Reducing antibiotic prescribing in Australian general practice: time for a national strategy

Assessing Decision Fatigue in General Practitioners' Prescribing Decisions Using the Australian BEACH Data Set

BACKGROUND

General practitioners (GPs) make numerous care decisions throughout their workdays. Extended periods of decision making can result in decision fatigue, a gradual shift toward decisions that are less cognitively effortful. This study examines whether observed patterns in GPs' prescribing decisions are consistent with the decision fatigue phenomenon. We hypothesized that the likelihood of prescribing frequently overprescribed medications (antibiotics, benzodiazepines, opioids; less effortful to prescribe) will increase and the likelihood of prescribing frequently underprescribed medications (statins, osteoporosis medications; more effortful to prescribe) will decrease over the workday.

METHODS

This study used nationally representative primary care data on GP-patient encounters from the Bettering the Evaluation and Care of Health program from Australia. The association between prescribing decisions and order of patient encounters over a GP's workday was assessed with generalized linear mixed models accounting for clustering and adjusting for patient, provider, and encounter characteristics.

RESULTS

Among 262,456 encounters recorded by 2,909 GPs, the odds of prescribing antibiotics significantly increased by 8.7% with 15 additional patient encounters (odds ratio [OR] = 1.087; confidence interval [CI] = 1.059-1.116). The odds of prescribing decreased significantly with 15 additional patient encounters by 6.3% for benzodiazepines (OR = 0.937; CI = 0.893-0.983), 21.9% for statins (OR = 0.791; CI = 0.753-0.831), and 25.0% for osteoporosis medications (OR = 0.750; CI = 0.690-0.814). No significant effects were observed for opioids. All findings were replicated in confirmatory analyses except the effect of benzodiazepines.

CONCLUSIONS

GPs were increasingly likely to prescribe antibiotics and were less likely to prescribe statins and osteoporosis medications as the workday wore on, which was consistent with decision fatigue. There was no convincing evidence of decision fatigue effects in the prescribing of opioids or benzodiazepines. These findings establish decision fatigue as a promising target for optimizing prescribing behavior.

HIGHLIGHTS

We found that as general practitioners progress through their workday, they become more likely to prescribe antibiotics that are reportedly overprescribed and less likely to prescribe statins and osteoporosis medications that are reportedly underprescribed.This change in decision making over time is consistent with the decision fatigue phenomenon. Decision fatigue occurs when we make many decisions without taking a rest break. As we make those decisions, we become gradually more likely to make decisions that are less difficult.The findings of this study show that decision fatigue is a possible target for improving guideline-compliant prescribing of pharmacologic medications.

Inappropriate prescribing in patients with kidney disease: A rapid review of prevalence, associated clinical outcomes and impact of interventions

BACKGROUND

The prevalence of patients with chronic kidney disease (CKD) and polypharmacy is increasing and has amplified the importance of examining inappropriate prescribing (IP) in CKD. This review focuses on the latest research regarding the prevalence of IP in CKD and the related adverse clinical effects and explores new interventions against IP.

METHOD

A literature search was performed using PubMed, EMBASE and the Cochrane Library searching articles published between June 2016 and March 2022.

RESULTS

Twenty-seven studies were included. An IP prevalence of 12.6% to 96% and 0.3% to 66% was reported in hospital and outpatient settings, respectively. In nonhospital settings, the prevalence of IP varied between 3.9% and 60%. IP was associated with higher risk of hospitalisation (HR 1.46, 95% CI 1.17-1.81), higher bleeding rate (HR 2.34, 95% CI 1.32 to 3.37) and higher risk of all-cause mortality (OR 1.07, 95% CI 1.02 to 1.13). Three studies reported the impact of interventions on IP.

CONCLUSION

This review highlights widespread IP in CKD patients across healthcare settings, with varying prevalence rates. IP is substantially linked to adverse outcomes in patients. While limited interventions show promise, urgent research is needed to develop effective strategies addressing IP and improving CKD patient care.

The dilemmas of antimicrobial stewardship in aged care: The perspectives of the family members of older Australians

Antimicrobial resistance makes the misuse of antibiotics in residential aged care facilities (RACFs) a significant concern. Family members influence antibiotic prescribing for RACF residents, but there is limited understanding of the beliefs and knowledge that drive their involvement. Drawing on a fictional scenario, forty-six participants with a parent aged 75 or over took part in eight dialogue groups exploring family members' perspectives on antibiotic use and risks in older relatives. Main themes were identified using framework analysis. Participants supported judicious use of antibiotics in RACFs, but perceived vulnerabilities of older people, both structural and physiological prompt family pressure for antibiotics. Empirical antibiotic use became more acceptable when pathways to a prompt diagnosis are not apparent or confidence in RACF monitoring and care is lacking. The role of antibiotics in end-of-life decision-making was significantly under-recognised. Overall, elevation of discussion around antibiotics and end of life care are required.

Patients' Experiences, Expectations, Motivations, and Perspectives around Urinary Tract Infection Care in General Practice: A Qualitative Interview Study

While there are many alternatives to antibiotics for the symptomatic treatment of urinary tract infections (UTIs), their application in practice is limited. Among other things, general practitioners (GPs) often feel pressure from patients to prescribe antibiotics. To gain a better understanding of why this happens and where this pressure originates from, we investigated experiences, expectations, motivations, and perspectives of patients with UTIs in general practice. During this qualitative study we performed 14 semi-structured online interviews among female UTI patients in general practice. Interviews were based on a topic list derived from sensitising concepts. All the interviews were recorded, transcribed, and analysed using a constant comparative technique. Three main categories emerged from the data; (1) experienced versus unexperienced patients with UTI, (2) patient's lack of knowledge, and (3) patients feeling understood. Inexperienced patients consult a general practitioner for both diagnosis and symptom relief, while experienced patients seem to consult specifically to obtain antibiotics. In addition, patients have a lack of knowledge with regard to the diagnosis, treatment, self-care, and cause of UTIs. Finally, patients' satisfaction is increased by involving them more in the process of decision making, so they feel understood and taken seriously. Patients' expectations in UTI management in general practice often arise during their first experience(s) and play a major role in subsequent episodes. In conclusion, preventing misconceptions is especially important in the inexperienced patient group, as this may prevent future overtreatment of UTIs. In addition, involving patients in the decision making process will lead to greater understanding of the GP's treatment choices.

Shared decision making for women with uncomplicated Cystitis in Primary Care in the Netherlands: a qualitative interview study

BACKGROUND

Urinary tract infections (UTIs) are common, especially among women. Antibiotics are commonly used to treat UTIs, but might not always be necessary, for example in the case of uncomplicated UTIs such as cystitis. Shared decision making (SDM) could reduce the risk of unnecessary antibiotic prescriptions for uncomplicated cystitis. We investigated the current management and the use of SDM for uncomplicated cystitis in primary care.

METHODS

We performed a qualitative semi-structured interview study among 23 women with a history of cystitis, 12 general practitioner (GP) assistants, and 12 GPs in the Netherlands from July to October 2020. All interviews were individually performed by telephone. The data were analyzed through the use of using open and axial coding.

RESULTS

The GP assistants managed the initial diagnostics and treatment of uncomplicated cystitis in all general practices. Usually, antibiotics were considered the standard treatment of cystitis. In most general practices, SDM was not used in the treatment of uncomplicated cystitis, mainly because of a lack of time. Women reported that they valued being involved in the treatment decision-making process, but they were not always involved. Further, both GP assistants and GPs indicated that SDM would improve the care pathway of uncomplicated UTIs.

CONCLUSION

In our study, SDM was infrequently used to help women with uncomplicated cystitis. To reduce the use of antibiotics for uncomplicated UTIs, a tailored intervention is needed to implement SDM for the treatment of uncomplicated cystitis in primary care.

A Double-Blinded, Randomised, Placebo-Controlled Trial of Antibiotic Prophylaxis in Elective Non-Hysterectomy Laparoscopic Surgery for Benign Gynaecological Conditions: A Pilot Study

STUDY OBJECTIVE

To determine the feasibility of a double-blinded randomised, placebo-controlled study in determining the efficacy of antibiotic prophylaxis in preventing postoperative infections (POI) in elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions.

DESIGN

Double-blinded, randomised, placebo-controlled trial.

SETTING

University-affiliated tertiary referral hospital in Sydney, Australia.

PATIENTS

Women over the age of 18 undergoing elective non-hysterectomy laparoscopic procedures for benign gynaecological conditions were eligible for the study and approached.

INTERVENTIONS

Prior to surgery, participants were randomised to receive either 2g cephazolin or placebo (10ml normal saline) administered by the anaesthetist. Participants and other research staff were blinded to group allocation.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was study feasibility measured by recruitment rates, compliance rates of drug administration, compliance rates of delivery, maintenance of double blinding and follow-up rates. Secondary outcomes included rate of postoperative infections, length of hospitalisation, re-admission to hospital, unscheduled presentations to healthcare facilities and antibiotic-related reactions. Between February 2019 and March 2021, 170 patients were approached with 117 (68.8%) participants recruited and randomised. The study had a high compliance rate of trial drug delivery (95.7%) and a high follow-up rate (99.1%).

CONCLUSION

This pilot study has demonstrated feasibility of a large-scale study with a recruitment rate of 68% of patients approached and excellent trial drug delivery and follow-up rates. As anticipated, it is underpowered for identifying clinically significant findings for postoperative infection rates. A large-scale study is appropriate and essential to determine the health-related risks of antibiotic prophylaxis with an emphasis on antimicrobial stewardship. The sample size for a large-scale study is 1678 participants based on infection rates in this pilot study.

Model architectures for bacterial membranes

The complex composition of bacterial membranes has a significant impact on the understanding of pathogen function and their development towards antibiotic resistance. In addition to the inherent complexity and biosafety risks of studying biological pathogen membranes, the continual rise of antibiotic resistance and its significant economical and clinical consequences has motivated the development of numerous in vitro model membrane systems with tuneable compositions, geometries, and sizes. Approaches discussed in this review include liposomes, solid-supported bilayers, and computational simulations which have been used to explore various processes including drug-membrane interactions, lipid-protein interactions, host-pathogen interactions, and structure-induced bacterial pathogenesis. The advantages, limitations, and applicable analytical tools of all architectures are summarised with a perspective for future research efforts in architectural improvement and elucidation of resistance development strategies and membrane-targeting antibiotic mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12551-021-00913-7.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

BACKGROUND

Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use.

METHODS

National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model.

RESULTS

Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden.

CONCLUSIONS

Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.

Lack of regulation over antibiotic prescription and dispensation: A prospective cohort in a community setting

Background

The emergence of bacterial resistance caused health authorities to attempt to implement strict regulations for rational antibiotic prescription. However, supervision is often neglected in low- and middle-income countries, leading to inappropriate administration of antibiotics. The objective of our study is to highlight the lack of monitoring in the community setting of a middle-income country.

Material and methods

We asked 68 patients presenting to an infectious diseases consultation office to report the antibiotic courses they had taken in the three months preceding their visit. We assessed for treatment indication, molecule choice, dosing and duration, as well as microbial cultures, demographics and specialty of the prescriber.

Results

Among the 68 patients included in our study, we counted a total of 95 outpatient antibiotic courses, mostly composed of quinolones (36%), followed by amoxicillin-clavulanate (21%). The prescriber was most commonly a primary care physician, but we reported several cases of auto-medication and dispensation of antibiotics by pharmacists. Only 30% of cases had true indications for antibiotics.

Conclusion

In sum, our results indicate an evident lack of regulation over the administration of antibiotics. This easy accessibility needs to be promptly addressed as we run the risk of inevitable bacterial resistance.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Consumption of Antibacterials for Systemic Use in Slovakia: A National Study and the Quality Indicators for Outpatient Antibiotic Use

This paper aims to analyse the consumption of antibiotics in the Slovak health care system from 2011 to 2020. The data source on the consumption of antibiotics is sales data from SUKL and NCZI. The study employed the ATC/DDD Index and focused on the consumption of antibiotics in the primary care sector. Total antibiotic consumption decreased from 19.21 DID in 2011 to 13.16 DID in 2020. Consumption of beta-lactamase-sensitive penicillins, expressed as a percentage of the total consumption of antibiotics, decreased from 8.4% in 2011 to 4.2% in 2020. Consumption of the combination of penicillins, including beta-lactamase inhibitor, expressed as a percentage of the total consumption of antibiotics, increased from 16.2% in 2011 to 17.9% in 2020. Consumption of third- and fourth-generation cephalosporins, expressed as the percentage of the total consumption of antibiotics, increased from 2.0% in 2011 to 4.6% in 2020. Consumption of fluoroquinolones, expressed as the percentage of the total consumption of antibiotics, decreased from 10.7% in 2011 to 8.6% in 2020. Overall, antibiotic consumption significantly changed in Slovakia from 2011 to 2020. The ratio of the consumption of broad-spectrum to the consumption of narrow-spectrum penicillins, cephalosporins and macrolides decreased from 14.98 in 2011 to 13.38 in 2020.

Prescribers' Knowledge, Attitudes and Behaviors on Antibiotics, Antibiotic Use and Antibiotic Resistance in Jordan

More research is needed on the drivers of irrational antibiotic prescribing among healthcare professionals and to ensure effective prescribing and an adequate understanding of the issue of antibiotic resistance. This study aimed at evaluating prescribers’ knowledge, attitudes and behaviors about antibiotic use and antibiotic resistance. A cross-sectional study was conducted utilizing an online questionnaire and included physicians and dentists from all sectors in Jordan. A total of 613 prescribers were included (physicians n = 409, dentists n = 204). Respondents’ knowledge on effective use, unnecessary use or associated side effects of antibiotics was high (>90%), compared with their knowledge on the spread of antibiotic resistance (62.2%). For ease of access to the required guidelines on managing infections, and to materials that advise on prudent antibiotic use and antibiotic resistance, prescribers agreed in 62% and 46.1% of cases, respectively. 28.4% of respondents had prescribed antibiotics when they would have preferred not to do so more than once a day or more than once a week. Among respondents who prescribed antibiotics, 63.4% would never or rarely give out resources on prudent use of antibiotics for infections. The findings are of importance to inform antibiotic stewardships about relevant interventions aimed at changing prescribers’ behaviors and improving antibiotic prescribing practices.

Effectiveness of interventions involving pharmacists on antibiotic prescribing by general practitioners: a systematic review and meta-analysis

BACKGROUND

The use of community antibiotic stewardship programmes (ASPs) is rising; however, their effectiveness when pharmacists are involved is uncertain.

OBJECTIVES

To assess the effectiveness of ASPs involving pharmacists at improving antibiotic prescribing by general practitioners (GPs).

METHODS

Medline, Embase, Emcare, PubMed, PsycINFO, Cochrane CENTRAL, CINAHL Plus and Web of Science databases were searched to February 2018. Randomized and non-randomized studies of ASPs involving pharmacists as interventionists to GPs were included. Primary outcomes were absolute changes in GPs' antibiotic prescribing rate (APR) and antibiotic prescribing adherence rate (APAR) according to recommendations/guidelines. Meta-analysis used random effects models.

RESULTS

Fifteen studies reporting 18 trials were included in the meta-analysis: 8 assessed the APR and 10 the APAR. APR reductions (OR 0.86, 95% CI 0.78-0.95, moderate-certainty evidence) and APAR improvements (OR 1.96, 95% CI 1.56-2.45, high-certainty evidence) were observed at 6 months median intervention follow-up. High-quality randomized trials reduced the APR (OR 0.92, 95% CI 0.90-0.94) and increased the APAR (OR 2.55, 95% CI 2.16-3.01). Interventions were successful in decreasing the APR (OR 0.93, 95% CI 0.90-0.95) and increasing the APAR (OR 1.72, 95% CI 1.04-2.84) when implemented by a pharmacist-GP team. Interventions involving pharmacist-infectious disease professional teams also decreased the APR (OR 0.81, 95% CI 0.66-1.0) and increased the APAR (OR 2.36, 95% CI 1.87-2.96). GP education plus prescribing feedback, and group meetings were effective in both outcomes, whereas GP education, academic detailing and workshop training were effective in APAR outcome. However, substantial heterogeneity was demonstrated.

CONCLUSIONS

ASPs involving pharmacists are effective in decreasing antibiotic prescribing and increasing guideline-adherent antibiotic prescribing by GPs.

Antibiotic prescribing patterns of general practice registrars for infective conjunctivitis: a cross-sectional analysis

INTRODUCTION Over-prescription of antibiotics for common infective conditions is an important health issue. Infective conjunctivitis represents one of the most common eye-related complaints in general practice. Despite its self-limiting nature, there is evidence of frequent general practitioner (GP) antibiotic prescribing for this condition, which is inconsistent with evidence-based guidelines. AIM To investigate the prevalence and associations of GP registrars' (trainees') prescription of antibiotics for infective conjunctivitis. METHODS We performed a cross-sectional analysis of the Registrar Encounters in Clinical Training (ReCEnT) ongoing prospective cohort study, which documents GP registrars' clinical consultations (involving collection of information from 60 consecutive consultations, at three points during registrar training). The outcome of the analyses was antibiotic prescription for a new diagnosis of conjunctivitis. Patient, registrar, practice and consultation variables were included in uni- and multivariable logistic regression analyses to test associations of these prescriptions. RESULTS In total, 2333 registrars participated in 18 data collection rounds from 2010 to 2018. There were 1580 new cases of infective conjunctivitis (0.31% of all problems). Antibiotics (mainly topical) were prescribed in 1170 (74%) of these cases. Variables associated with antibiotic prescription included patients' Aboriginal or Torres Strait Islander status, registrar organisation of a follow up (both registrar and other GP follow up), and earlier registrar training term (more junior status). DISCUSSION GP registrars, like established GPs, prescribe antibiotics for conjunctivitis in excess of guideline recommendations, but prescribing rates are lower in later training. These prescribing patterns have educational, social and economic consequences. Further educational strategies may enhance attenuation of registrars' prescribing during training.

Feasibility and Validity of a Framework for Antimicrobial Stewardship in General Practice: Key Stakeholder Interviews

There is little guidance about developing systems for antimicrobial stewardship (AMS) for general practice. A literature review identified six key components: governance, monitoring of antibiotic prescribing and resistance with feedback to prescribers, consultation support, education of the public and general practitioners, pharmacist and nurse involvement, and research, which were incorporated into a potential framework for the general practice context. Objectives: to determine the feasibility and validity of the proposed AMS framework. A secondary objective was to identify likely bodies responsible for implementation in Australia. We undertook interviews with 12 key stakeholders from government, research, and professional groups. Data were analysed with a thematic approach. The framework was considered valid and feasible. No clear organisation was identified to lead AMS implementation in general practice. The current volume-based antibiotic prescription monitoring system was considered insufficient. AMS education for the public, further development of GP education, and improved consultation support were strongly recommended. The role of community-based pharmacists and nurses is largely unexplored, but their involvement was recommended. A clear leader to drive AMS in general practice is essential for an action framework to gain traction. Monitoring and feedback of antibiotic prescribing require urgent development to include monitoring of prescribing appropriateness and patient outcomes.

Does point-of-care testing in general practice for leucocyte and differential count change use of antimicrobial medicines? A pilot study

Diagnostic uncertainty when considering prescription of antimicrobials ('antibiotics') in primary care contributes to the major problem of microbial resistance. We conducted a feasibility evaluation of rapid testing for leucocyte and differential count in two urban general practices, surveying the GPs online and interviewing them. GPs reported that the machines were easy to use, the test results influenced their care and they would adopt the system if costs were off-set. Feasibility, acceptability and perceived benefit justify a randomised trial to test the effect on antibiotic prescribing rates and quality of care, with an economic evaluation to inform the cost-benefit.

Where Is the Value of Laboratory Medicine and How Do You Unlock It?

BACKGROUND

The innovation pathway by which a newly discovered biomarker is developed into a medical test and used in routine clinical practice comprises a number of different processes split between 2 phases. The first follows on from biomarker discovery and involves the development of a robust analytical method, the accumulation of evidence to show its clinical and cost-effectiveness, and then adoption into clinical pathways. The second phase is one of implementation and sustainability, with active performance management to ensure that the test continues to deliver the benefits promised at the time of its adoption.

CONTENT

To date there has been much more emphasis on the first phase of discovery and accumulation of evidence to demonstrate effectiveness. Insufficient attention has been paid to the second phase of translating that evidence into routine practice, with little real-world evidence to demonstrate the benefits to all of the stakeholders involved in delivering and receiving care. Changes in healthcare that include a move away from activity-based costing to a more value-based approach require more attention be paid to what happens after a test is adopted, including an understanding of the clinical pathway, the stakeholders within that pathway, and the benefits and "disbenefits" that accrue to these stakeholders.

SUMMARY

The value proposition provides a guide for successful implementation of a test. Although it can address both adoption and implementation, it highlights that the requirements for test implementation are quite different to those of adoption, with an emphasis on real-world evidence and outcomes.

Antimicrobial Stewardship in General Practice: A Scoping Review of the Component Parts

There is no published health-system-wide framework to guide antimicrobial stewardship (AMS) in general practice. The aim of this scoping review was to identify the component parts necessary to inform a framework to guide AMS in general practice. Six databases and nine websites were searched. The sixteen papers included were those that reported on AMS in general practice in a country where antibiotics were available by prescription from a registered provider. Six multidimensional components were identified: 1. Governance, including a national action plan with accountability, prescriber accreditation, and practice level policies. 2. Education of general practitioners (GPs) and the public about AMS and antimicrobial resistance (AMR). 3. Consultation support, including decision support with patient information resources and prescribing guidelines. 4. Pharmacist and nurse involvement. 5. Monitoring of antibiotic prescribing and AMR with feedback to GPs. 6. Research into gaps in AMS and AMR evidence with translation into practice. This framework for AMS in general practice identifies health-system-wide components to support GPs to improve the quality of antibiotic prescribing. It may assist in the development and evaluation of AMS interventions in general practice. It also provides a guide to components for inclusion in reports on AMS interventions.

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review

BACKGROUND

Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.

RESULTS

Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.

CONCLUSIONS

DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

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.

A Nationwide Survey of Australian General Practitioners on Antimicrobial Stewardship: Awareness, Uptake, Collaboration with Pharmacists and Improvement Strategies

Implementing antimicrobial stewardship (AMS) programs is central to optimise antimicrobial use in primary care. This study aims to assess general practitioners’ (GPs’) awareness of AMS, uptake of AMS strategies, attitudes towards GP–pharmacist collaboration in AMS and future AMS improvement strategies. A paper-based survey of nationally representative GPs across Australia was conducted in 2019. Of 386 respondent GPs, 68.9% were familiar with AMS. Respondents most frequently used the Therapeutic Guidelines (TG) (83.2%, 321/385) and delayed antimicrobial prescribing (72.2%, 278/385) strategies, whereas few utilised point-of-care tests (18.4%, 71/382), patient information leaflets (20.2%, 78/384), peer prescribing reports (15.5%, 60/384) and audit and feedback (9.8%, 38/384). GPs were receptive to pharmacists’ recommendations on the choice (50.5%, 192/381) and dose (63%, 241/382) of antimicrobials, and more than 60% (235/381) supported a policy fostering increased GP–pharmacist collaboration. Most GPs agreed to have AMS training (72%, 278/386), integration of electronic TG (eTG) with prescribing software (88.3%, 341/386) and policies limiting the prescribing of selected antimicrobials (74.4%, 287/386) in the future. Conclusively, GPs are aware of the importance of judicious antimicrobial prescribing but inadequately uptake evidence-based AMS strategies. The majority of GPs support GP–pharmacist collaborative AMS approaches to optimise antimicrobial use. Developing a feasible GP–pharmacist collaborative AMS implementation model and facilitating stewardship resources and training could foster AMS activities in primary care.

Antimicrobial resistance in southern China: results of prospective surveillance in Dongguan city, 2017

BACKGROUND

Few studies have estimated the burden of infections due to antimicrobial-resistant (AMR) pathogens in China.

AIM

To summarize antimicrobial resistance and assess the frequency of community-associated infections (CAIs) and healthcare-associated infections (HCAIs) due to AMR pathogens in Dongguan city, China.

METHODS

Seven acute care hospitals provided antimicrobial susceptibility data for 2017, from which 'bug-drug' combinations were analysed. To calculate incidence proportions of CAI and incidence densities of HCAI, data from three tertiary care hospitals were merged with patient data, obtained from the Dongguan Nosocomial Infection Surveillance System.

FINDINGS

A total of 16,548 pathogens were analysed. Non-susceptibility to third-generation cephalosporins (3GCs) in Escherichia coli and Klebsiella pneumoniae was 43.9% and 30.2%, respectively. Non-susceptibility to carbapenems in Pseudomonas aeruginosa and Acinetobacter baumannii was 29.5% and 50.9%, respectively. A quarter of Staphylococcus aureus (26.3%) were non-susceptible to oxacillin. The incidence density of HCAI due to E. coli non-susceptible to 3GCs and fluoroquinolones combined was 0.09 (95% confidence interval: 0.07-0.11) per 1000 patient-days. Both E. coli and K. pneumoniae were the predominant pathogens isolated from blood. Compared with the 2017 European Antimicrobial Resistance Surveillance Network report, the incidence proportion of bloodstream infections due to multidrug-resistant E. coli was significantly higher (14.9% and 4.6%, respectively).

CONCLUSION

The incidence of non-susceptible bug-drug combinations in Dongguan city was lower compared with China as a whole. Non-susceptible bug-drug combinations were significantly more frequent in HCAI compared with CAI. The incidence proportion of bloodstream infections due to multidrug-resistant pathogens in Dongguan City was higher compared with Europe.

A nationwide parent survey of antibiotic use in Australian children

BACKGROUND

Antimicrobial resistance is increasing globally, largely due to high rates of antibiotic use and misuse. Factors that influence frequent antibiotic use in children are poorly understood.

OBJECTIVES

This study describes rates of antibiotic use in Australian children and investigates parental factors including knowledge, attitudes and behaviours that influence antibiotic use.

METHODS

An online questionnaire relating to antibiotic use was administered as part of the Royal Children's Hospital National Child Health Poll to a randomly recruited nationwide sample of parents or guardians of children aged 0-17 years in Australia. Data on antibiotic use in children and parental knowledge of appropriate indications for antibiotics and behaviours were collected. Standard binary logistic regression was used to assess associations between parent demographics and behaviour with antibiotic administration.

RESULTS

The survey was completed by 2157 parents (64% completion rate), of which 1131 (52%) reported having given oral antibiotics to one or more of their children in the preceding 12 months. Of the 3971 children represented overall, 1719 (43%) had received at least one course of antibiotics. The average number of courses per child was 0.86 overall and 1.96 courses per child among those with reported antibiotic use. Notably, 194/1131 (17%) parents reported giving antibiotics to their child without a prescription. Poor parental knowledge of antibiotic indications was associated with antibiotic use.

CONCLUSIONS

Reducing excessive use of antibiotics in children is necessary in the global strategy for preventing antimicrobial resistance. This study identified areas for public health interventions to educate parents and increase regulation of access to antibiotics.

Assessing the appropriateness of paediatric antibiotic overuse in Australian children: a population-based sample survey

Background

Infections caused by antibiotic resistant pathogens are increasing, with antibiotic overuse a key contributing factor.

Objective

The CareTrack Kids (CTK) team assessed the care of children in Australia aged 0–15 years in 2012 and 2013 to determine the proportion of care in line with clinical practice guidelines (CPGs) for 17 common conditions. This study analyses indicators relating to paediatric antibiotic overuse to identify those which should be prioritised by antimicrobial stewardship and clinical improvement programs.

Method

A systematic search was undertaken for national and international CPGs relevant to 17 target conditions for Australian paediatric care in 2012–2013. Recommendations were screened and ratified by reviewers. The sampling frame comprised three states containing 60% of the Australian paediatric population (South Australia, New South Wales and Queensland). Multi-stage cluster sampling was used to select general practices, specialist paediatric practices, emergency departments and hospital inpatient services, and medical records within these. Medical records were reviewed by experienced paediatric nurses, trained to assess eligibility for indicator assessment and compliance with indicators. Adherence rates were estimated.

Results

Ten antibiotic overuse indicators were identified; three for tonsillitis and one each for seven other conditions. A total of 2621 children were assessed. Estimated adherence for indicators ranged from 13.8 to 99.5% while the overall estimate of compliance was 61.9% (95% CI: 47.8–74.7). Conditions with high levels of appropriate avoidance of antibiotics were gastroenteritis and atopic eczema without signs of infection, bronchiolitis and croup. Indicators with less than 50% adherence were asthma exacerbation in children aged > 2 years (47.1%; 95% CI: 33.4–61.1), sore throat with no other signs of tonsillitis (40.9%; 95% CI: 16.9, 68.6), acute otitis media in children aged > 12 months who were mildly unwell (13.8%; 95% CI: 5.1, 28.0), and sore throat and associated cough in children aged < 4 years (14.3%; 95% CI: 9.9, 19.7).

Conclusion

The results of this study identify four candidate indicators (two for tonsillitis, one for otitis media and one for asthma) for monitoring by antibiotic stewardship and clinical improvement programs in ambulatory and hospital paediatric care, and intervention if needed.

Antibiotic Use Associated with Confirmed Influenza, Pertussis, and Nontyphoidal Salmonella Infections

Purpose: Antibiotics are not the recommended treatment for uncomplicated influenza or nontyphoidal salmonella infections, whereas they are for current pertussis infection. We investigated adherence to these recommendations in a population of older community-dwelling adults. Methods: Population-based prospective cohort study of Australian adults 45 years of age and older followed by record-linkage to laboratory-confirmed influenza, pertussis, and nontyphoidal salmonella notifications, hospitalization records, and antibiotic dispensing data from January 1, 2009 to December 31, 2015. Proportions of those with infections who were prescribed antibiotics were estimated, and characteristics associated with antibiotic prescribing were examined. Results: There were 1,056 influenza, 151 pertussis, and 334 nontyphoidal salmonella cases in the cohort eligible for analysis. Antibiotics were dispensed in 56.2% (594/1,056) of influenza, 78.8% (119/151) of pertussis, and 39.5% (132/334) of nontyphoidal salmonella cases within the ±10-day window around the infection onset date. The likelihood of antibiotic dispensing did not differ according to most participant characteristics examined, including whether cases had an associated hospitalization, their age, and recorded comorbidities. Macrolides were the predominant class of antibiotics dispensed for pertussis (79%), whereas both beta-lactams (36.3%) and macrolides (35.4%) were used for cases of influenza. There was no dominant antibiotic class dispensed among those with nontyphoidal salmonella. Conclusions: Given concerns regarding increasing antibiotic resistance, the high proportion of adults with influenza and nontyphoidal salmonella cases dispensed antibiotics indicate the need for further strengthening of antimicrobial stewardship by raising education and awareness of guidelines for managing these infections.

Influenza-like illness and antimicrobial prescribing in Australian general practice from 2015 to 2017: a national longitudinal study using the MedicineInsight dataset

OBJECTIVES

To investigate the epidemiology of influenza-like illness (ILI) by general practice and patient characteristics, and explore whether sociodemographic variables or comorbidities affect antiviral or antibiotic prescribing.

DESIGN

Open cohort study.

SETTING

A representative sample of 550 Australian general practices contributing data to the MedicineInsight programme.

PARTICIPANTS

4 228 149 patients of all age groups who had at least one consultation between 2015 and 2017. Median age was 37 years (Interquartile range: 21-57), 54.4% women, 16.4% aged ≥65 years, 2.2% Aboriginal or Torres Strait Islander, 17.6% had a chronic disease and 18.1% a mental health condition.

PRIMARY AND SECONDARY OUTCOME MEASURES

ILI consultation rates (per 1000 consultations) were calculated using all ILI diagnoses for all clinical encounters with a general practitioner between 2015 and 2017. Antiviral and antibiotic prescribing for ILI cases were investigated and logistic regression models adjusted for practice and patient characteristics used to analyse associations.

RESULTS

ILI consultation rates in 2017 were higher than in previous years. Antiviral prescribing increased from 20.6% in 2015, to 23.7 in 2016 and 29.7% in 2017, while antibiotic prescribing decreased from 30.3% to 28.0% and 26.7%, respectively (p<0.05 in both cases). Practices located in high socioeconomic areas had higher ILI consultation rates (4.3 vs 2.5 per 1000 consultations, p<0.05), antibiotic (30.7% vs 23.4%, p<0.05) and antiviral (34.2% vs 13.5%, p<0.05) prescribing than those in lower socioeconomic areas. The coexistence of chronic or mental health conditions was associated with lower ILI consultation rates, higher antibiotic use, but not with antiviral prescribing. However, those with chronic respiratory conditions had a higher frequency of antibiotic and antiviral prescribing in 2017 than individuals with other comorbidities.

CONCLUSIONS

Although the apparent decline in antibiotic prescribing for ILI is welcome, the increase in antiviral use may not be targeting those at high risk of complications from infection.