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Llor C, Cordoba G, de Oliveira SM, Bjerrum L, Moragas A. Antibiotic deprescribing: Spanish general practitioners' views on a new strategy to reduce inappropriate use of antibiotics in primary care. Eur J Gen Pract 2022; 28:217-223. [PMID: 36314609 PMCID: PMC9629099 DOI: 10.1080/13814788.2022.2130887] [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: 06/03/2022] [Revised: 08/07/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A doctor may recommend that a patient stop an antibiotic course before its scheduled completion time if further treatment may cause more harm than benefit. OBJECTIVES This study explores general practitioners' (GP) opinions about the use of antibiotic deprescribing (AD) in general practice. METHODS A cross-sectional, questionnaire-based study answered from February to March 2022. GPs (n = 6,083) affiliated with the largest Spanish scientific society of primary care were invited to participate. The survey included two statements related to use and fourteen views about AD rated by GPs using a 5-item Likert scale. RESULTS Eleven hundred and seven doctors completed the surveys (18.2%), of whom 92.5% (95% confidence interval [CI] 90.8-94%) reported having used the AD strategy in their practice at least once. GPs felt very confident in using a deprescribing strategy in patients with common cold and influenza (97.6% and 93.5%, respectively) but less with acute bronchitis (45.5%); 12.1% (95% CI, 10.2-14.2%) considered this practice harmful to patients. Respondents reported using AD more frequently when they initiated the antibiotic course (96.8%; 95% CI, 95.5-97.7) than when the treatment was initiated by another doctor (52.3%; 95% CI, 49.3-55.3%). However, doctors aged >60 years were more prone to use AD compared with younger colleagues (64.5% vs. 50%; p < 0.005). CONCLUSION The GPs in this study employ the strategy of AD. Nonetheless, essential differences lie in their views of the way the strategy is used. Further studies are warranted to explore the beliefs behind these perceptions and promote wider use of AD by GPs.
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Affiliation(s)
- Carl Llor
- Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
- Health Centre Via Roma, University Institute in Primary Care Research Jordi Gol i Gurina, CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Barcelona, Spain
| | - Gloria Cordoba
- International Centre for Antimicrobial Resistance Solutions (ICARS), Denmark
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Sandi Michele de Oliveira
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Denmark
| | - Ana Moragas
- Jaume I Health Centre, University Rovira i Virgili, Tarragona, Spain
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Hampton T, Ogden J, Higgins HM. Understanding doctors' emergency department antibiotic prescribing decisions in children with respiratory symptoms in the UK: a qualitative study. BMJ Open 2021; 11:e051561. [PMID: 34930732 PMCID: PMC8688728 DOI: 10.1136/bmjopen-2021-051561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Exploration of the factors that influence hospital doctors' antibiotic prescribing decisions when treating children with respiratory symptoms in UK emergency departments. METHODS A qualitative study using semistructured interviews based on a critical incident technique with 21 physicians of different grades and specialties that treat children in the UK. Interviews were audio-recorded then transcribed verbatim and analysed using thematic analysis. RESULTS Four themes were identified. These themes illustrate factors which influence clinician prescribing. The three principal themes were authorities, pressures and risk. The fourth transcending theme that ran through all themes was clinician awareness and complicity ('knowing but still doing'). CONCLUSIONS Hospital doctors prescribe antibiotics even when they know they should not. This appears to be due to the influence of those in charge or external pressures experienced while weighing up the immediate and longer term risks but clinicians do this with full insight into their actions. These findings have implications for invested parties seeking to develop future antimicrobial stewardship programmes. It is recommended that stewardship interventions acknowledge and target these themes which may in turn facilitate behaviour change and antimicrobial prescribing practice in emergency departments.
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Affiliation(s)
- Thomas Hampton
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jane Ogden
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Helen Mary Higgins
- Department of Livestock and One Health, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Bruyndonckx R, Stuart B, Little P, Hens N, Ieven M, Butler CC, Verheij TJM, Goossens H, Coenen S. The Effect of Amoxicillin in Adult Patients Presenting to Primary Care with Acute Cough Predicted to Have Pneumonia or a Combined Viral-Bacterial Infection. Antibiotics (Basel) 2021; 10:antibiotics10070817. [PMID: 34356738 PMCID: PMC8300796 DOI: 10.3390/antibiotics10070817] [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: 05/10/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
While most cases of acute cough are self-limiting, antibiotics are prescribed to over 50%. This proportion is inappropriately high given that benefit from treatment with amoxicillin could only be demonstrated in adults with pneumonia (based on chest radiograph) or combined viral-bacterial infection (based on modern microbiological methodology). As routine use of chest radiographs and microbiological testing is costly, clinical prediction rules could be used to identify these patient subsets. In this secondary analysis of data from a multicentre randomised controlled trial in adults presenting to primary care with acute cough, we used prediction rules for pneumonia or combined infection and assessed the effect of amoxicillin in patients predicted to have pneumonia or combined infection on symptom duration, symptom severity and illness deterioration. In total, 2056 patients that fulfilled all inclusion criteria were randomised, 1035 to amoxicillin, 1021 to placebo. Neither patients with a predicted pneumonia nor patients with a predicted combined infection were significantly more likely to benefit from amoxicillin. While the studied clinical prediction rules may help primary care clinicians to reduce antibiotic prescribing for low-risk patients, they did not identify adult acute cough patients that would benefit from amoxicillin treatment.
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Affiliation(s)
- Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Correspondence: ; Tel.: +32-11-268-631
| | - Beth Stuart
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Paul Little
- Aldermoor Health Centre, University of Southampton, Southampton SO16 5ST, UK; (B.S.); (P.L.)
| | - Niel Hens
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, 3500 Hasselt, Belgium;
- Centre for Health Economic Research and Modelling Infectious Diseases (CHERMID), Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK;
| | - Theo J. M. Verheij
- Julius Centre for Health, Sciences and Primary Care, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands;
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, 2610 Antwerp, Belgium; (M.I.); (H.G.); (S.C.)
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp, 2610 Antwerp, Belgium
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Smith DRM, Dolk FCK, Pouwels KB, Christie M, Robotham JV, Smieszek T. Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care. J Antimicrob Chemother 2019; 73:ii11-ii18. [PMID: 29490061 DOI: 10.1093/jac/dkx503] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives To assess the appropriateness of prescribing systemic antibiotics for different clinical conditions in primary care, and to quantify 'ideal' antibiotic prescribing proportions in conditions for which antibiotic treatment is sometimes but not always indicated. Methods Prescribing guidelines were consulted to define the appropriateness of antibiotic therapy for the conditions that resulted in antibiotic prescriptions between 2013 and 2015 in The Health Improvement Network (THIN) primary care database. The opinions of subject experts were then formally elicited to quantify ideal antibiotic prescribing proportions for 10 common conditions. Results Of the antibiotic prescriptions in THIN, 52.5% were for conditions that could be assessed using prescribing guidelines. Among these, the vast majority of prescriptions (91.4%) were for conditions where antibiotic appropriateness is conditional on patient-specific indicators. Experts estimated low ideal prescribing proportions in acute, non-comorbid presentations of many of these conditions, such as cough (10% of patients), rhinosinusitis (11%), bronchitis (13%) and sore throat (13%). Conversely, antibiotics were believed to be appropriate in 75% of non-pregnant women with non-recurrent urinary tract infection. In impetigo and acute exacerbation of chronic obstructive pulmonary disease, experts clustered into distinct groups that believed in either high or low prescribing. Conclusions In English primary care, most antibiotics are prescribed for conditions that only sometimes require antibiotic treatment, depending on patient-specific indicators. Experts estimated low ideal prescribing proportions in many of these conditions. Incomplete prescribing guidelines and disagreement about prescribing in some conditions highlight further research needs.
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Affiliation(s)
- David R M Smith
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - F Christiaan K Dolk
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK.,PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Koen B Pouwels
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK.,PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, UK
| | - Morag Christie
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Timo Smieszek
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK.,MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College School of Public Health, London, UK
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Adverse Effects of Amoxicillin for Acute Lower Respiratory Tract Infection in Primary Care: Secondary and Subgroup Analysis of a Randomised Clinical Trial. Antibiotics (Basel) 2017; 6:antibiotics6040036. [PMID: 29236038 PMCID: PMC5745479 DOI: 10.3390/antibiotics6040036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/06/2017] [Accepted: 12/08/2017] [Indexed: 11/26/2022] Open
Abstract
A European placebo-controlled trial of antibiotic treatment for lower respiratory tract infection (LRTI) conducted in 16 primary care practices networks recruited participants between November 2007 and April 2010, and found adverse events (AEs) occurred more often in patients prescribed amoxicillin compared to placebo. This secondary analysis explores the causal relationship and estimates specific AEs (diarrhoea, nausea, rash) due to amoxicillin treatment for LRTI, and if any subgroup is at increased risk of any or a specific AE. A total of 2061 patients were randomly assigned to amoxicillin (1038) and placebo (1023); 595 (28%) were 60 and older. A significantly higher proportion of any AEs (diarrhoea or nausea or rash) (OR = 1.31, 95% CI 1.05–1.64, number needed to harm (NNH) = 24) and of diarrhoea (OR 1.43 95% CI 1.08–1.90, NNH = 29) was reported in the amoxicillin group during the first week after randomisation. Subgroup analysis showed rash was significantly more often reported in males prescribed amoxicillin (interaction term 3.72 95% CI 1.22–11.36; OR of amoxicillin in males 2.79 (95% CI 1.08–7.22). No other subgroup at higher risk was identified. Although the study was not powered for subgroup analysis, this analysis suggests that most patients are likely to be equally harmed when prescribed antibiotics.
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Llor C. Should we always improve adherence to antimicrobial treatment? I don’t think we should. Aten Primaria 2014; 46:583-4. [PMID: 24933164 PMCID: PMC6983775 DOI: 10.1016/j.aprim.2014.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/17/2014] [Indexed: 10/28/2022] Open
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Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014; 5:229-41. [PMID: 25436105 DOI: 10.1177/2042098614554919] [Citation(s) in RCA: 901] [Impact Index Per Article: 90.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.
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Affiliation(s)
- Carl Llor
- School of Medicine, Cardiff University, Department of Primary Care and Public Health, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4XN, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Llor C, Plana-Ripoll O, Moragas A, Bayona C, Morros R, Pera H, Miravitlles M. Is C-reactive protein testing useful to predict outcome in patients with acute bronchitis? Fam Pract 2014; 31:530-7. [PMID: 25037854 DOI: 10.1093/fampra/cmu037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A recent clinical trial could not find differences between anti-inflammatory drugs, antibiotics and placebo in shortening the duration of symptoms in acute bronchitis. OBJECTIVES To investigate if C-reactive protein (CRP) concentrations at presentation are predictive of symptom resolution in these patients. METHODS We performed a secondary analysis of the data from a placebo-controlled, randomized clinical trial carried out in primary care. Patients from 18 to 70 years of age presenting a respiratory tract infection of <1 week of evolution, with cough as the predominant symptom and the presence of discoloured expectoration, were enrolled in the study. On the baseline visit, CRP was determined in capillary blood and a five-item symptom diary was given. Patients were followed up to 30 days. The main outcome measure was the number of days with persistent cough. RESULTS A total of 312 subjects fulfilled all the criteria for the efficacy analysis and had undergone the CRP test; of these, 56.4% presented a CRP value <8 mg/l and 76% presented <20 mg/l. There were no significant differences in the median duration of cough: 10 days among patients with CRP concentrations <8 mg/l [95% confidence interval (CI): 8-11 days], 11 days among those with concentrations ranging from 8 to 19 mg/l (95% CI: 8-16) and 11 days in those with CRP >20 mg/l (95% CI: 9-12) (P = 0.337). CONCLUSION Among patients with uncomplicated acute bronchitis and discoloured sputum, the CRP concentrations at presentation are not helpful for predicting symptom resolution.
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Affiliation(s)
- Carl Llor
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain,
| | - Oleguer Plana-Ripoll
- Section of Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Ana Moragas
- University Rovira i Virgili, Primary Care Centre Jaume I, Tarragona, Spain
| | - Carolina Bayona
- Primary Care Centre Valls Urbà, Valls (Tarragona), Spain and
| | - Rosa Morros
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Helena Pera
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Marc Miravitlles
- Servei de Pneumologia, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Llor C. ¿Puede mejorar el consumo de antimicrobianos en los pacientes ambulatorios de nuestro país? Enferm Infecc Microbiol Clin 2014; 32:409-11. [DOI: 10.1016/j.eimc.2014.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
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