotics prescribed in October 2012 by 21 GPs working in southeastern France. Two specialists (general medicine and infectious diseases) independently assessed the compliance with recommendations of antibiotic prescriptions using a validated algorithm.

RESULTS

Two hundred and thirty-two antibiotic courses were prescribed, mainly for low respiratory tract infections (30%), ENT (26%), urinary tract (22%) or skin (13%) infections. Forty prescriptions were considered as appropriate (17%), 77 as inappropriate (33%; mainly due to a non-recommended molecule choice [77%] or a too long treatment duration [44%]) and 115 prescriptions were unnecessary (50%), due to diagnostic issues. There were wide variations between GPs. An essential laboratory or imaging investigation was missing for 36% of prescriptions: chest X-ray for pneumonia (80% were missing), rapid antigen diagnostic test for acute pharyngitis (23% missing) and urine dipstick for urinary tract infections (80% missing). Fluoroquinolones and macrolides/synergistins accounted for 31% of the prescriptions, and were associated with a lower prevalence of appropriate prescriptions (7% and 2% respectively, P<0.001). There was a co-prescription of anti-inflammatory drugs in 15% of the cases.

CONCLUSION

The misuse of antibiotics was frequent in this study. Improving the diagnostic workout is of paramount importance. Urgent actions are needed to improve antibiotic use in general practice.