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Smith G, Crago AL, Alexandre S, Gravel-Tropper D, Isada M, Knight B, Mackenzie J, Shurgold J. Prevalence and correlates of oral antibiotic use in Canada. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2024; 50:312-325. [PMID: 39262453 PMCID: PMC11389847 DOI: 10.14745/ccdr.v50i09a04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
Background Antimicrobial use (AMU) is a known driver of antimicrobial resistance. Insight into prevalence and correlates of AMU can help identify health inequities and areas for targeted action. To better understand sociodemographic and medical dimensions of AMU in Canada, the Public Health Agency of Canada, in partnership with Statistics Canada, developed a Rapid Response Module questionnaire on self-reported oral antibiotic use, to be administered as part of the 2018 Canadian Community Health Survey (CCHS). Objective To provide data on the proportion of people in Canada that self-report the use of antibiotics and sociodemographic and health factors associated with use. Methods This cross-sectional study used data from the CCHS, a national survey of 24,176 people with a clustered multi-stage stratified random sampling design. In 2018, an antibiotic use module was administered to CCHS participants. Results Among respondents 18 years and older, 26% reported receipt of at least one oral antibiotic over the past year. Several sociodemographic and health factors had higher adjusted odds of receiving an antibiotic prescription, including those aged 18 years compared to aged 48 years (mean), women compared to men, immigrants compared to non-immigrants (excluding Indigenous), current and former smokers compared to those who have never smoked, and those with comorbidities (asthma, chronic obstructive pulmonary disease, arthritis, heart disease, cancer, bowel disorder and urinary incontinence). Conclusion Variations in AMU across different key populations and sociodemographic groups highlight the need to improve our understanding of different drivers of AMU and for tailored interventions to reduce inequitable risks of antimicrobial resistance.
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Affiliation(s)
- Glenys Smith
- Antimicrobial Resistance Task Force, Public Health Agency of Canada
| | | | | | | | - Melissa Isada
- Antimicrobial Resistance Task Force, Public Health Agency of Canada
| | - Braden Knight
- Antimicrobial Resistance Task Force, Public Health Agency of Canada
| | - Jami Mackenzie
- Antimicrobial Resistance Task Force, Public Health Agency of Canada
| | - Jayson Shurgold
- Antimicrobial Resistance Task Force, Public Health Agency of Canada
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Stenlund S, Appelt KC, Ruby MB, Smith N, Lishman H, Patrick DM. Testing Different Message Styles about Unnecessary Antibiotics Using an Online Platform. Antibiotics (Basel) 2024; 13:657. [PMID: 39061339 PMCID: PMC11273919 DOI: 10.3390/antibiotics13070657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Patients' expectations are a major contributor to the unnecessary prescribing of antibiotics, yet limited research has examined how physicians can calibrate these expectations. The studies we conducted tested how varying messages could impact patients' expectations for antibiotics and their experience of medical appointments. All the participants read a short scenario about an appointment for mild sinusitis symptoms, with the patient's expectation of antibiotics. In Study 1, the participants (n = 1069) were randomly assigned to read a positively framed, neutral, or negatively framed message regarding unnecessary antibiotics. In Study 2, the participants (n = 1073) read a message emphasizing either the societal or personal harms of unnecessary antibiotics, or a message without additional rationale. None of our pre-registered hypotheses were supported, but our exploratory analyses indicated that the societal message increased concern about antibiotic resistance. The participants who were more concerned about resistance were less likely to ask for antibiotics, more satisfied when the physician did not prescribe them, and more likely to recommend the physician to a friend. Discussing the consequences of the different courses of action did not appear to negatively impact physician-patient rapport. These studies demonstrate an inexpensive method with which to pre-test various messages about antibiotic consumption, and suggest that such messages are not negatively received by patients.
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Affiliation(s)
- Säde Stenlund
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada (D.M.P.)
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- Department of Public Health, University of Turku, 20014 Turku, Finland
| | - Kirstin C. Appelt
- Sauder School of Business, University of British Columbia, Vancouver, BC V6T 1Z2, Canada
| | - Matthew B. Ruby
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086, Australia
| | - Nick Smith
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada (D.M.P.)
| | - Hannah Lishman
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada (D.M.P.)
| | - David M. Patrick
- BC Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada (D.M.P.)
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
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Morkem R, Smith G, Knight B, Wong ST, Barber D. Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data. Antimicrob Resist Infect Control 2024; 13:76. [PMID: 38997756 PMCID: PMC11242630 DOI: 10.1186/s13756-024-01434-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Inappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs. METHODS This was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions. RESULTS The odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points. CONCLUSIONS Encouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.
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Affiliation(s)
- Rachael Morkem
- Department of Family Medicine, Queen's University, 220 Bagot St., Kingston, ON, K7L 5E9, Canada.
| | - Glenys Smith
- Public Health Agency of Canada, Ottawa, ON, Canada
| | | | - Sabrina T Wong
- Centre for Health Services and Policy Research and School of Nursing, University of British Columbia, Vancouver, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, 220 Bagot St., Kingston, ON, K7L 5E9, Canada
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Haider MIS, Liu G, Yousaf B, Arif M, Aziz K, Ashraf A, Safeer R, Ijaz S, Pikon K. Synergistic interactions and reaction mechanisms of biochar surface functionalities in antibiotics removal from industrial wastewater. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2024; 356:124365. [PMID: 38871166 DOI: 10.1016/j.envpol.2024.124365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/31/2024] [Accepted: 06/11/2024] [Indexed: 06/15/2024]
Abstract
Biochar, a carbon-rich material with a unique surface chemistry (high abundance of surface functional groups, large surface area, and well-distributed), has shown great potential as a sustainable solution for industrial wastewater treatment as compared to conventional industrial wastewater treatment techniques demand substantial energy consumption and generate detrimental byproducts. This critical review emphasizes the surface functionalities formation and development in biochar to enhance its physiochemical properties, for utilization in antibiotics removal. Factors affecting the formation of functionalities, including carbonization processes, feedstock materials, operating parameters, and the influence of pre-post treatments, are thoroughly highlighted to understand the crucial role of factors influencing biochar properties for optimal antibiotics removal. Furthermore, the research explores the removal mechanisms and interactions of biochar-based surface functionalities, hydrogen bonding, encompassing electrostatic interactions, hydrophobic interactions, π-π interactions, and electron donor and acceptor interactions, to provide insights into the adsorption/removal behavior of antibiotics on biochar surfaces. The review also explains the mechanism of factors influencing the removal of antibiotics in industrial wastewater treatment, including particle size and pore structure, nature and types of surface functional groups, pH and surface charge, temperature, surface modification strategies, hydrophobicity/hydrophilicity, biochar dose, pollutant concentration, contact time, and the presence of coexisting ions and other substances. Finally, the study offers reusability and regeneration, challenges and future perspectives on the development of biochar-based adsorbents and their applications in addressing antibiotics. It concludes by summarizing the key findings and emphasizing the significance of biochar as a sustainable and effective solution for mitigating antibiotics contamination in industrial wastewater.
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Affiliation(s)
- Muhammad Irtaza Sajjad Haider
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China
| | - Guijian Liu
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China.
| | - Balal Yousaf
- Department of Technologies and Installations for Waste Management, Faculty of Energy and Environmental Engineering, Silesian University of Technology, 44 -100, Gliwice, Poland
| | - Muhammad Arif
- Department of Soil and Environmental Sciences, MNS University of Agriculture, Multan, 60000, Pakistan
| | - Kiran Aziz
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China; Department of Botany, Ghazi University, Dera Ghazi Khan, Pakistan
| | - Aniqa Ashraf
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China
| | - Rabia Safeer
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China
| | - Samra Ijaz
- CAS-Key Laboratory of Crust-Mantle Materials and the Environments, School of Earth and Space Sciences, University of Science and Technology of China, Hefei, 230026, PR China
| | - Krzysztof Pikon
- Department of Technologies and Installations for Waste Management, Faculty of Energy and Environmental Engineering, Silesian University of Technology, 44 -100, Gliwice, Poland
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5
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Schwartz KL, Shuldiner J, Langford BJ, Brown KA, Schultz SE, Leung V, Daneman N, Tadrous M, Witteman HO, Garber G, Grimshaw JM, Leis JA, Presseau J, Silverman MS, Taljaard M, Gomes T, Lacroix M, Brehaut J, Thavorn K, Gushue S, Friedman L, Zwarenstein M, Ivers N. Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial. BMJ 2024; 385:e079329. [PMID: 38839101 PMCID: PMC11151833 DOI: 10.1136/bmj-2024-079329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms. DESIGN Pragmatic, factorial randomised controlled trial. SETTING Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial. INTERVENTION A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics. MAIN OUTCOME MEASURES Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression. RESULTS 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)). CONCLUSIONS Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT04594200.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Bradley J Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada
- Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Gary Garber
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
| | - Jeremy M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Jerome A Leis
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Tara Gomes
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Meagan Lacroix
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | | | - Merrick Zwarenstein
- Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Noah Ivers
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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6
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Langford BJ, Bailey P, Livorsi DJ, Brown KA, Advani SD, Dodds Ashley E, Bearman G, Nori P. Five steps to high quality antimicrobial stewardship research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e82. [PMID: 38751942 PMCID: PMC11094375 DOI: 10.1017/ash.2024.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024]
Abstract
The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.
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Affiliation(s)
- Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel J. Livorsi
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth Dodds Ashley
- Division of Infectious Diseases, Duke University School of Medicine and Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Gonzalo Bearman
- Healthcare Infection Prevention Program, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Priya Nori
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
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7
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Soucy JPR, Low M, Acharya KR, Ellen M, Hulth A, Löfmark S, Garber GE, Watson W, Moran-Gilad J, Davidovitch N, Amar T, McCready J, Orava M, Brownstein JS, Brown KA, Fisman DN, MacFadden DR. Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study. Microbiol Spectr 2024; 12:e0001724. [PMID: 38411087 PMCID: PMC10986525 DOI: 10.1128/spectrum.00017-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.
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Affiliation(s)
- Jean-Paul R. Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Low
- Chief Physician’s Office, Clalit Health Services, Tel Aviv, Israel
| | - Kamal R. Acharya
- Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anette Hulth
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sonja Löfmark
- The Public Health Agency of Sweden, Stockholm, Sweden
| | | | - William Watson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nadav Davidovitch
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Tamar Amar
- Department of Epidemiology, Biostatistics, and Community Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Janine McCready
- Division of Infectious Diseases, Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Matthew Orava
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kevin A. Brown
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - David N. Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek R. MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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8
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Dillen H, Wouters J, Snijders D, Wynants L, Verbakel JY. Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis. J Antimicrob Chemother 2024; 79:498-511. [PMID: 38113395 PMCID: PMC10904728 DOI: 10.1093/jac/dkad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship. OBJECTIVES To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries. METHODS On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed. RESULTS We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible. CONCLUSIONS Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jo Wouters
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Daniëlle Snijders
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Laure Wynants
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, 1 Peter Debyeplein, Maastricht, 6229 HA, The Netherlands
- Department of Development and Regeneration, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- NIHR Community Healthcare MedTech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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McBurney SH, Kwong JC, Brown KA, Rudzicz F, Chen B, Candido E, Crowcroft NS. Validating pertussis data measures using electronic medical record data in Ontario, Canada 1986-2016. Vaccine X 2023; 15:100408. [PMID: 38161988 PMCID: PMC10755117 DOI: 10.1016/j.jvacx.2023.100408] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 09/14/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Background Pertussis is a reportable disease in many countries, but ascertainment bias has limited data accuracy. This study aims to validate pertussis data measures using a reference standard that incorporates different suspected case severities, allowing for the impact of case severity on accuracy and detection to be explored. Methods We evaluated 25 pertussis detection algorithms in a primary care electronic medical record database between January 1, 1986 and December 30, 2016. We estimated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We used sensitivity analyses to explore areas of uncertainty and evaluated reasons for lack of detection. Results The algorithm including all data measures achieved the highest sensitivity at 20.6%. Sensitivity increased to 100% after reclassifying symptom-only cases as non-cases, but the PPV remained low. Age at first episode was significantly associated with detection in half of the tested scenarios, and false negatives often had some history of immunization. Conclusions Sensitivity improved by reclassifying symptom-only cases but remained low unless multiple data sources were used. Results demonstrate a trade-off between PPV and sensitivity. EMRs can enhance detection through patient history and clinical note data. It is essential to improve case identification of older individuals with vaccination history to reduce ascertainment bias.
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Affiliation(s)
- Shilo H. McBurney
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S121-2, Providence, RI 02912, United States of America
| | - Jeffrey C. Kwong
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Public Health Ontario, 661 University Avenue, Suite 1701, Toronto, ON M5G 1M1, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King’s College Circle, 6th Floor, Toronto, ON M5S 1A8, Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON M5G 1V7, Canada
| | - Kevin A. Brown
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Public Health Ontario, 661 University Avenue, Suite 1701, Toronto, ON M5G 1M1, Canada
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, 40 St. George Street, Room 4283, Toronto, ON M5S 2E4, Canada
- Faculty of Computer Science, Dalhousie University, Halifax, Nova Scotia, Canada
- Vector Institute for Artificial Intelligence, 661 University Ave Suite 710, Toronto, ON M5G 1M1, Canada
| | - Branson Chen
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Elisa Candido
- ICES, G1 06, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
| | - Natasha S. Crowcroft
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
- Immunization, Vaccines and Biologicals, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
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Fu M, Gong Z, Li C, Ling K, Zhu Y, Li H, Shi L, Guan X. Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100880. [PMID: 37636127 PMCID: PMC10458636 DOI: 10.1016/j.lanwpc.2023.100880] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 08/29/2023]
Abstract
Background The appropriateness of antibiotic use for acute respiratory infections (ARIs) in Chinese primary healthcare facilities (PHFs) remained uncertain. We aimed to evaluate to what degree antibiotic prescribing for ARIs were aligned with guideline recommendations in primary settings across China. Methods We collected outpatient prescriptions from 262 Chinese PHFs in 27 cities of six provinces between 2017 and 2019. The appropriate antibiotic prescribing was defined as prescribing antibiotic classes that were recommended by Chinese clinical guidelines, if patients were prescribed antibiotics. We evaluated the magnitude of antibiotics prescribed for acute upper respiratory infections (AURIs), acute bronchitis, and community-acquired pneumonia (CAP) and their appropriateness. Findings Overall, 55.1% (87,684/159,150), 66.8% (30,836/46,153), and 68.5% (4615/6733) of outpatients with AURIs, acute bronchitis, and CAP treated at PHFs in China were prescribed with antibiotics. Of all antibiotic prescriptions, only 20.0% (17,542/87,684), 18.6% (5724/30,836) and 69.6% (3211/4615) used antibiotic classes that were recommended by the guidelines for AURIs, acute bronchitis, and CAP, respectively. Patients residing in the Chinese central region (17.0%, 15.4%, 69.3% for AURIs, acute bronchitis, and CAP, respectively) were less likely to be prescribed with antibiotics that were appropriately selected. Interpretation Unnecessary antibiotics were widely prescribed for patients with AURIs or acute bronchitis and most patients with ARIs did not receive guideline-recommended antibiotic classes in Chinese PHFs. Interventions to promote evidence-based treatment and the appropriate use of antibiotics are urgently needed at the primary level across China. Funding This work was supported by the National Natural Science Foundation of China [grant number 72074007, 81973294].
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Affiliation(s)
- Mengyuan Fu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Zhiwen Gong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Can Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Kexin Ling
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yuezhen Zhu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Center for Medicinal Administration, Peking University, Beijing, China
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Tandon P, Brown KA, Daneman N, Langford BJ, Leung V, Friedman L, Schwartz KL. Variability in changes in physician outpatient antibiotic prescribing from 2019 to 2021 during the COVID-19 pandemic in Ontario, Canada. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e171. [PMID: 38028902 PMCID: PMC10644162 DOI: 10.1017/ash.2023.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 12/01/2023]
Abstract
Objective To evaluate inter-physician variability and predictors of changes in antibiotic prescribing before (2019) and during (2020/2021) the coronavirus disease 2019 (COVID-19) pandemic. Methods We conducted a retrospective cohort analysis of physicians in Ontario, Canada prescribing oral antibiotics in the outpatient setting between January 1, 2019 and December 31, 2021 using the IQVIA Xponent data set. The primary outcome was the change in the number of antibiotic prescriptions between the prepandemic and pandemic period. Secondary outcomes were changes in the selection of broad-spectrum agents and long-duration (>7 d) antibiotic use. We used multivariable linear regression models to evaluate predictors of change. Results There were 17,288 physicians included in the study with substantial inter-physician variability in changes in antibiotic prescribing (median change of -43.5 antibiotics per physician, interquartile range -136.5 to -5.0). In the multivariable model, later career stage (adjusted mean difference [aMD] -45.3, 95% confidence interval [CI] -52.9 to -37.8, p < .001), family medicine (aMD -46.0, 95% CI -62.5 to -29.4, p < .001), male patient sex (aMD -52.4, 95% CI -71.1 to -33.7, p < .001), low patient comorbidity (aMD -42.5, 95% CI -50.3 to -34.8, p < .001), and high prescribing to new patients (aMD -216.5, 95% CI -223.5 to -209.5, p < .001) were associated with decreases in antibiotic initiation. Family medicine and high prescribing to new patients were associated with a decrease in selection of broad-spectrum agents and prolonged antibiotic use. Conclusions Antibiotic prescribing changed throughout the COVID-19 pandemic with overall decreases in antibiotic initiation, broad-spectrum agents, and prolonged antibiotic courses with inter-physician variability. These findings present opportunities for community antibiotic stewardship interventions.
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Affiliation(s)
- Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A. Brown
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Bradley J. Langford
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Toronto East Health Network, Toronto, ON, Canada
| | | | - Kevin L. Schwartz
- Public Health Ontario, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto, Toronto, ON, Canada
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Bittner CB, Steindl H, Abramov-Sommariva D, Plach M, Abels C, Bachert C. Efficacy and effectiveness of the herbal medicinal product BNO 1016 in the management of acute rhinosinusitis in the context of antibiotic stewardship. Postgrad Med 2023; 135:607-614. [PMID: 37431675 DOI: 10.1080/00325481.2023.2234274] [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: 02/02/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVES To substantiate the clinical efficacy and investigate the real-world effectiveness of the herbal medicinal product BNO 1016 in acute rhinosinusitis (ARS) in the context of antibiotic stewardship. METHODS We performed a meta-analysis of the clinical trials ARhiSi-1 (EudraCT No. 2008-002794-13) and ARhiSi-2 (EudraCT No. 2009-016682-28) comprising 676 patients, analyzing the reduction of the Major Symptom Score (MSS) and improvement of the Sino-Nasal Outcome Test 20 (SNOT-20) by the herbal medicinal product BNO 1016. In addition, we performed a retrospective cohort study including 203,382 patients, comparing the real-life effectiveness of BNO 1016 in reducing ARS-related adverse outcomes in comparison to antibiotics and several other established therapies. RESULTS Treatment with BNO 1016 ameliorated symptoms of ARS by reducing MSS by 1.9 points (p < 0.0001) and improved quality of life (QoL) for patients by improving SNOT-20 by 3.5 points (p = 0.001) in comparison to placebo. In patients with moderate/severe symptoms, the positive effects of BNO 1016 were even more pronounced (MSS: -2.3 points (p < 0.0001); SNOT-20: -4.9 points (p = 0.0158)). In addition, treatment with BNO 1016 was as effective or significantly more effective in reducing the risk for adverse ARS-related outcomes such as follow-up antibiotic prescriptions, sick leave ≥7 days or medical appointments due to ARS, especially when compared to antibiotics. CONCLUSION BNO 1016 is a safe and effective treatment for ARS that can help reduce the overuse of antibiotics.
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Affiliation(s)
| | - Hubert Steindl
- Research & Development, Bionorica SE, Neumarkt i. d. OPf, Germany
| | | | - Michael Plach
- Research & Development, Bionorica SE, Neumarkt i. d. OPf, Germany
| | - Christoph Abels
- Research & Development, Bionorica SE, Neumarkt i. d. OPf, Germany
| | - Claus Bachert
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Muenster, Muenster, Germany
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Leslie M, Fadaak R, Lethebe BC, Szostakiwskyj JH. Assessing the appropriateness of community-based antibiotic prescribing in Alberta, Canada, 2017-2020, using ICD-9-CM codes: a cross-sectional study. CMAJ Open 2023; 11:E579-E586. [PMID: 37402557 PMCID: PMC10325582 DOI: 10.9778/cmajo.20220114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is a rising threat to human health, and, with up to 90% of antibiotics prescribed in the community, it is critical to examine Canadian antibiotic stewardship practices in outpatient settings. We carried out a large-scale analysis of appropriateness in community-based prescribing of antibiotics to adults in Alberta, reporting on 3 years of data from physicians practising in the province. METHODS The study cohort was composed of all adult (age 18-65 yr) Alberta residents who filled at least 1 antibiotic prescription written by a community-based physician between Apr. 1, 2017, and Mar. 6, 2020. We linked diagnosis codes from the clinical modification of the International Classification of Diseases, 9th Revision (ICD-9-CM), as used for billing purposes by the province's fee-for-service community physicians, to drug dispensing records, as maintained in the province's pharmaceutical dispensing database. We included physicians practising in community medicine, general practice, generalist mental health, geriatric medicine and occupational medicine. Following an approach used in previous research, we linked diagnosis codes with antibiotic drug dispensations, classified across a spectrum of appropriateness (always, sometimes never, no diagnosis code). RESULTS We identified 3 114 400 antibiotic prescriptions dispensed to 1 351 193 adult patients by 5577 physicians. Of these prescriptions, 253 038 (8.1%) were "always appropriate," 1 168 131 (37.5%) were "potentially appropriate," 1 219 709 (39.2%) were "never appropriate," and 473 522 (15.2%) were not associated with an ICD-9-CM billing code. Among all dispensed antibiotic prescriptions, amoxicillin, azithromycin and clarithromycin were the most commonly prescribed drugs labelled "never appropriate." INTERPRETATION We found that nearly 40% of prescriptions dispensed to 1.35 million adult patients in Alberta's community-based settings over a 35-month period were inappropriate. This finding suggests that additional policies and programs to improve stewardship among physicians prescribing antibiotics for adult outpatients in Alberta may be warranted.
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Affiliation(s)
- Myles Leslie
- School of Public Policy (Leslie, Fadaak) Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Leslie) Cumming School of Medicine, University of Calgary; Clinical Research Unit (Lethebe, Hart Szostakiwskyj), Cumming School of Medicine, University of Calgary, Calgary, Alta.
| | - Raad Fadaak
- School of Public Policy (Leslie, Fadaak) Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Leslie) Cumming School of Medicine, University of Calgary; Clinical Research Unit (Lethebe, Hart Szostakiwskyj), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Brendan Cord Lethebe
- School of Public Policy (Leslie, Fadaak) Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Leslie) Cumming School of Medicine, University of Calgary; Clinical Research Unit (Lethebe, Hart Szostakiwskyj), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jessie Hart Szostakiwskyj
- School of Public Policy (Leslie, Fadaak) Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Leslie) Cumming School of Medicine, University of Calgary; Clinical Research Unit (Lethebe, Hart Szostakiwskyj), Cumming School of Medicine, University of Calgary, Calgary, Alta
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14
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McBurney SH, Kwong JC, Brown KA, Rudzicz F, Chen B, Candido E, Crowcroft NS. Developing a reference standard for pertussis by applying a stratified sampling strategy to electronic medical record data. Ann Epidemiol 2023; 77:53-60. [PMID: 36372292 DOI: 10.1016/j.annepidem.2022.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 10/13/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE Pertussis surveillance remains essential in Canada, but ascertainment bias limits the accuracy of surveillance data. Introducing other sources to improve detection has highlighted the importance of validation. However, challenges arise due to low prevalence, and oversampling suspected cases can introduce partial verification bias. The aim of this study was to build a reference standard for pertussis validation studies that provides adequate analytic precision and minimizes bias. METHODS We used a stratified strategy to sample the reference standard from a primary care electronic medical record cohort. We incorporated abstractor notes into definite, possible, ruled-out, and no mention of pertussis classifications which were based on surveillance case definitions. RESULTS We abstracted eight hundred records from the cohort of 404,922. There were 208 (26%) definite and 261 (32.6%) possible prevalent pertussis cases. Classifications demonstrated a wide variety of case severities. Abstraction reliability was moderate to substantial based on Cohen's kappa and raw percent agreement. CONCLUSIONS When conducting validation studies for pertussis and other low prevalence diseases, this stratified sampling strategy can be used to develop a reference standard using limited resources. This approach mitigates verification and spectrum bias while providing sufficient precision and incorporating a range of case severities.
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Affiliation(s)
- Shilo H McBurney
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Jeffrey C Kwong
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Kevin A Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Public Health Ontario, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, ON, Canada; International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | | | | | - Natasha S Crowcroft
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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McIsaac WJ, Kukan S. Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care. J Prim Care Community Health 2023; 14:21501319231210616. [PMID: 37978835 PMCID: PMC10657523 DOI: 10.1177/21501319231210616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. METHODS The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. RESULTS Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). CONCLUSIONS Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.
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Affiliation(s)
- Warren J. McIsaac
- Sinai Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Simeoni M, Saragosa M, Laur C, Desveaux L, Schwartz K, Ivers N. Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing. BMC PRIMARY CARE 2022; 23:188. [PMID: 35902821 PMCID: PMC9330951 DOI: 10.1186/s12875-022-01806-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022]
Abstract
Background Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms. Methods Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20th percentile versus “medium” defined as 40th to 60th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved. Results Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty. Conclusions Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01806-8.
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Prevalence of Antibiotic Prescription in Patients with Acute Rhinosinusitis Treated by General Practitioners and Otolaryngologists in Germany-A Retrospective Cohort Study. Antibiotics (Basel) 2022; 11:antibiotics11111576. [PMID: 36358231 PMCID: PMC9686956 DOI: 10.3390/antibiotics11111576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
(1) Background: The goal of this retrospective cohort study, based on real-world data and conducted in Germany, was to investigate the prevalence of antibiotic (AB) prescription in patients with acute rhinosinusitis (ARS). (2) Methods: Data from the Disease Analyzer database were used for this cross-sectional study. Patients aged ≥18 years diagnosed with acute sinusitis by general practitioners (GPs) and ear, nose, throat (ENT) specialists between January 2012 and December 2020 were included. The main outcome of the study was the proportion of patients with ARS who received an AB prescription on the day of diagnosis or within three days afterwards. The proportion was estimated separately for patients treated by GPs and ENTs, and also for five age groups, as well as women and men. (3) Results: In total, 308,095 patients were diagnosed with ARS (187,838 by GPs and 120,257 by ENTs). 50.9% of patients treated by GPs and 50.0% treated by ENTs received an AB prescription. AB prevalence increased with age from 46.9% in the age group 18−30 years to 55.5% in the age group > 60 years. (4) Conclusions: We have shown a high prevalence of potentially inappropriate AB prescription for adult patients with ARS in both GP and ENT practices and also among both women and men and in several age groups. There is an urgent need for interventions to reduce inappropriate AB use.
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Bursey K, Hall A, Pike A, Etchegary H, Aubrey-Bassler K, Patey AM, Romme K. Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. BMJ Open 2022; 12:e066681. [PMID: 36319054 PMCID: PMC9628688 DOI: 10.1136/bmjopen-2022-066681] [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: 11/06/2022] Open
Abstract
INTRODUCTION Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis. METHODS AND ANALYSIS We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.
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Affiliation(s)
- Krystal Bursey
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Andrea Pike
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kristen Romme
- Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
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Irfan M, Almotiri A, AlZeyadi ZA. Antimicrobial Resistance and Its Drivers-A Review. Antibiotics (Basel) 2022; 11:1362. [PMID: 36290020 PMCID: PMC9598832 DOI: 10.3390/antibiotics11101362] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/25/2022] [Accepted: 10/01/2022] [Indexed: 07/30/2023] Open
Abstract
Antimicrobial resistance (AMR) is a critical issue in health care in terms of mortality, quality of services, and financial damage. In the battle against AMR, it is crucial to recognize the impacts of all four domains, namely, mankind, livestock, agriculture, and the ecosystem. Many sociocultural and financial practices that are widespread in the world have made resistance management extremely complicated. Several pathways, including hospital effluent, agricultural waste, and wastewater treatment facilities, have been identified as potential routes for the spread of resistant bacteria and their resistance genes in soil and surrounding ecosystems. The overuse of uncontrolled antibiotics and improper treatment and recycled wastewater are among the contributors to AMR. Health-care organizations have begun to address AMR, although they are currently in the early stages. In this review, we provide a brief overview of AMR development processes, the worldwide burden and drivers of AMR, current knowledge gaps, monitoring methodologies, and global mitigation measures in the development and spread of AMR in the environment.
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Affiliation(s)
- Mohammad Irfan
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Shaqra University, Ad Dawadmi 17464, Saudi Arabia
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20
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Rocha V, Estrela M, Neto V, Roque F, Figueiras A, Herdeiro MT. Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact. Antibiotics (Basel) 2022; 11:1186. [PMID: 36139965 PMCID: PMC9495011 DOI: 10.3390/antibiotics11091186] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Vânia Rocha
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Marta Estrela
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Vanessa Neto
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300-559 Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6201-001 Covilhã, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), 28001 Madrid, Spain
| | - Maria Teresa Herdeiro
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
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Fortin É, Deceuninck G, Sirois C, Quach C, Simard M, Dionne M, Jean S, Irace-Cima A, Magali-Ufitinema N. Chronic diseases and compliance with provincial guidelines for outpatient antibiotic prescription in cases of otitis media and respiratory infections: a population-based study of linked data in Quebec, Canada, 2010-2017. CMAJ Open 2022; 10:E841-E847. [PMID: 36167419 PMCID: PMC9578749 DOI: 10.9778/cmajo.20210257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Quebec, antibiotic use is higher among outpatients with chronic diseases. We sought to measure compliance with provincial guidelines for the treatment of otitis media and common respiratory infections, and to measure variations in compliance according to the presence of certain chronic diseases. METHODS We conducted a population-based study of linked data on antibiotic dispensing covered by the public drug insurance plan between April 2010 and March 2017. We included patients who had consulted a primary care physician within 2 days before being dispensed an antibiotic for an infection targeted by provincial guidelines, including bronchitis in patients with chronic obstructive pulmonary disease, otitis media, pharyngitis, pneumonia and sinusitis. We computed proportions of prescriptions compliant with guidelines (use of recommended antibiotic for children, and use of recommended antibiotic and dosage for adults) by age group (children or adults) and chronic disease (respiratory, cardiovascular, diabetes, mental disorder or none). We measured the impact of chronic diseases on compliance using robust Poisson regression. RESULTS We analyzed between 14 677 and 198 902 prescriptions for each infection under study. Compliance was greater than 87% among children, but was lower among children with asthma (proportion ratios between 0.97 and 1.00). In adults, the chosen antibiotic was compliant for at least 73% of prescriptions, except for pharyngitis (≤ 61%). Accounting for dosage lowered compliance to between 31% and 61%. Compliance was lower in the presence of chronic diseases (proportion ratios between 0.94 and 0.98). INTERPRETATION It is possible that prescribing noncompliant prescriptions was sometimes appropriate, but the high frequency of noncompliance suggests room for improvement. Given that variations associated with chronic diseases were small, disease-specific guidelines for antibiotic prescriptions are likely to have a limited impact on compliance.
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Affiliation(s)
- Élise Fortin
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que.
| | - Geneviève Deceuninck
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Caroline Sirois
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Caroline Quach
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Marc Simard
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Marc Dionne
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Sonia Jean
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Alejandra Irace-Cima
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
| | - Nadine Magali-Ufitinema
- Institut national de santé publique du Québec (Fortin, Deceuninck, Sirois, Simard, Jean, Irace-Cima), Québec, Que.; Department of Microbiology, Infectious Diseases and Immunology (Fortin, Quach), Faculty of Medicine, University of Montreal, Montréal, Que.; Department of Social and Preventive Medicine (Fortin, Sirois, Simard), Faculty of Medicine, Laval University; Centre d'excellence sur le vieillissement de Québec (Sirois), Centre de recherche du CHU de Québec; Faculty of Medicine (Dionne), Laval University; Centre de recherche du CHU de Québec (Dionne); Department of Medicine (Jean), Faculty of Medicine, Laval University; Direction de la prévention et du contrôle des maladies infectieuses (Magali-Ufitinema), Direction générale adjointe de la protection de la santé publique, Ministère de la Santé et des Services sociaux, Québec, Que
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22
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Perspectives of Immigrants and Native Dutch on Antibiotic Use: A Qualitative Study. Antibiotics (Basel) 2022; 11:antibiotics11091179. [PMID: 36139959 PMCID: PMC9495072 DOI: 10.3390/antibiotics11091179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/24/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Immigrants constitute large proportions of the population in many high-income countries. Knowledge about their perceptions of antibiotics, in comparison to native populations, is limited. We explored these perceptions by organizing nine homogeneous focus group discussions (FGDs) with first-generation immigrant and native Dutch participants (N = 64) from Rotterdam and Utrecht, who were recruited with the assistance of immigrant (community support) organizations. The FGDs were audio-recorded and transcribed verbatim. Inductive thematic analyses were performed with the qualitative analysis software Atlas.ti, using open and axial coding. We did not find noteworthy differences between immigrants and native Dutch participants; all participants had an overall reluctant attitude towards antibiotics. Within-group differences were larger than between-group differences. In each FGD there were, for instance, participants who adopted an assertive stance in order to receive antibiotics, who had low antibiotic-related knowledge, or who used antibiotics incorrectly. Native Dutch participants expressed similar difficulties as immigrant participants in the communication with their GP, which mainly related to time constraints. Immigrants who encountered language barriers experienced even greater communicational difficulties and reported that they often feel embarrassed and refrain from asking questions. To stimulate more prudent use of antibiotics, more attention is needed for supportive multilingual patient materials. In addition, GPs need to adjust their information, guidance, and communication for the individual’s needs, regardless of the patient’s migration background.
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23
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Zhao H, Wang S, Meng R, Liu G, Hu J, Zhang H, Yan S, Zhan S. Appropriateness of Antibiotic Prescriptions in Chinese Primary Health Care and the Impact of the COVID-19 Pandemic: A Typically Descriptive and Longitudinal Database Study in Yinchuan City. Front Pharmacol 2022; 13:861782. [PMID: 35496308 PMCID: PMC9049214 DOI: 10.3389/fphar.2022.861782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background: The appropriateness of antibiotic prescriptions in primary care has not been well evaluated in China in recent years. Furthermore, the impact of coronavirus disease 2019 (COVID-19) on antibiotic prescriptions has not yet been investigated in China. We aimed to assess the appropriateness of antibiotic prescriptions and to evaluate the potential association between the COVID-19 pandemic and antibiotic prescriptions in primary care settings of Yinchuan, a city in China. Methods: This study included 155 primary care institutions and 10,192,713 outpatient visits. Outpatient prescriptions were classified as appropriate, potentially appropriate, inappropriate, or not linked to any diagnosis for antibiotic use following a validated evaluation scheme. Interrupted time-series analyses were performed to assess the effects of the COVID-19 pandemic on antibiotic prescriptions in Chinese primary care facilities. Results: During the study period, 1,287,678 (12.6%, 95% confidence interval [12.6-12.7]) of 10,192,713 outpatient visits in primary care resulted in antibiotic prescriptions. Among 1,287,678 antibiotic prescriptions, 653,335 (50.7% [50.6-50.9]) were inappropriate, 463,081 (36.0% [35.8-36.1]) were potentially appropriate, 171,056 (13.3% [13.1-13.5]) were appropriate, and 206 could not be linked to any diagnosis. Furthermore, patient, physician, and institutional factors were associated with inappropriate antibiotic prescriptions; there was an overall decreasing trend in the proportions of inappropriate antibiotic prescriptions, with the highest level in 2017 (67.1% [66.8-67.5]) and the lowest in 2021 (40.8% [40.3-41.3]). A total of 1,416,120 individual antibiotics were prescribed, of which 1,087,630 (76.8%) were broad-spectrum and 777,672 (54.9%) were classified in the World Health Organization's "Watch" category. In addition, the COVID-19 pandemic was associated with changes of -2.8% (-4.4 to -1.3) in the level and 0.3% (0.2-0.3) in the monthly trend of antibiotic prescription rates, as well as changes of -5.9% (-10.2 to -1.5) in the level and 1.3% (1.0-1.6) in the monthly trend of the proportions of inappropriate antibiotic prescriptions. Conclusion: More than half of the antibiotic prescriptions were inappropriate during the study period in primary care in Yinchuan. The COVID-19 pandemic may be associated with a decrease in the overall and inappropriate use of antibiotics in primary care settings in China.
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Affiliation(s)
- Houyu Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Ruogu Meng
- National Institute of Health Data Science, Peking University, Beijing, China
| | - Guozhen Liu
- Peking University Health Information Technology, Beijing, China
| | - Jing Hu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Huina Zhang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, China
| | - Shaohua Yan
- Department of Oncology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
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24
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Shuldiner J, Schwartz KL, Langford BJ, Ivers NM, Taljaard M, Grimshaw JM, Lacroix M, Tadrous M, Leung V, Brown K, Morris AM, Garber G, Presseau J, Thavorn K, Leis JA, Witteman HO, Brehaut J, Daneman N, Silverman M, Greiver M, Gomes T, Kidd MR, Francis JJ, Zwarenstein M, Lam J, Mulhall C, Gushue S, Uppal S, Wong A. Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations. Implement Sci 2022; 17:17. [PMID: 35164805 PMCID: PMC8842929 DOI: 10.1186/s13012-022-01194-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/26/2022] [Indexed: 11/25/2022] Open
Abstract
Background Audit and feedback (A&F) that shows how health professionals compare to those of their peers, can be an effective intervention to reduce unnecessary antibiotic prescribing among family physicians. However, the most impactful design approach to A&F to achieve this aim is uncertain. We will test three design modifications of antibiotic A&F that could be readily scaled and sustained if shown to be effective: (1) inclusion of case-mix-adjusted peer comparator versus a crude comparator, (2) emphasizing harms, rather than lack of benefits, and (3) providing a viral prescription pad. Methods We will conduct two interrelated pragmatic randomized trials in January 2021. One trial will include family physicians in Ontario who have signed up to receive their MyPractice: Primary Care report from Ontario Health (“OH Trial”). These physicians will be cluster-randomized by practice, 1:1 to intervention or control. The intervention group will also receive a Viral Prescription Pad mailed to their office as well as added emphasis in their report on use of the pad. Ontario family physicians who have not signed up to receive their MyPractice: Primary Care report will be included in the other trial administered by Public Health Ontario (“PHO Trial”). These physicians will be allocated 4:1 to intervention or control. The intervention group will be further randomized by two factors: case-mix adjusted versus unadjusted comparator and emphasis or not on harms of antibiotics. Physicians in the intervention arm of this trial will receive one of four versions of a personalized antibiotic A&F letter from PHO. For both trials, the primary outcome is the antibiotic prescribing rate per 1000 patient visits, measured at 6 months post-randomization, the primary analysis will use Poisson regression and we will follow the intention to treat principle. A mixed-methods process evaluation will use surveys and interviews with family physicians to explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectancies, descriptive norms, and goal prioritization. Discussion This protocol describes the rationale and methodology of two interrelated pragmatic trials testing variations of theory-informed components of an audit and feedback intervention to determine how to optimize A&F interventions for antibiotic prescribing in primary care. Trial registration NCT04594200, NCT05044052. CIHR Grant ID: 398514 Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01194-8.
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Korppi M, Heikkilä P, Palmu S, Huhtala H, Csonka P. Antibiotic prescribing for children with upper respiratory tract infection: a Finnish nationwide 7-year observational study. Eur J Pediatr 2022; 181:2981-2990. [PMID: 35606593 PMCID: PMC9126572 DOI: 10.1007/s00431-022-04512-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 12/18/2022]
Abstract
UNLABELLED Upper respiratory tract infection (URTI) is a self-limiting viral infection and should not be treated with antibiotics. The aim was to evaluate antibiotic prescriptions for children with uncomplicated URTI in a large nationwide private clinic network between 2014 and 2020. Special focus was given to macrolide prescriptions and costs. The data were obtained from the electronic health records (EHR) of the largest private healthcare company in Finland (with about 250,000 paediatric visits annually across the country). The collected variables included diagnoses, age, visit year, speciality of the doctor, and prescribed antibiotics. The number of uncomplicated URTIs in < 18-year-old children was 156,187 (53.0% in boys). The prescription rate of antibiotics decreased from 18.0% in 2014 to 8.8% in 2020, and that of macrolides from 6.1 to 1.7%. The costs decreased accordingly. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists. CONCLUSION Antibiotic prescriptions for uncomplicated URTIs, especially macrolides, decreased substantially during the 7-year surveillance period; however, 8.8% of children still received unnecessary antibiotics. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system. WHAT IS KNOWN • Upper respiratory tract infection (URTI) is the most common infection in children. Uncomplicated URTI is a self-limiting viral infection, and antibiotic treatment is not warranted. WHAT IS NEW • Almost 9% of children with uncomplicated URTIs still received unnecessary antibiotics. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.
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Affiliation(s)
- Matti Korppi
- Department of Pediatrics, Tampere University Hospital, and Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpönkatu 34 (ARVO B235), 33014, Tampere, Finland
| | - Paula Heikkilä
- Department of Pediatrics, Tampere University Hospital, and Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpönkatu 34 (ARVO B235), 33014, Tampere, Finland
| | - Sauli Palmu
- Department of Pediatrics, Tampere University Hospital, and Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpönkatu 34 (ARVO B235), 33014, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Péter Csonka
- Department of Pediatrics, Tampere University Hospital, and Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpönkatu 34 (ARVO B235), 33014, Tampere, Finland.
- Terveystalo Healthcare, Tampere, Finland.
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Crosby M, von den Baumen TR, Chu C, Gomes T, Schwartz KL, Tadrous M. Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study. CMAJ Open 2022; 10:E262-E268. [PMID: 35318250 PMCID: PMC8946648 DOI: 10.9778/cmajo.20210095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Geographic trends in antibiotic prescribing show regional variation in antibiotic overuse and antimicrobial resistance, posing a threat to global health care systems. This study's objective was to examine interprovincial variation in outpatient antibiotic dispensing in Canada in 2019. METHODS We conducted a cross-sectional study of antibiotic prescriptions dispensed in Canadian provinces in 2019, leveraging the IQVIA Geographic Prescription Monitor database. We report annual rates of overall antibiotic dispensing, broad-spectrum antibiotic dispensing and age-specific antibiotic dispensing as prescriptions per 1000 population in each province and nationally. RESULTS A total of 23 406 640 antibiotic prescriptions were dispensed nationally in 2019, at a rate of 627.3 prescriptions per 1000 population. Overall antibiotic dispensing rates in Newfoundland and Labrador (920.5 prescriptions per 1000 population) and Saskatchewan (713.7 prescriptions per 1000 population) significantly exceeded the national rate, whereas the rate in British Columbia (543.3 prescriptions per 1000 population) was significantly below the national rate. We observed additional variation when provincial rates of antibiotic dispensing were stratified by drug class and age group. INTERPRETATION We identified interprovincial variation in antibiotic use in Canadian provinces in 2019. These findings highlight the need for provincial targets for antibiotic use to reduce overuse and antimicrobial resistance.
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Affiliation(s)
- Michael Crosby
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont
| | - Teagan Rolf von den Baumen
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont
| | - Cherry Chu
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont
| | - Kevin L Schwartz
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy (Crosby, Rolf von den Baumen, Gomes, Tadrous), University of Toronto; Institute for Health System Solutions and Virtual Care (Chu), Women's College Hospital; Li Ka Shing Knowledge Institute (Gomes), St. Michael's Hospital; ICES Central (Gomes, Schwartz, Tadrous); Public Health Ontario (Schwartz); Dalla Lana School of Public Health (Schwartz), University of Toronto; Women's College Research Institute (Tadrous), Toronto, Ont.
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Impact of a pilot multimodal intervention to decrease antibiotic use for respiratory infections in a geriatric clinic. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e1. [PMID: 36310812 PMCID: PMC9614947 DOI: 10.1017/ash.2021.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/26/2021] [Accepted: 11/04/2021] [Indexed: 01/12/2023]
Abstract
Background: More than 80% of antibiotics are prescribed in the outpatient setting, of which 30% are inappropriate. The National Action Plan for Combating Antimicrobial Resistance called for a 50% decrease in outpatient antibiotic use by 2020. Inappropriate antibiotics are associated with adverse reactions and Clostridioides difficile infection, especially among older adults. Study design: Before and after study. Methods: We performed a quality improvement initiative at the University of Colorado Seniors Clinic. Providers received education on antibiotic guidelines, electronic antibiotic order sets were introduced with standardized stop dates. Antibiotic use data were collected for 6 months before and 6 months after the intervention, from December to May to avoid seasonal variation. Descriptive statistics and linear mixed-effects regression models were used for this comparison. Results: Total antibiotic prescriptions for acute respiratory conditions decreased from 137 prescriptions before the intervention (December 1, 2017, to May 31, 2018) to 112 prescriptions after the intervention (December 1, 2018, to May 31, 2019), driven primarily by decreases in antibiotic prescriptions for pneumonia, sinusitis, and bronchitis. Prescriptions for broad-spectrum antibiotics declined following the intervention including decreases in levofloxacin from 12 (9%) to 3 (3%) and amoxicillin-clavulanate from 15 (12%) to 7 (7%). We detected significant reductions in prescribed antibiotic durations (days) after the intervention for sinusitis (estimate, −2.0; 95% CI, −3.1 to −1.0; P = .0003), pharyngitis (estimate, −2.5; 95% CI, −4.6 to −0.5; P = .018), and otitis (−3.2; 95% CI, −5.2 to −1.3; P = .008). Conclusions: Low-cost interventions were initially successful in changing patterns of antibiotic use and decreasing overall antibiotic prescribing among older patients in the outpatient setting. Long-term follow-up studies are needed to determine the sustainability and clinical impact of these interventions.
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Saatchi A, Reid JN, Povitz M, Shariff SZ, Silverman M, Morris AM, Reyes RC, Patrick DM, Marra F. Appropriateness of Outpatient Antibiotic Use in Seniors across Two Canadian Provinces. Antibiotics (Basel) 2021; 10:antibiotics10121484. [PMID: 34943696 PMCID: PMC8698544 DOI: 10.3390/antibiotics10121484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/21/2023] Open
Abstract
Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Jennifer N. Reid
- Institute for Clinical Evaluative Sciences, London, ON N6A 5W9, Canada; (J.N.R.); (S.Z.S.)
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
| | - Marcus Povitz
- Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Salimah Z. Shariff
- Institute for Clinical Evaluative Sciences, London, ON N6A 5W9, Canada; (J.N.R.); (S.Z.S.)
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
| | - Michael Silverman
- Lawson Health Research Institute, London, ON N6C 2R5, Canada;
- Faculty of Medicine, Division of Infectious Diseases, University of Western Ontario, London, ON N6A 3K7, Canada
| | - Andrew M. Morris
- Department of Medicine, Sinai Health, University Health Network, University of Toronto, Toronto, ON N6A 3K7, Canada;
| | | | - David M. Patrick
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- Correspondence: ; Tel.: +1-604-822-7898
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Saatchi A, Yoo JW, Schwartz KL, Silverman M, Morris AM, Patrick DM, McCormack J, Marra F. Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada. Antibiotics (Basel) 2021; 10:1428. [PMID: 34827366 PMCID: PMC8615253 DOI: 10.3390/antibiotics10111428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/13/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022] Open
Abstract
Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from 1 January 2000 to 31 December 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2-18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2-8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Ji-Won Yoo
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Kevin L. Schwartz
- Public Health Ontario, Toronto, ON M5G 1V2, Canada;
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Michael Silverman
- Lawson Health Research Institute, London, ON N6A 4V2, Canada;
- Faculty of Medicine, University of Western Ontario, London, ON N6A 5C1, Canada
| | - Andrew M. Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, ON M5G 1L7, Canada;
| | - David M. Patrick
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
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The impact of COVID-19 on community antibiotic use in Canada: an ecological study. Clin Microbiol Infect 2021; 28:426-432. [PMID: 34757115 PMCID: PMC8556063 DOI: 10.1016/j.cmi.2021.10.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 12/01/2022]
Abstract
Objectives The COVID-19 pandemic has had an effect on the incidence of infectious diseases and medical care. This study aimed to describe the impact of the COVID-19 pandemic on community-level antibiotic use. Methods Using national antibiotic dispensing data from IQVIA's CompuScript database, this ecological study investigated antibiotic dispensing through community retail pharmacies in Canada from November 2014 to October 2020. Analyses were stratified by age, sex, prescription origin and approximate indication. Results Adjusting for seasonality, the national rate of antibiotic dispensing in Canada decreased by 26.5% (50.4 to 37.0 average prescriptions per 1000 inhabitants) during the first 8 months of the Canadian COVID-19 period (March to October 2020), compared with the pre-COVID-19 period. Prescribing rates in children ≤18 years decreased from 43.7 to 12.2 prescriptions per 1000 inhabitants in males (–72%) and from 46.8 to 14.9 prescriptions per 1000 inhabitants in females (–68%) in April 2020. Rates in adults ≥65 decreased from 74.9 to 48.8 prescriptions per 1000 inhabitants in males (–35%) and from 91.7 to 61.3 prescriptions per 1000 inhabitants in females (–33%) in May 2020. Antibiotic prescriptions from family physicians experienced a greater decrease than from surgeons and infectious disease physicians. Prescribing rates for antibiotics for respiratory indications decreased by 56% in May 2020 (29.2 to 12.8 prescriptions per 1000 inhabitants), compared with prescribing rates for urinary tract infections (9.4 to 7.8 prescriptions per 1000 inhabitants; –17%) and skin and soft tissue infections (6.4 to 5.2 prescriptions per 1000 inhabitants; –19%). Discussion The first 8 months of the COVID-19 pandemic reduced community antibiotic dispensing by 26.5% in Canada, compared with the marginal decrease of 3% in antibiotic consumption between 2015 and 2019. Further research is needed to understand the implications and long-term effects of the observed reductions on antibiotic use on antibiotic resistance in Canada.
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Saatchi A, Morris AM, Patrick DM, Mccormack J, Reyes RC, Morehouse P, Reid J, Shariff S, Povitz M, Silverman M, Marra F. Outpatient antibiotic use in British Columbia, Canada: reviewing major trends since 2000. JAC Antimicrob Resist 2021; 3:dlab116. [PMID: 34396123 PMCID: PMC8360297 DOI: 10.1093/jacamr/dlab116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/06/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND With 90% of all antibiotics in Canada being used in the community setting, tracking outpatient prescribing is integral to mitigate the issue of antimicrobial resistance. In 2005, a provincial programme was launched in British Columbia (BC) to disseminate information regarding the judicious use of antibiotics. These efforts include educational campaigns, updated practitioner guidelines and academic detailing. The impact of provincial stewardship on community prescribing requires ongoing evaluation. OBJECTIVES This study examines outpatient prescribing to quantify rates of antibiotic use, evaluate major trends over time and identify new targets for stewardship. METHODS A retrospective cohort design using population-level data. RESULTS This study included over 3.5 million unique individuals with a total of 51 367 938 oral antibiotic prescriptions dispensed over a 19 year period (2000-18). Overall antibiotic utilization decreased by 23% over the course of the study period. This trend in the reduction of antibiotic prescription was observed across all major antibiotic classes, apart from the class of other antibacterials, which was mostly related to use of nitrofurantoin. The largest magnitudes of decreased prescribing were observed in the paediatric population. Prescribing across two distinct eras of provincial stewardship reaffirmed preliminary findings of programme efficacy, when compared with pre-stewardship levels of antibiotic use. CONCLUSIONS Outpatient prescribing in BC is decreasing overall, and this study confirms an association between provincial stewardship interventions and improvements in antibiotic use. Pronounced declines in paediatric populations are promising, and further research is underway to examine prescribing quality.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Andrew M Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, ON, Canada
| | - David M Patrick
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - James Mccormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Romina C Reyes
- LifeLabs, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | - Marcus Povitz
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael Silverman
- Faculty of Medicine, University of Western Ontario, London, ON, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
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Schwartz KL, Ivers N, Langford BJ, Taljaard M, Neish D, Brown KA, Leung V, Daneman N, Alloo J, Silverman M, Shing E, Grimshaw JM, Leis JA, Wu JHC, Garber G. Effect of Antibiotic-Prescribing Feedback to High-Volume Primary Care Physicians on Number of Antibiotic Prescriptions: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:1165-1173. [PMID: 34228086 PMCID: PMC8261687 DOI: 10.1001/jamainternmed.2021.2790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/27/2021] [Indexed: 01/07/2023]
Abstract
Importance Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance. Objective To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing. Design, Setting, and Participants In this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada. Interventions Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis. Main Outcomes and Measures The primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis. Results Of the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months. Conclusions and Relevance In this randomized clinical trial, a single mailed letter to the highest-prescribing PCPs in Ontario, Canada providing peer-comparison feedback, including messaging on limiting antibiotic-prescribing durations, led to statistically significant reductions in total and prolonged-duration antibiotic prescriptions, as well as drug costs. Trial Registration ClinicalTrials.gov Identifier: NCT03776383.
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Affiliation(s)
- Kevin L. Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Unity Health Toronto, Toronto, Ontario, Canada
| | - Noah Ivers
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Javed Alloo
- Section on General and Family Practice, Ontario Medical Association, Toronto, Ontario, Canada
- Ontario College of Family Physicians, Toronto, Ontario
| | - Michael Silverman
- Division of Infectious Diseases, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Emily Shing
- Public Health Ontario, Toronto, Ontario, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jerome A. Leis
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Gary Garber
- Public Health Ontario, Toronto, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Leung V, Langford BJ, Ha R, Schwartz KL. Metrics for evaluating antibiotic use and prescribing in outpatient settings. JAC Antimicrob Resist 2021; 3:dlab098. [PMID: 34286273 PMCID: PMC8287042 DOI: 10.1093/jacamr/dlab098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial stewardship interventions in outpatient settings are diverse and a variety of outcomes have been used to evaluate these efforts. This narrative review describes, compares and provides specific examples of antibiotic use and other prescribing measures to help antimicrobial stewards better understand, interpret and implement metrics for this setting. A variety of data have been used including those generated from drug sales, prescribing and dispensing activities, however data generated closest to when an individual patient consumes an antibiotic is usually more accurate for estimating antibiotic use. Availability of data is often dependent on context such as information technology infrastructure and the healthcare system under consideration. While there is no ideal antibiotic use or prescribing metric for evaluating antimicrobial stewardship activities in the outpatient setting, the intervention of interest and available data sources are important factors. Common metrics for estimating antimicrobial use include DDD per 1000 inhabitants per day (DID) and days of therapy per 1000 inhabitants/day (DOTID). Other prescribing metrics such as antibiotic prescribing rate (APR), proportion of prescriptions containing an antibiotic, proportion of prolonged antibiotic courses prescribed, estimated appropriate APR and quality indicators are used to assess specific aspects of antimicrobial prescribing behaviour such as initiation, selection, duration and appropriateness. Understanding the context of prescribing practices helps to ensure feasibility and relevance when implementing metrics and targets for improvement in the outpatient setting.
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Affiliation(s)
- Valerie Leung
- Public Health Ontario, ON, Canada
- Toronto East Health Network, Michael Garron Hospital, ON, Canada
| | - Bradley J Langford
- Public Health Ontario, ON, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, ON, Canada
| | - Rita Ha
- North York Family Health Team, ON, Canada
| | - Kevin L Schwartz
- Public Health Ontario, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
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Rolf von den Baumen T, Crosby M, Tadrous M, Schwartz KL, Gomes T. Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019. J Antimicrob Chemother 2021; 76:2472-2478. [PMID: 34223899 DOI: 10.1093/jac/dkab205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. OBJECTIVES We explored the impact of this campaign on antibiotic utilization in Canada. METHODS We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. RESULTS There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. CONCLUSIONS The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.
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Affiliation(s)
| | - Michael Crosby
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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Sulis G, Daniels B, Kwan A, Gandra S, Daftary A, Das J, Pai M. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003393. [PMID: 32938614 PMCID: PMC7493125 DOI: 10.1136/bmjgh-2020-003393] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction Determining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions. Methods Secondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models. Results Across health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%). Conclusion Good-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.
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Affiliation(s)
- Giorgia Sulis
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Ontario, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA.,Centre for Policy Research, New Delhi, Delhi, India
| | - Madhukar Pai
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada .,McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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36
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Kitano T, Langford BJ, Brown KA, Pang A, Chen B, Garber G, Daneman N, Tu K, Leung V, Candido E, Wu JHC, Hwee J, Silverman M, Schwartz KL. The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records. Clin Infect Dis 2021; 72:e345-e351. [PMID: 32785696 DOI: 10.1093/cid/ciaa1139] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing. METHODS This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing. RESULTS There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate. CONCLUSIONS We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.
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Affiliation(s)
- Taito Kitano
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Kevin A Brown
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | | | - Gary Garber
- Public Health Ontario, Toronto, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Karen Tu
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada.,Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | | | | | - Jeremiah Hwee
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Unity Health Network, St. Joseph Health Centre, Toronto, Ontario, Canada
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37
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Tarr GAM, Tarr PI. Pediatric Enteric Diagnostic Stewardship: The Right Test in the Right Context. Pediatrics 2021; 147:peds.2020-044941. [PMID: 33837135 DOI: 10.1542/peds.2020-044941] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Gillian A M Tarr
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota; and
| | - Phillip I Tarr
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
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38
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Wu JHC, Khalid F, Langford BJ, Beahm NP, McIntyre M, Schwartz KL, Garber G, Leung V. Community pharmacist prescribing of antimicrobials: A systematic review from an antimicrobial stewardship perspective. Can Pharm J (Ott) 2021; 154:179-192. [PMID: 34104272 PMCID: PMC8165883 DOI: 10.1177/1715163521999417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background: Pharmacist prescribing authority is expanding, while antimicrobial resistance is an increasing global concern. We sought to synthesize the evidence for antimicrobial prescribing by community pharmacists to identify opportunities to advance antimicrobial stewardship in this setting. Methods: We conducted a systematic review to characterize the existing literature on community pharmacist prescribing of systemic antimicrobials. We searched MEDLINE, EMBASE and International Pharmaceutical Abstracts for English-language articles published between 1999 and June 20, 2019, as well as hand-searched reference lists of included articles and incorporated expert suggestions. Results: Of 3793 articles identified, 14 met inclusion criteria. Pharmacists are most often prescribing for uncomplicated urinary tract infection (UTI), acute pharyngitis and cold sores using independent and supplementary prescribing models. This was associated with high rates of clinical improvement (4 studies), low rates of retreatment and adverse effects (3 studies) and decreased health care utilization (7 studies). Patients were highly satisfied (8 studies) and accessed care sooner or more easily (7 studies). Seven studies incorporated antimicrobial stewardship into study design, and there was overlap between study outcomes and those relevant to outpatient antimicrobial stewardship. Pharmacist intervention reduced unnecessary prescribing for acute pharyngitis (2 studies) and increased the appropriateness of prescribing for UTI (3 studies). Conclusion: There is growing evidence to support the role of community pharmacists in antimicrobial prescribing. Future research should explore additional opportunities for pharmacist antimicrobial prescribing and ways to further integrate advanced antimicrobial stewardship strategies in the community setting. Can Pharm J (Ott) 2021;154:xx-xx.
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Affiliation(s)
| | | | | | - Nathan P Beahm
- the Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta
| | - Mark McIntyre
- the Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto
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39
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Kern WV. [Inadequate antibiotic prescribing and areas for improvement]. Dtsch Med Wochenschr 2020; 145:1683-1687. [PMID: 33202452 DOI: 10.1055/a-1114-3875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Inadequate antibiotic prescribing has been observed in many settings both in hospitals as well as in primary care. Most often there is uncertainty about the indication for antibiotic treatment itself, prescribers are reluctant to deescalate, and therapy duration is too long which results most often in overprescribing. The burden of overprescribing is difficult to estimate, but many studies in the hospital setting report a rate of approximately 30 % of inadequate prescribing - with wide variation. Over- but also underprescribing of antimicrobial agents is a serious patient safety issue that needs to be addressed in specific programmes at different levels of the healthcare system. Interventional studies have shown that programmes implementing or intensifying audit and feedback with clinical reevaluation by experts can be very efficient to reduce inadequate prescribing.
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