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Meropol SB, Glick HA, Asch DA. Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media. Pediatrics 2008; 121:657-68. [PMID: 18381528 DOI: 10.1542/peds.2007-1913] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines' 3-criteria algorithm, and (3) initially watching without antibiotics. METHODS A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day. RESULTS For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children. CONCLUSIONS The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.
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Affiliation(s)
- Sharon B Meropol
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 108 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104, USA.
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253
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Park TR, Brooks JM, Chrischilles EA, Bergus G. Estimating the effect of treatment rate changes when treatment benefits are heterogeneous: antibiotics and otitis media. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2008; 11:304-314. [PMID: 18380643 DOI: 10.1111/j.1524-4733.2007.00234.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Contrast methods to assess the health effects of a treatment rate change when treatment benefits are heterogeneous across patients. Antibiotic prescribing for children with otitis media (OM) in Iowa Medicaid is the empirical example. METHODS Instrumental variable (IV) and linear probability model (LPM) are used to estimate the effect of antibiotic treatments on cure probabilities for children with OM in Iowa Medicaid. Local area physician supply per capita is the instrument in the IV models. Estimates are contrasted in terms of their ability to make inferences for patients whose treatment choices may be affected by a change in population treatment rates. RESULTS The instrument was positively related to the probability of being prescribed an antibiotic. LPM estimates showed a positive effect of antibiotics on OM patient cure probability while IV estimates showed no relationship between antibiotics and patient cure probability. CONCLUSIONS Linear probability model estimation yields the average effects of the treatment on patients that were treated. IV estimation yields the average effects for patients whose treatment choices were affected by the instrument. As antibiotic treatment effects are heterogeneous across OM patients, our estimates from these approaches are aligned with clinical evidence and theory. The average estimate for treated patients (higher severity) from the LPM model is greater than estimates for patients whose treatment choices are affected by the instrument (lower severity) from the IV models. Based on our IV estimates it appears that lowering antibiotic use in OM patients in Iowa Medicaid did not result in lost cures.
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Affiliation(s)
- Tae-Ryong Park
- Health Research Consultant, Health Dialog Analytic Solutions, Portland, ME, USA
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Woodburn JD, Smith KL, Nelson GD. Quality of care in the retail health care setting using national clinical guidelines for acute pharyngitis. Am J Med Qual 2008; 22:457-62. [PMID: 18006426 DOI: 10.1177/1062860607309626] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rates of adherence to an acute pharyngitis practice guideline in the retail clinic setting were measured as an indicator of clinical quality. An analysis of 57,331 patient visits for the evaluation of acute pharyngitis was conducted. In 39,530 patients with a negative rapid strep test result, nurse practitioner and physician assistant staff adhered to guidelines in 99.05% of cases by withholding unnecessary antibiotics. Of 13,471 patients with a positive rapid strep test result, 99.75% received an appropriate antibiotic prescription. The combined guideline adherence rate for groups with positive and negative rapid strep test results was 99.15%. Strep cultures were performed on 99.1% of patients with a negative rapid strep test result, and 96.2% of patients with a positive culture were treated with an antibiotic. Finally, 0.95% of patients with a negative rapid strep test result were provided an antibiotic outside clinical guidelines; however, approximately half of these prescriptions (n = 190) were supported by documentation of clinical concerns for which an antibiotic was a reasonable choice.
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255
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Saver RS. In tepid defense of population health: physicians and antibiotic resistance. AMERICAN JOURNAL OF LAW & MEDICINE 2008; 34:431-491. [PMID: 19216245 DOI: 10.1177/009885880803400401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Antibiotic resistance menaces the population as a dire public health threat and costly social problem. Recent proposals to combat antibiotic resistance focus to a large degree on supply side approaches. Suggestions include tinkering with patent rights so that pharmaceutical companies have greater incentives to discover novel antibiotics as well as to resist overselling their newer drugs already on market. This Article argues that a primarily supply side emphasis unfortunately detracts attention from physicians' important demand side influences. Physicians have a vital and unavoidably necessary role to play in ensuring socially optimal access to antibiotics. Dismayingly, physicians' management of the antibiotic supply has been poor and their defense of population health tepid at best. Acting as a prudent steward of the antibiotic supply often seems to be at odds with a physician's commonly understood fiduciary duties, ethical obligations, and professional norms, all of which traditionally emphasize the individual health paradigm as opposed to population health responsibilities. Meanwhile, physicians face limited incentives for antibiotic conservation from other sources, such as malpractice liability, regulatory standards, and reimbursement systems. While multifaceted efforts are needed to combat antibiotic resistance effectively, physician gatekeeping behavior should become a priority area of focus. This Article considers how health law and policy tools could favorably change the incentives physicians face for antibiotic conservation. A clear lesson from the managed care reform battles of the recent past is that interventions, to have the best chance of success, need to respect physician interest in clinical autonomy and individualized medicine even if, somewhat paradoxically, vigorously promoting population health perspectives. Also, physicians' legal and ethical obligations need to be reconceptualized in the antibiotic context in order to better support gatekeeping in defense of population health. The principal recommendation is for increased use of financial incentives to reward physicians for compliance with recommended guidelines on antibiotic prescribing. Although not a panacea, greater experimentation with financial incentives can provide a much needed jump-start to physician interest in antibiotic conservation and likely best address physicians' legitimate clinical autonomy concerns.
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Affiliation(s)
- Richard S Saver
- Health Law and Policy Institute, University of Houston Law Center, USA
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256
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Nyquist AC, Todd JK. The epidemiology, microbiology, and antimimcrobial management of head and neck infections in children--a different perspective. Adv Pediatr 2008; 55:327-8. [PMID: 19048736 DOI: 10.1016/j.yapd.2008.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ann-Christine Nyquist
- Department of Pediatrics, University of Colorado at Denver School of Medicine, Aurora, CO, USA.
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257
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Feder HM, Collins M. How Connecticut primary care physicians view treatments for streptococcal and nonstreptococcal pharyngitis. Clin Ther 2008; 30:158-63. [DOI: 10.1016/j.clinthera.2008.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2007] [Indexed: 10/22/2022]
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Martinez FJ, Curtis JL, Albert R. Role of macrolide therapy in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2008; 3:331-50. [PMID: 18990961 PMCID: PMC2629987 DOI: 10.2147/copd.s681] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability worldwide. The Global Burden of Disease study has concluded that COPD will become the third leading cause of death worldwide by 2020, and will increase its ranking of disability-adjusted life years lost from 12th to 5th. Acute exacerbations of COPD (AECOPD) are associated with impaired quality of life and pulmonary function. More frequent or severe AECOPDs have been associated with especially markedly impaired quality of life and a greater longitudinal loss of pulmonary function. COPD and AECOPDs are characterized by an augmented inflammatory response. Macrolide antibiotics are macrocyclical lactones that provide adequate coverage for the most frequently identified pathogens in AECOPD and have been generally included in published guidelines for AECOPD management. In addition, they exert broad-ranging, immunomodulatory effects both in vitro and in vivo, as well as diverse actions that suppress microbial virulence factors. Macrolide antibiotics have been used to successfully treat a number of chronic, inflammatory lung disorders including diffuse panbronchiolitis, asthma, noncystic fibrosis associated bronchiectasis, and cystic fibrosis. Data in COPD patients have been limited and contradictory but the majority hint to a potential clinical and biological effect. Additional, prospective, controlled data are required to define any potential treatment effect, the nature of this effect, and the role of bronchiectasis, baseline colonization, and other cormorbidities.
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Affiliation(s)
- Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI 48109-0360, USA.
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259
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Cadieux G, Tamblyn R, Dauphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ 2007; 177:877-83. [PMID: 17923655 DOI: 10.1503/cmaj.070151] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Inappropriate use of antibiotics promotes antibiotic resistance. Little is known about physician characteristics that may be associated with inappropriate antibiotic prescribing. Our objective was to assess whether physician knowledge, time in practice, place of training and practice volume explain the differences in antibiotic prescribing among physicians. METHODS A historical cohort of 852 primary care physicians in Quebec who became certified between 1990 and 1993 was followed for their first 6-9 years of practice (1990-1998). We evaluated whether inappropriate antibiotic prescribing had occurred during the study period (1990-1998) for viral (prescription of antibiotics) and bacterial (prescription of second-or third-line antibiotics given orally) infections. We used logistic regression to estimate the independent contributions of time in practice, practice volume, place of medical training and scores on licensure examinations. Physician sex and visit setting were controlled for, as were patient age, sex, education, income and geographic area of residence. RESULTS A total of 104 230 patients who received a diagnosis of a viral infection and 65 304 who received a diagnosis of a bacterial infection were included in our study. International medical graduates were more likely than University of Montréal graduates to prescribe antibiotics for viral respiratory infections (risk ratio [RR] 1.78, 95% confidence interval [CI] 1.30-2.44). Inappropriate antibiotic prescribing increased with time in practice. Physicians with a high practice volume were more likely than those with low practice volume to prescribe antibiotics for viral respiratory infections (RR 1.27, 95% CI 1.09-1.48) and to prescribe second-and third-line antibiotics as first-line treatment (RR 1.20, 95% CI 1.06-1.37). Physician scores on licensure examinations were not predictive of inappropriate antibiotic prescribing. INTERPRETATION International medical graduates, physicians with high-volume practices and those who were in practice longer were more likely to prescribe antibiotics inappropriately. Developing effective interventions will require increased knowledge of the mechanisms that underlie these predictors of inappropriate antibiotic prescribing.
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Affiliation(s)
- Genevieve Cadieux
- Department of Epidemiology and Biostatistics, McGill University, Montréal, Que.
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260
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María Navarro-Marí J, Pérez-Ruiz M. [Respiratory viruses: old and new. Review of diagnostic methods]. Enferm Infecc Microbiol Clin 2007; 25:60-65. [PMID: 38620190 PMCID: PMC7130279 DOI: 10.1157/13111839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory infections (ARI) of viral origin are one of the main causes of morbidity and mortality worldwide. In addition to traditional viruses, such as the influenza virus, respiratory syncytial virus, rhinovirus, parainfluenza viruses 1 to 4, and adenovirus, other viruses such as metapneumovirus, new coronaviruses (human coronavirus NL63 and HKU1 and severe acute respiratory syndrome [SARS]-coronavirus), and recently bocaviruses, have been identified as causal agents of ARI. Although most of these viral infections follow a benign and selflimiting course in healthy adults, the consequences for the health care systems increase when they involve children, the elderly, immunosuppressed individuals, or those with chronic underlying diseases. These viral infections are an important cause of hospitalization and death, mainly during the cold months of the year, and, from a social-health perspective, ARI are a drain on economic resources and a frequent cause of work absenteeism. Occasionally, some of these viruses may cause emergent world health problems, as has occurred with the influenza virus pandemic strain and SARScoronavirus. While classical diagnostic methods based on culture and antigen detection remain useful for traditional respiratory viruses, recently described viruses are diagnosed mainly by molecular amplification techniques.
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261
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Foglé-Hansson M, White P, Hermansson A. Prediction of upper respiratory tract bacteria in acute otitis media. Acta Otolaryngol 2007; 127:927-31. [PMID: 17712670 DOI: 10.1080/00016480601091719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONCLUSIONS Thorough otomicroscopical examination of the tympanic membrane in acute otitis media (AOM) might distinguish AOM episodes caused by different bacteria. It thus might be a way to select appropriate treatment for each patient without raising the number of dangerous complications. OBJECTIVES The aim of this study was to see if it might be possible to predict the causative bacterium by judging the otomicroscopical appearance of the tympanic membrane in episodes of AOM. PATIENTS AND METHODS The study was prospective. Patients suffering from non-perforated AOM were included. The tympanic membrane was photographed. A prediction of the causative bacterium was made and tympanocentesis was performed. Effusion from the middle ear and a nasopharyngeal swab were obtained for bacterial culturing. The causative bacteria were categorized into gram-positive (Streptococcus pneumoniae and S. pyogenes) or gram-negative (non-typable Haemophilus influenzae and Moraxella catarrhalis). RESULTS A total of 82 patients were included in the study. A correct prediction was made in 47/63, a false prediction in 16/63 (kappa 0.48, p<0.001).
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262
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Bishara J, Hershkovitz D, Paul M, Rotenberg Z, Pitlik S. Appropriateness of antibiotic therapy on weekends versus weekdays. J Antimicrob Chemother 2007; 60:625-8. [PMID: 17595287 DOI: 10.1093/jac/dkm233] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To compare the appropriateness of antibiotic treatment prescribed in an emergency department (ED) of a tertiary medical centre on weekdays and weekends. METHODS During a 1 month period, medical charts of 1029 ED visits for patients who were discharged from the ED were reviewed. Data of patients who were discharged with antibiotics were blind evaluated by two infectious disease specialists, and an 'appropriateness score' was given to the antibiotic prescription. RESULTS Antibiotics were prescribed at discharge for 182 (17.7%) patients. Appropriate antibiotic treatment was administered significantly less frequently on weekends when compared with weekdays (P = 0.004). Appropriateness scores were higher for the surgical and urological wings (P = 0.011) and for diagnoses of pneumonia and urinary tract infection (P = 0.005). Time of the day and patient's age and sex did not have a significant effect on the appropriateness score. Adjusting for all variables, only weekends remained significantly associated with less appropriate antibiotic treatment, odds ratio 0.35 and 95% confidence intervals 0.16-0.78. CONCLUSIONS This study shows less appropriate antibiotic prescription in an ED on weekends than weekdays. More studies are required to clarify measures to improve appropriate antibiotic therapy at weekends.
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Affiliation(s)
- Jihad Bishara
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tiqwa 49100, Israel.
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263
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Metlay JP, Camargo CA, MacKenzie T, McCulloch C, Maselli J, Levin SK, Kersey A, Gonzales R. Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments. Ann Emerg Med 2007; 50:221-30. [PMID: 17509729 DOI: 10.1016/j.annemergmed.2007.03.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Revised: 03/09/2007] [Accepted: 03/16/2007] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. METHODS Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. RESULTS The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval -3% to 5%) and at intervention sites decreased by 10% (95% confidence interval -18% to -2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. CONCLUSION Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.
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Affiliation(s)
- Joshua P Metlay
- Center for Health Equity Research and Promotion, VA Medical Center, Philadelphia, PA, USA.
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264
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Abstract
BACKGROUND Acute laryngitis is a common illness worldwide. Diagnosis is often made by case history alone and treatment is often directed towards controlling symptoms. OBJECTIVES The aim of this review was to assess the effectiveness of different antibiotic therapies in adults suffering acute laryngitis. A secondary objective was to report the rates of adverse events associated with these treatments. SEARCH STRATEGY We systematically screened the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2006); MEDLINE (January 1966 to December Week 2 2006); and EMBASE (1974 to June 2006), LILACS (from 1982 to December 2006 ) and BIOSIS (1980 to June 2002). Other strategies included hand searching relevant journals, searching ongoing trial databases and general databases such as Google scholar. SELECTION CRITERIA Randomized controlled trials comparing any antibiotic therapy with placebo in acute laryngitis. The main outcome measurement was objective voice scores. DATA COLLECTION AND ANALYSIS Data were independently extracted by two review authors and then descriptively synthesized. MAIN RESULTS Only two trials met study inclusion criteria after extensive literature searches. One hundred participants were randomly selected to receive either penicillin V (800 mg twice a day for five days), or an identical placebo, in a study of penicillin V in acute laryngitis in adults. A tape recording of each patient reading a standardized text was obtained during the first visit, subsequently during re-examination after one and two weeks, and at follow up after two to six months. No significant differences were found between the groups. The trial also measured symptoms reported by participants and found no significant differences. The second trial investigated erythromycin for treating acute laryngitis in 106 adults. The mean objective voice scores measured at the first visit, at re-examination after one and two weeks, and at follow up after two to six months did not significantly differ between control and intervention groups. At one week there were significant beneficial differences in the severity of reported vocal symptoms as judged by the participants (P = 0.042). Comparing the erythromycin and placebo groups on subjective voice scores the a priori relative risk (RR) was 0.7 (95% confidence interval (CI) 0.51 to 0.96, P = 0.034) and the number needed to treat (NNT) was 4.5. AUTHORS' CONCLUSIONS Antibiotics appear to have no benefit in treating acute laryngitis. Erythromycin could reduce voice disturbance at one week and cough at two weeks when measured subjectively. We consider that these outcomes are not relevant in clinical practice. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.
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Affiliation(s)
- L Reveiz
- Epidemiologist Sanitas Research Institute School of Medicine, Department of General Practice, Fundación Universitaria Sanitas, Diagonal 127 A # 31 - 48 Cons 221, Bogota, Colombia.
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Abstract
ABSTRACT
The purpose of this state‐of‐the‐science review was to identify strategies and household‐level interventions for public health nurses to help prevent the acquisition and spread of viral upper respiratory infections (URI) in the community. Even though viral URI are a major global economic and social problem, surprisingly little research has been conducted to attempt to prevent them or reduce their transmission, probably because URI (with the exception of epidemic influenza) are generally considered to be mild and self‐limited. Based on the research to date, public health nurses can use several promising strategies for prevention: (a) provide more tailored educational messages regarding preventive strategies such as vaccination, hand hygiene, spatial separation of infected household members, avoidance of antibiotics to treat viral URI, and environmental cleaning (e.g., for toys or other shared items), which are delivered personally rather than passively (e.g., pamphlets placed in a waiting room); (b) use each patient encounter in any setting to encourage influenza vaccination for relevant risk groups; (c) encourage use of alcohol hand sanitizers by household members during the cold and flu season; and (d) provide opportunities for skill development for adult and child household members (e.g., cover your cough, when to seek care or an antibiotic).
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Affiliation(s)
- Elaine L Larson
- School of Nursing and Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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266
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Doern GV. Optimizing the management of community-acquired respiratory tract infections in the age of antimicrobial resistance. Expert Rev Anti Infect Ther 2007; 4:821-35. [PMID: 17140358 DOI: 10.1586/14787210.4.5.821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Community-acquired respiratory tract infections (CARTIs) are the most common reason for prescribing antibiotics in the primary care setting. However, over the last decade, the management of CARTIs has become increasingly complicated by the steady increase in prevalence of drug-resistant pathogens responsible for these infections. As a result, significant attention has been directed at understanding the mechanisms of pathogen acquisition of resistance, drivers of resistance and methods for preventing the development of resistance. Data from recent surveillance studies suggest a slowing or decline in resistance rates to agents, such as beta-lactams, macrolides, tetracyclines and folic acid metabolism inhibitors. However, resistance to one antimicrobial family--the fluoroquinolones--while still low, appears to be on the increase. This is of significant concern given the rapid increase in resistance noted with older antibiotics in recent history. While the clinical implications of antibacterial resistance are poorly understood, the overall rates of antimicrobial resistance, as reported in recent surveillance studies, do not correspond to current rates of failure in patients with CARTIs. This disconnection between laboratory-determined resistance and clinical outcome has been termed the in vitro-in vivo paradox and several explanations have been offered to explain this phenomenon. Solving the problem of antimicrobial resistance will be multifactorial. Important factors in this effort include the education of healthcare providers, patients and the general healthcare community regarding the hazards of inappropriate antibiotic use, prevention of infections through vaccination, development of accurate, inexpensive and timely point-of-care diagnostic tests to aid in patient assessment, institution of objective treatment guidelines and use of more potent agents, especially those with a focused spectrum of activity, earlier in the treatment of CARTIs as opposed to reserving them as second-line treatment options. Ultimately, the single-most important factor will be the judicious use of antibiotics, as fewer antibiotic prescriptions lead to fewer antimicrobial-resistant bacteria.
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Affiliation(s)
- Gary V Doern
- University of Iowa, College of Medicine, Iowa City, Iowa, USA.
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267
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Harrington NG, Norling GR, Witte FM, Taylor J, Andrews JE. The effects of communication skills training on pediatricians' and parents' communication during "sick child" visits. HEALTH COMMUNICATION 2007; 21:105-14. [PMID: 17523856 DOI: 10.1080/10410230701306974] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
This article reports the development and evaluation of a physician-parent communication skills training program designed to improve communication regarding antibiotic prescribing for children. Four pediatricians and 81 parents participated in the study, which involved audiotaping "sick child" office visits and then coding transcripts for evidence of program influence on information seeking, giving, and verifying, as well as relational communication. Parents who received training were more likely to verify information, t(79) = 1.82, p = .04, and more likely to express concerns, t(79) = 1.79, p = .04, than were parents who did not receive training; there was a nonsignificant trend for trained parents to be more likely to give information, t(79) = 1.7, p = .051. In terms of physician behavior, there were nonsignificant trends for physicians to spend more time creating a partnership with parents after training than before training, t(3) = 2.29, p = .053, and to encourage more questions from parents after training than before, t(3) = 2.15, p = .06. In addition, once one outlier parent in the control condition was removed from the analysis, the results showed that physicians spent more time addressing treatment options after training than before, t(3) = 2.9, p = .03. The results of this study are considered promising, with effects shown for various important elements of physician-parent communication. Implications of results and directions for future research are discussed.
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268
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Euler CW, Ryan PA, Martin JM, Fischetti VA. M.SpyI, a DNA methyltransferase encoded on a mefA chimeric element, modifies the genome of Streptococcus pyogenes. J Bacteriol 2006; 189:1044-54. [PMID: 17085578 PMCID: PMC1797290 DOI: 10.1128/jb.01411-06] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
While screening the clonality of Streptococcus pyogenes isolates from an outbreak of erythromycin-resistant pharyngitis in Pittsburgh, PA, we found a correlation between the presence of the chimeric element Phi10394.4 (carrying the macrolide efflux gene, mefA) and genomic DNA being resistant to cleavage by SmaI restriction endonuclease. A search of the open reading frames in Phi10394.4 identified a putative type II restriction-modification (R-M) cassette containing a cytosine methyltransferase gene (spyIM). Heterologous expression of the cloned spyIM gene, as well as allelic-replacement experiments, showed that the action of this methyltransferase (M.SpyI) was responsible for the inhibition of SmaI digestion of genomic DNA in the Phi10394.4-containing isolates. Analysis of the methylation patterns of streptococcal genomic DNA from spyIM-positive strains, a spyIM deletion mutant, and a spyIM-negative strain determined that M.SpyI specifically recognized and methylated the DNA sequence to generate 5'-C(m)CNGG. To our knowledge, this is the first methyltransferase gene from S. pyogenes to be cloned and to have its activity characterized. These results reveal why pulsed field gel electrophoresis analysis of SmaI-digested genomic DNA cannot be used to analyze the clonality of some streptococci containing Phi10394.4 and may explain the inability of previous epidemiological studies to use SmaI to analyze DNAs from macrolide-resistant streptococci. The presence of the SpyI R-M cassette in Phi10394.4 could impart a selective advantage to host strain survival and may provide another explanation for the observed increase in macrolide-resistant streptococci.
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Affiliation(s)
- Chad W Euler
- Laboratory of Bacterial Pathogenesis and Immunology, The Rockefeller University, Box 172, 1230 York Avenue, New York, NY 10021, USA.
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269
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Rubin MA, Bateman K, Donnelly S, Stoddard GJ, Stevenson K, Gardner RM, Samore MH. Use of a personal digital assistant for managing antibiotic prescribing for outpatient respiratory tract infections in rural communities. J Am Med Inform Assoc 2006; 13:627-34. [PMID: 16929045 PMCID: PMC1656956 DOI: 10.1197/jamia.m2029] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2005] [Accepted: 08/01/2006] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess the acceptability and usage of a standalone personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the diagnosis and management of acute respiratory tract infections (RTIs) in the outpatient setting. DESIGN Observational study performed as part of a larger randomized trial in six rural communities in Utah and Idaho from January 2002 to March 2004. Ninety-nine primary care providers received a PDA-based CDSS for use at the point-of-care, and were asked to use the tool with at least 200 patients with suspected RTIs. MEASUREMENTS Clinical data were collected electronically from the devices at periodic intervals. Providers also completed an exit questionnaire at the end of the study period. RESULTS Providers logged 14,393 cases using the CDSS, the majority of which (n=7624; 53%) were from family practitioners. Overall adherence with CDSS recommendations for the five most common diagnoses (pharyngitis, otitis media, sinusitis, bronchitis, and upper respiratory tract infection) was 82%. When antibiotics were prescribed (53% of cases), adherence with the CDSS-recommended antibiotic was high (76%). By logistic regression analysis, the odds of adherence with CDSS recommendations increased significantly with each ten cases completed (P=0.001). Questionnaire respondents believed the CDSS was easy to use, and most (44/65; 68%) did not believe it increased their encounter time with patients, regardless of prior experience with PDAs. CONCLUSION A standalone PDA-based CDSS for acute RTIs used at the point-of-care can encourage better outpatient antimicrobial prescribing practices and easily gather a rich set of clinical data.
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Affiliation(s)
- Michael A Rubin
- Department of Internal Medicine, University of Utah School of Medicine, 300 North 1900 East, Room AC-230A, Salt Lake City, UT 84132, USA.
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270
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Drew RH, Kawamoto K, Adams MB. Information technology for optimizing the management of infectious diseases. Am J Health Syst Pharm 2006; 63:957-65. [PMID: 16675654 DOI: 10.2146/ajhp050315] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Richard H Drew
- School of Medicine, Duke University, Durham, NC 27710, USA.
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271
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Nokso-Koivisto J, Hovi T, Pitkäranta A. Viral upper respiratory tract infections in young children with emphasis on acute otitis media. Int J Pediatr Otorhinolaryngol 2006; 70:1333-42. [PMID: 16564578 PMCID: PMC7112939 DOI: 10.1016/j.ijporl.2006.01.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 01/29/2006] [Accepted: 01/30/2006] [Indexed: 11/24/2022]
Abstract
Viral upper respiratory infection is the most common reason for seeking medical care for children. Recurrent viral respiratory infections and subsequent complications (e.g. acute otitis media (AOM)) are a burden for children, their families and society. Over the past decade, our knowledge on the significance of respiratory viruses has broadened remarkably. Viruses cause large variety of respiratory diseases and cause alone diseases, which previously have been assumed to be bacterial only (e.g. AOM and pneumonia). Methods for detection analysis of respiratory viruses are developing making both the diagnosis and epidemiological investigations of respiratory infections easier. Accurate diagnosis of respiratory infections and awareness of possible viral etiology could reduce the use of antibiotics. Etiologic studies of viral infections are becoming increasingly important, with the emergence of new antiviral drugs and vaccines.
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Affiliation(s)
- Johanna Nokso-Koivisto
- Department of Virology and Immunology, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland.
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272
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Gjelstad S, Fetveit A, Straand J, Dalen I, Rognstad S, Lindbaek M. Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice--the Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155]. BMC Health Serv Res 2006; 6:75. [PMID: 16776824 PMCID: PMC1569835 DOI: 10.1186/1472-6963-6-75] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 06/15/2006] [Indexed: 12/17/2022] Open
Abstract
Background More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections (RTIs), despite convincing evidence that many of these infections are caused by viruses. Frequent misuse of antimicrobial agents is of great global health concern, as we face an emerging worldwide threat of bacterial antibiotic resistance. There is an increasing need to identify determinants and patterns of antibiotic prescribing, in order to identify where clinical practice can be improved. Methods/Design Approximately 80 peer continuing medical education (CME) groups in southern Norway will be recruited to a cluster randomized trial. Participating groups will be randomized either to an intervention- or a control group. A multifaceted intervention has been tailored, where key components are educational outreach visits to the CME-groups, work-shops, audit and feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained GPs, will conduct the educational outreach visits. During these visits, evidence-based recommendations of antibiotic prescriptions for RTIs will be presented and software will be handed out for installation in participants PCs, enabling collection of prescription data. These data will subsequently be linked to corresponding data from the Norwegian Prescription Database (NorPD). Individual feedback reports will be sent all participating GPs during and one year after the intervention. Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention. Discussion Improvement of prescription patterns in medical practice is a challenging task. A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits, whereas inappropriate prescribing entails substantial costs, as well as undesirable consequences like development of antibiotic resistance. Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions, as well as reducing the amount of broad-spectrum antibiotics, with special emphasis on macrolides.
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Affiliation(s)
- Svein Gjelstad
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Arne Fetveit
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Jørund Straand
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Ingvild Dalen
- Institute of Basic Medical Sciences, Department of Biostatistics, University of Oslo, PO Box 1122 Blindern, 0317 Oslo, Norway
| | - Sture Rognstad
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
| | - Morten Lindbaek
- Department of General Practice and Community Medicine, University of Oslo, PO Box 1130 Blindern, 0317 Oslo, Norway
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273
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Abstract
Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be > or = 10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile-associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.
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Affiliation(s)
- Neil Fishman
- Department of Healthcare Epidemiology and Infection Control, Antimicrobial Management Program, University of Pennsylvania Health System, Philadelphia, PA 19104-4283, USA.
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274
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Weese JS. Investigation of antimicrobial use and the impact of antimicrobial use guidelines in a small animal veterinary teaching hospital: 1995-2004. J Am Vet Med Assoc 2006; 228:553-8. [PMID: 16478430 DOI: 10.2460/javma.228.4.553] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate patterns of antimicrobial use and the impact of antimicrobial use guidelines at a small animal veterinary teaching hospital. DESIGN Retrospective study. SAMPLE POPULATION All antimicrobial prescriptions for dogs and cats admitted to the hospital in 1995 through 2004. PROCEDURE Pharmacy records were reviewed, and antimicrobial prescriptions for all dogs and cats admitted during the study period were recorded. Amounts of individual drugs dispensed directly to the intensive care and surgical units were determined. Changes in antimicrobial use during the study period were assessed; changes in antimicrobial use patterns in 2000 through 2004 were evaluated to assess the impact of implementation of antimicrobial use guidelines in 2001. RESULTS There was a significant decrease in prescriptions/1,000 admissions during the study period. From 1995 to 2004, the use of first-generation cephalosporins, fluoroquinolones, penicillins, and trimethoprim-sulfonamides decreased, whereas the use of metronidazole increased. The use of first-generation cephalosporins, fluoroquinolones, and penicillins decreased from 2000 to 2004. First-line drugs accounted for 90.7% of prescriptions during the study period. The use of third-line drugs decreased from 2000 to 2004. CONCLUSIONS AND CLINICAL RELEVANCE Characterization of antimicrobial use is an important step in defining and evaluating the prudent use of antimicrobials. Whereas the true effect of antimicrobial use guidelines is unclear, these results suggest that the guidelines may have had an effect on antimicrobial prescription patterns in this small animal veterinary teaching hospital. Analysis of objective data regarding antimicrobial use and changes in antimicrobial use patterns over time is important in veterinary practices.
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Affiliation(s)
- J Scott Weese
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada
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275
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Abstract
Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be >/=10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile-associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.
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Affiliation(s)
- Neil Fishman
- Department of Healthcare Epidemiology and Infection Control, Antimicrobial Management Program, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104-4283, USA.
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276
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Salo H, Kilpi T, Sintonen H, Linna M, Peltola V, Heikkinen T. Cost-effectiveness of influenza vaccination of healthy children. Vaccine 2006; 24:4934-41. [PMID: 16678945 DOI: 10.1016/j.vaccine.2006.03.057] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Revised: 03/10/2006] [Accepted: 03/20/2006] [Indexed: 10/24/2022]
Abstract
Influenza vaccination of children 6-23 months of age is recommended in the United States and Canada because of high rates of influenza-associated hospitalisations, but few other countries have adopted similar policies. Most children with influenza are treated in the primary care setting, and the cost-effectiveness of influenza vaccination of children has not been fully established. We used a decision analysis model to assess the cost-effectiveness of influenza vaccination of children 6 months to 13 years of age in Finland. The analyses were based on comprehensive clinical data on virologically confirmed influenza infections, hospital medical records, and national registers. We estimated the impact of influenza on outpatient and hospitalised children and their families, and performed the analyses from the health care provider and societal perspective. Influenza vaccination resulted in savings in all programs including children <or=13 years of age from both the health care provider and societal perspective. Investing 1.7 million euros in vaccination of children <5 years of age yielded savings of 2.7 million euros in health care costs. From the health care provider perspective, the savings per vaccinated child ranged between 5.7 and 12.6 euros in any program including children up to 13 years of age. The vaccination was cost saving in all age groups even with assumed vaccine efficacy of 60%. The results show that influenza vaccination would be cost saving in all children <or=13 years of age in Finland, which advocates reconsideration of the current influenza vaccine recommendations in all countries.
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Affiliation(s)
- Heini Salo
- Department of Vaccines, National Public Health Institute, KTL, 00300 Helsinki, Finland
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277
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Abstract
During the past century the excitement of discovering antibiotics as a treatment of infectious diseases has given way to a sense of complacency and acceptance that when faced with antimicrobial resistance there will always be new and better antimicrobial agents to use. Now, with clear indications of a decline in pharmaceutical company interest in anti-infective research, at the same time when multi-drug resistant micro-organisms continue to be reported, it is very important to review the prudent use of the available agents to fight these micro-organisms. Injudicious use of antibiotics is a global problem with some countries more affected than others. There is no dearth of interest in this subject with scores of scholarly articles written about it. While over the counter access to antibiotics is mentioned as an important contributor towards injudicious antibiotic use in developing nations, as shown in a number of studies, there are many provider, practice and patient characteristics which drive antibiotic overuse in developed nations such as the United States. Recognizing that a thorough review of this subject goes far and beyond the page limitations of a review article we provide a summary of some of the salient aspects of this global problem with a focus towards readers practicing in developing nations.
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Affiliation(s)
- Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA.
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278
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Foglé-Ansson M, White P, Hermansson A, Melhus A. Otomicroscopic findings and systemic interleukin-6 levels in relation to etiologic agent during experimental acute otitis media. APMIS 2006; 114:285-91. [PMID: 16689828 DOI: 10.1111/j.1600-0463.2006.apm_297.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The aim of the present study was to explore whether it was possible to differentiate the clinical course and the otomicroscopic appearance of acute otitis media (AOM) caused by common otitis pathogens in an animal model. Systemic interleukin (IL)-6 levels as early markers for bacterial AOM were also studied. Four groups of rats were inoculated with either Streptococcus pneumoniae, Streptococcus pyogenes, non-typeable Haemophilus influenzae or Moraxella catarrhalis. The animals were monitored by otomicroscopy, photos of the tympanic membrane, cultures and IL-6 detection in serum the following 4 days. The gram-positive S. pneumoniae and S. pyogenes induced severe AOM with opaque effusion behind the tympanic membrane, pronounced dilation of the vessels and spontaneous perforations. The gram-negative H. influenzae and M. catarrhalis induced a less severe infection with cloudy, sometimes foamy effusion, and no spontaneous perforations. With the otomicroscopic findings it was possible to distinguish between infections induced by gram-positive bacteria and gram-negative bacteria. Detection of interleukin-6 in serum appeared to be of limited use for all infections except the pneumococcal AOM, but this needs to be further investigated.
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279
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Martinez FJ, Han MK, Flaherty K, Curtis J. Role of infection and antimicrobial therapy in acute exacerbations of chronic obstructive pulmonary disease. Expert Rev Anti Infect Ther 2006; 4:101-24. [PMID: 16441213 DOI: 10.1586/14787210.4.1.101] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Over the past several years, the significance of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in patients with chronic airflow obstruction has become increasingly apparent due to the impact these episodes have on the natural history of disease. It is now known that frequent AECOPD can adversely affect a patient's health-related quality of life and short- and long-term pulmonary function. The economic burden of these episodes is also substantial. AECOPDs represent a local and systemic inflammatory response to both infectious and noninfectious stimuli, but the majority of episodes are likely related to bacterial or viral pathogens. Patients with purulent sputum and multiple symptoms are the most likely to benefit from treatment with antibiotics. Antibiotic choice should be tailored to the individual patient, taking into account the severity of the episode and host factors which might increase the likelihood of treatment failure. Current evidence suggests that therapeutic goals not only include resolution of the acute episode, but also prolonging the time to the next event. In the future, preventing exacerbations will likely become increasingly accepted as an additional therapeutic goal in chronic obstructive pulmonary disease patients.
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Affiliation(s)
- Fernando J Martinez
- The University of Michigan Health System, 1500 East Medical Center Drive, 3916 Taubman Center, Box 0360, Ann Arbor, MI 48109, USA.
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280
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Alanis AJ. Resistance to antibiotics: are we in the post-antibiotic era? Arch Med Res 2006; 36:697-705. [PMID: 16216651 DOI: 10.1016/j.arcmed.2005.06.009] [Citation(s) in RCA: 750] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2005] [Accepted: 06/23/2005] [Indexed: 11/21/2022]
Abstract
Serious infections caused by bacteria that have become resistant to commonly used antibiotics have become a major global healthcare problem in the 21st century. They not only are more severe and require longer and more complex treatments, but they are also significantly more expensive to diagnose and to treat. Antibiotic resistance, initially a problem of the hospital setting associated with an increased number of hospital-acquired infections usually in critically ill and immunosuppressed patients, has now extended into the community causing severe infections difficult to diagnose and treat. The molecular mechanisms by which bacteria have become resistant to antibiotics are diverse and complex. Bacteria have developed resistance to all different classes of antibiotics discovered to date. The most frequent type of resistance is acquired and transmitted horizontally via the conjugation of a plasmid. In recent times new mechanisms of resistance have resulted in the simultaneous development of resistance to several antibiotic classes creating very dangerous multidrug-resistant (MDR) bacterial strains, some also known as "superbugs". The indiscriminate and inappropriate use of antibiotics in outpatient clinics, hospitalized patients and in the food industry is the single largest factor leading to antibiotic resistance. In recent years, the number of new antibiotics licensed for human use in different parts of the world has been lower than in the recent past. In addition, there has been less innovation in the field of antimicrobial discovery research and development. The pharmaceutical industry, large academic institutions or the government are not investing the necessary resources to produce the next generation of newer safe and effective antimicrobial drugs. In many cases, large pharmaceutical companies have terminated their anti-infective research programs altogether due to economic reasons. The potential negative consequences of all these events are relevant because they put society at risk for the spread of potentially serious MDR bacterial infections.
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Affiliation(s)
- Alfonso J Alanis
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285, USA.
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281
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Devasia RA, Varma JK, Whichard J, Gettner S, Cronquist AB, Hurd S, Segler S, Smith K, Hoefer D, Shiferaw B, Angulo FJ, Jones TF. Antimicrobial Use and Outcomes in Patients with Multidrug-Resistant and Pansusceptible Salmonella Newport Infections, 2002–2003. Microb Drug Resist 2005; 11:371-7. [PMID: 16359197 DOI: 10.1089/mdr.2005.11.371] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Multidrug-resistant Salmonella Newport with decreased susceptibility to ceftriaxone (MDR-AmpC) is becoming increasingly common in its food animal reservoirs and in humans. Few data exist on rates of antimicrobial use or differences in clinical outcomes in persons infected with MDR-AmpC or other Salmonella strains. We conducted a case-comparison analysis of data from a multistate population-based case-control study to identify antimicrobial treatment choices and differences in clinical outcomes in those infected with MDRAmpC compared to pansusceptible S. Newport. Of isolates from 215 laboratory-confirmed S. Newport cases, 54 (25%) were MDR-AmpC, 146 (68%) were pansusceptible, and 15 (7%) had other resistance patterns; 146 (68%) patients with S. Newport were treated with antimicrobial agents and 66 (33%) were hospitalized. Over two-thirds of cases at low-risk for serious complications received antimicrobial therapy, most commonly with fluoroquinolones, to which this strain was susceptible. There were no significant differences in symptoms, hospitalization, duration of illness, or other outcomes between the persons infected with MDR-AmpC and pansusceptible S. Newport. Although currently prevalent MDR-AmpC S. Newport strains remains susceptible to the antimicrobial most commonly prescribed for it, continued efforts to reduce unnecessary use of antimicrobial agents in food animals and humans are critical to prevent further development of resistance to quinolones and cephalosporins, which is likely to lead to substantial adverse outcomes.
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Affiliation(s)
- Rose A Devasia
- Tennessee Department of Health, Nashville, Tennessee, USA
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282
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Podolsky SH. The changing fate of pneumonia as a public health concern in 20th-century America and beyond. Am J Public Health 2005; 95:2144-54. [PMID: 16257952 PMCID: PMC1449499 DOI: 10.2105/ajph.2004.048397] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2004] [Indexed: 11/04/2022]
Abstract
For a brief period from the 1930s through the early 1940s, public health advocates made pneumonia a leading public health concern. Predicated on the need for antipneumococcal antiserum, but also incorporating physician reeducation, state "pneumonia control programs" were established nationwide. However, with the advent of penicillin and the sulfonamides, the pneumonia control programs soon collapsed. Pneumonia reverted to the domain of the private practitioner, which was devoid of state oversight. With the emergence of pneumococcal antibiotic resistance in the 1990s, the possibility again arose that pneumonia could become a public health concern, given the nationwide need to curb unnecessary antibiotic usage and to encourage vaccination. An understanding of the history of pneumonia's changing status could shed light on current attempts to reformulate the disease and elucidate the contested domains of private practice and public health.
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Affiliation(s)
- Scott H Podolsky
- Massachusetts General Hospital, Department of Social Medicine, Harvard Medical School, Boston, MA 02114, USA.
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283
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Llor C, Hernández Anadón S, Calviño Domínguez O, Moragas Moreno A. [Delayed prescription of antibiotics in Spain]. Med Clin (Barc) 2005; 125:76. [PMID: 15970190 DOI: 10.1157/13076465] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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284
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Huang N, Morlock L, Lee CH, Chen LS, Chou YJ. Antibiotic prescribing for children with nasopharyngitis (common colds), upper respiratory infections, and bronchitis who have health-professional parents. Pediatrics 2005; 116:826-32. [PMID: 16199689 DOI: 10.1542/peds.2004-2800] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Antibiotic resistance might be reduced if patients could be better informed regarding the lack of benefits of antibiotics for children with viral infections and avoid antibiotic prescriptions in these circumstances. This study investigated whether children having health professionals as parents, a group whose parents are expected to have more medical knowledge and expertise, are less likely than other children to receive antibiotics for nasopharyngitis (common colds), upper respiratory tract infections (URIs), and acute bronchitis. METHODS Retrospective analyses were conducted by using National Health Insurance data for children of physicians, nurses, pharmacists, and non-health personnel, who had visited hospital outpatient departments or physician clinics for common colds, URIs, and acute bronchitis in Taiwan in 2000. A total of 53733 episodes of care for common colds, URIs, and acute bronchitis in a nationally representative sample of children (aged < or =18 years) living in nonremote areas were analyzed. RESULTS The study found that, after adjusting for characteristics of the children (demographic, socioeconomic, and health status) and the treating physicians (demographic, practice style, and setting), children with a physician (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.36-0.68) or a pharmacist (OR: 0.69; 95% CI: 0.52-0.91) as a parent were significantly less likely than other children to receive antibiotic prescriptions. The likelihood of receiving an antibiotic for the children of nurses (OR: 0.91; 95% CI: 0.77-1.09) was similar to that for children in the comparison group. CONCLUSIONS This finding supports our hypothesis that better parental education does help to reduce the frequency of injudicious antibiotic prescribing. Medical knowledge alone, however, may not fully reduce the overuse of antibiotics. Physician-parents, the expected medically savvy parents, can serve as a benchmark for the improvement potentially achievable in Taiwan through a combination of educational, regulatory, communication, and policy efforts targeted at more appropriate antibiotic prescribing in ambulatory settings.
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Affiliation(s)
- Nicole Huang
- School of Medicine, National Yang Ming University, Taipei, Taiwan
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285
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Domej W, Flögel E, Tilz GP, Demel U. Sinn und Unsinn der Antibiotikatherapie respiratorischer Infekte. Internist (Berl) 2005; 46:795-9. [PMID: 15815891 DOI: 10.1007/s00108-005-1397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Whether an antibiotic successfully eradicates pathogens depends on the pathogens involved, on pharmacokinetics and bioavailability in the target tissue, and on the antimicrobial resistance of the pathogen. Other determinants are drug interactions, individual risk factors, age and compliance with respect to correct dosage and duration of therapy. In many cases, antimicrobial therapy is begun on an empirical basis, because the responsible pathogen can be identified in only half of all respiratory infections. The eradication of the pathogen has to be the first aim if treatment is to be curative and the development of resistance prevented. Long-term prevention of antimicrobial resistance will require a more critical prospective evaluation of the prescription of antibiotics. This paper considers rational and irrational measures in the antimicrobial therapy of respiratory infections.
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Affiliation(s)
- W Domej
- Klinische Abteilung für Pulmonologie, Medizinische Universitätsklinik Graz, Osterreich.
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286
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Grossman RF, Rotschafer JC, Tan JS. Antimicrobial treatment of lower respiratory tract infections in the hospital setting. Am J Med 2005; 118 Suppl 7A:29S-38S. [PMID: 15993675 DOI: 10.1016/j.amjmed.2005.05.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Respiratory tract infections (RTIs) that may require hospitalization include acute exacerbations of chronic bronchitis (AECB), community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP), which includes ventilator-associated pneumonia (VAP). Healthcare-associated pneumonia (HCAP) is treated similar to HAP and may be considered with HAP. For CAP requiring hospitalization, the current guidelines for the treatments of RTIs generally recommend either a beta-lactam and macrolide combination or a fluoroquinolone. The respiratory fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin, and gemifloxacin) are excellent antibiotics due to high levels of susceptibility among gram-negative, gram-positive, and atypical pathogens. The fluoroquinolones are active against > 98% of Streptococcus pneumoniae, including penicillin-resistant strains. Fluoroquinolones are also recommended for AECB requiring hospitalization. Evidence from clinical trials suggests that levofloxacin monotherapy is as efficacious as combination ceftriaxone-erythromycin therapy in the treatment of patients hospitalized with CAP. For early-onset HAP, VAP, and HCAP without the risk of multidrug resistance, ceftriaxone, ampicillin-sulbactam, ertapenem, or one of the fluoroquinolones is recommended. High-dose, short-course therapy regimens may offer improved treatment due to higher drug concentrations, more rapid killing, increased adherence, and the potential to reduce development of resistance. Recent studies have shown that short-course therapy with levofloxacin, azithromycin, or telithromycin in patients with CAP was effective, safe, and tolerable and may control the rate of resistance.
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287
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Slama TG, Amin A, Brunton SA, File TM, Milkovich G, Rodvold KA, Sahm DF, Varon J, Weiland D. A clinician's guide to the appropriate and accurate use of antibiotics: the Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria. Am J Med 2005; 118 Suppl 7A:1S-6S. [PMID: 15993671 DOI: 10.1016/j.amjmed.2005.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In response to the overuse and misuse of antibiotics, leading to increasing bacterial resistance and decreasing development of new antibiotics, the Council for Appropriate and Rational Antibiotic Therapy (CARAT) has developed criteria to guide appropriate and accurate antibiotic selection. The criteria, which are aimed at optimizing antibiotic therapy, include evidence-based results, therapeutic benefits, safety, optimal drug for the optimal duration, and cost-effectiveness.
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Affiliation(s)
- Thomas G Slama
- Department of Infectious Diseases, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA
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288
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Huang B, Martin SJ, Bachmann KA, He X, Reese JH, Wei Y, Iwuagwu C. A nationwide survey of physician office visits found that inappropriate antibiotic prescriptions were issued for bacterial respiratory tract infections in ambulatory patients. J Clin Epidemiol 2005; 58:414-20. [PMID: 15862728 DOI: 10.1016/j.jclinepi.2004.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2003] [Revised: 09/11/2004] [Accepted: 09/19/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Correlations between probabilities of resistance and the frequencies with which antibiotics were prescribed for treating bacterial respiratory infections were examined in a nationwide ambulatory population. STUDY DESIGN AND SETTING The data of a nationwide probability sample survey of visits to physician offices in the United States in 1999 were used to conduct this study of drug use. A clinical pharmacologist identified antibiotics prescribed during those visits using a large online database. The participating physicians diagnosed the bacterial respiratory infections. An infectious disease expert determined the probabilities of bacterial resistance from a nationwide antibiotic surveillance database. RESULTS Various bacterial respiratory infections were diagnosed during 6.5% of physician office visits in 1999. One or more antibiotics were prescribed during 51.0% of those visits. The probabilities of resistance to the most frequently prescribed antibiotics varied from 20% to 40% and showed a weak positive correlation with the frequencies of antibiotic prescriptions. CONCLUSION A significant number of inappropriate antibiotic prescriptions were issued for infections with a high probability of bacterial resistance to the prescribed antibiotics.
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Affiliation(s)
- Boji Huang
- Department of Health Evaluation Sciences, Penn State College of Medicine, 600 Centerview Drive, Hershey, PA 17022-0855, USA.
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289
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Kiang KM, Kieke BA, Como-Sabetti K, Lynfield R, Besser RE, Belongia EA. Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug use. Emerg Infect Dis 2005; 11:904-11. [PMID: 15963286 PMCID: PMC3367606 DOI: 10.3201/eid1106.050144] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In 1999, Wisconsin initiated an educational campaign for primary care clinicians and the public to promote judicious antimicrobial drug use. We evaluated its impact on clinician knowledge and beliefs; Minnesota served as a control state. Results of pre- (1999) and post- (2002) campaign questionnaires indicated that Wisconsin clinicians perceived a significant decline in the proportion of patients requesting antimicrobial drugs (50% in 1999 to 30% in 2002; p<0.001) and in antimicrobial drug requests from parents for children (25% in 1999 to 20% in 2002; p = 0.004). Wisconsin clinicians were less influenced by nonpredictive clinical findings (purulent nasal discharge [p = 0.044], productive cough [p = 0.010]) in terms of antimicrobial drug prescribing. In 2002, clinicians from both states were less likely to recommend antimicrobial agent treatment for the adult case scenarios of viral respiratory illness. For the comparable pediatric case scenarios, only Wisconsin clinicians improved significantly from 1999 to 2002. Although clinicians in both states improved on several survey responses, greater overall improvement occurred in Wisconsin.
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Affiliation(s)
- Karen M Kiang
- Minnesota Department of Health, Minneapolis, Minnesota, USA
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290
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Chodosh S. Clinical Significance of the Infection-FreeInterval in the Management of Acute Bacterial Exacerbations of Chronic Bronchitis. Chest 2005; 127:2231-6. [PMID: 15947342 DOI: 10.1378/chest.127.6.2231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Rational and appropriate antibiotic use for patients with acute exacerbation of chronic bronchitis (AECB) is a major concern, as approximately half of these patients do not have a bacterial infection. Typically, the result of antimicrobial therapy for patients with acute bacterial exacerbation of chronic bronchitis (ABECB) is not eradication of the pathogen but resolution of the acute symptoms. However, the length of time before the next bacterial exacerbation can be another important variable, as the frequency of exacerbations will affect the overall health of the patient and the rate of lung deterioration over time. Clinical trials comparing antimicrobial therapies commonly measure resolution of symptoms in AECB patients as the primary end point, regardless of whether the exacerbation is documented as bacterial in nature. Ideally, the scientific approach to assessing the efficacy of antibiotic therapy for ABECB should include a measurement of acute bacterial eradication rates in patients with documented bronchial bacterial infection followed by measurement of the infection-free interval (IFI), ie, the time to the next ABECB. The use of these variables can provide a standard for comparing various antimicrobial therapies. As we learn more about how antibiotics can affect the IFI, treatment decisions should be adapted to ensure optimal management of ABECB for the long-term.
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291
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Gonzales R, Corbett KK, Leeman-Castillo BA, Glazner J, Erbacher K, Darr CA, Wong S, Maselli JH, Sauaia A, Kafadar K. The "minimizing antibiotic resistance in Colorado" project: impact of patient education in improving antibiotic use in private office practices. Health Serv Res 2005; 40:101-16. [PMID: 15663704 PMCID: PMC1361128 DOI: 10.1111/j.1475-6773.2005.00344.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practices. DATA SOURCES/STUDY SETTING Antibiotic prescription rates based on claims data from four managed care organizations in Colorado during baseline (winter 2000) and study (winter 2001) periods. STUDY DESIGN A nonrandomized controlled trial of a household and office-based patient educational intervention was performed. During both periods, Colorado physicians were mailed antibiotic prescribing profiles and practices guidelines as part of an ongoing quality improvement program. Intervention practices (n=7) were compared with local and distant control practices. DATA COLLECTION/EXTRACTION METHODS Office visits were extracted by managed care organizations using International Classification of Diseases-9-Clinical Modification codes for acute respiratory tract infections, and merged with pharmacy claims data based on visit and dispensing dates coinciding within 2 days. PRINCIPAL FINDINGS Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practices, and decreased from 39 to 37 percent at the local control practices, and from 34 to 30 percent at the intervention practices (p=.18 compared with distant control practices). Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practices, from 55 to 45 percent at the local control practices, and from 60 to 36 percent at the intervention practices (p<.002 and p=.006 compared with distant and local control practices, respectively). CONCLUSIONS In office practices, there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis. In contrast, patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts.
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Affiliation(s)
- Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA 94118, USA
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292
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Stivers T. Non-antibiotic treatment recommendations: delivery formats and implications for parent resistance. Soc Sci Med 2005; 60:949-64. [PMID: 15589666 DOI: 10.1016/j.socscimed.2004.06.040] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study draws on a database of 570 community-based acute pediatric encounters in the USA and uses conversation analysis as a methodology to identify two formats physicians use to recommend non-antibiotic treatment in acute pediatric care (using a subset of 309 cases): recommendations for particular treatment (e.g., "I'm gonna give her some cough medicine.") and recommendations against particular treatment (e.g., "She doesn't need any antibiotics."). The findings are that the presentation of a specific affirmative recommendation for treatment is less likely to engender parent resistance to a non-antibiotic treatment recommendation than a recommendation against particular treatment even if the physician later offers a recommendation for particular treatment. It is suggested that physicians who provide a specific positive treatment recommendation followed by a negative recommendation are most likely to attain parent alignment and acceptance when recommending a non-antibiotic treatment for a viral upper respiratory illness.
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Affiliation(s)
- Tanya Stivers
- Max Planck Institute for Psycholinguistics, Language and Cognition Group, PB 310, 6500 AH Nijmegen, The Netherlands.
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293
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Gaur AH, Hare ME, Shorr RI. Provider and practice characteristics associated with antibiotic use in children with presumed viral respiratory tract infections. Pediatrics 2005; 115:635-41. [PMID: 15741365 DOI: 10.1542/peds.2004-0670] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although overuse of antibiotics in children has been well documented, relatively little information is known about provider and facility characteristics associated with this prescribing practice. This study was done to evaluate the differences in overuse of antibiotics among staff physicians and resident/interns (housestaff [HS]) who work in hospital-based outpatient clinics. METHODS This cross-sectional study involved patient encounters in outpatient departments that were included in the US National Hospital Ambulatory Medical Care Survey database from 1995 to 2000. Encounters with patients who were aged <18 years and had a primary diagnosis suggestive of viral respiratory tract infection were evaluated. Patients with comorbid conditions that might justify antibiotic use were excluded. RESULTS This study included 1952 patient encounters with a primary diagnosis suggestive of a viral infection and 33.2% of these patients receiving antibiotics. Overall, antibiotic use was significantly less among HS (19.5%) than staff physicians (36.4%; odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.33-0.59). This difference between HS (19.5%) and staff physicians (32.5%) persisted even within teaching hospitals (OR: 0.5; 95% CI: 0.4-0.7). Among staff physicians, antibiotic use was greater among those who work in nonteaching (39.6%) compared with teaching hospitals (32.5%; OR: 1.51; 95%: CI 1.15-1.98). Controlling for other patient and provider variables, antibiotic use occurred less among HS than among staff physicians in teaching hospitals (OR: 0.53; 95% CI: 0.38-0.75). CONCLUSIONS Antibiotic prescribing in the context of an outpatient visit for a diagnosis suggestive of a viral respiratory tract illness occurs more commonly among staff physicians than trainees and among staff physicians more commonly in nonteaching compared with teaching institutions.
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Affiliation(s)
- Aditya H Gaur
- Department of Infectious Diseases, St Jude Children's Research Hospital, 332 N Lauderdale St, Memphis, TN 38105-2794, USA.
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294
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Abstract
Acute respiratory infections (ARIs) are the most common infections in humans, accounting for half of all acute conditions each year in the United States. Acute bronchitis episodes represent a significant portion of these illnesses. This article focuses on acute bronchitis in otherwise healthy individuals.
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295
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Abstract
BACKGROUND Acute laryngitis is a common illness worldwide. Diagnosis is often made by case history alone and treatment is often directed towards controlling symptoms. OBJECTIVES The aim of this review was to assess the effectiveness of different antibiotic therapies in adults suffering acute laryngitis. A secondary objective was to report the rates of adverse events associated with these treatments. SEARCH STRATEGY We systematically screened the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2004); MEDLINE (January 1966 to June Week 3 2004); and EMBASE (1974 to June 2004), LILACS (from 1982 to the 40th edition) and BIOSIS (1980 to June 2002). Other strategies included hand searching relevant journals, searching ongoing trial databases and general databases such as Alta Vista. SELECTION CRITERIA Randomized controlled trials comparing any antibiotic therapy with placebo in acute laryngitis. The main outcome measurement was objective voice scores. DATA COLLECTION AND ANALYSIS Data were independently extracted by two people and then descriptively synthesised. MAIN RESULTS Only two trials met study inclusion criteria after extensive literature searches. One hundred patients were randomly selected to receive either penicillin V (800 mg twice a day for five days), or an identical placebo, in a study of penicillin V in acute laryngitis in adults. A tape recording of each patient reading a standardised text was obtained during the first visit, subsequently during re-examination after one and two weeks, and at follow up after two to six months. No significant differences were found between the groups. The trial also measured symptoms reported by patients and found no significant differences. The second trial investigated erythromycin for treating acute laryngitis in 106 adults. The mean objective voice scores measured at the first visit, at re-examination after one and two weeks, and at follow up after two to six months did not significantly differ between control and intervention groups. At one week there were significant beneficial differences in the severity of reported vocal symptoms as judged by the patients (p = 0.042). Comparing the erythromycin and placebo groups on subjective voice scores the a priori relative risk (RR) was 0.7 (95% confidence interval (CI) 0.51 to 0.96, p = 0.034) and the number needed to treat (NNT) was 4.5. AUTHORS' CONCLUSIONS Antibiotics appear to have no benefit in treating acute laryngitis. Erythromycin could reduce voice disturbance at one week and cough at two weeks when measured subjectively. We consider that these outcomes are not relevant in clinical practice. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.
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Affiliation(s)
- L Reveiz
- Department of General Practice, Clinica Reina Sofía, Diagonal 127 A # 31 - 48 Cons 221, Bogota, Colombia.
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296
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Stivers T. Parent resistance to physicians' treatment recommendations: one resource for initiating a negotiation of the treatment decision. HEALTH COMMUNICATION 2005; 18:41-74. [PMID: 15918790 DOI: 10.1207/s15327027hc1801_3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This article examines pediatrician-parent interaction in the context of acute pediatric encounters for children with upper respiratory infections. Parents and physicians orient to treatment recommendations as normatively requiring parent acceptance for physicians to close the activity. Through acceptance, withholding of acceptance, or active resistance, parents have resources with which to negotiate for a treatment outcome that is in line with their own wants. This article offers evidence that even in acute care, shared decision making not only occurs but, through normative constraints, is mandated for parents and physicians to reach accord in the treatment decision.
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Affiliation(s)
- Tanya Stivers
- Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands.
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297
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Pontes MCF, Pontes NMH. Debiasing Effects of Education About Appropriate Antibiotic Use on Consumers' Preferences for Physicians. Health Care Manage Rev 2005; 30:9-16. [PMID: 15773249 DOI: 10.1097/00004010-200501000-00003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A major goal of this research was to identify an antibiotic education intervention that would increase young adult consumers' preference for physicians who do not unnecessarily prescribe antibiotics for simple acute upper respiratory infections (URIs). Results clearly showed that consumers who read the CDC brochure entitled, "A New Threat to Your Health: Antibiotic Resistance" significantly preferred the physician who would not prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability than the physician who would prescribe antibiotics. In contrast, consumers who did not read the CDC brochure significantly preferred the physician who would prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability and greater concern for patients than the physician who would not prescribe antibiotics. Thus, consumers with low knowledge exhibited a treatment bias and preferred physicians who provided more treatment, and consumer education successfully reversed the treatment bias.
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Affiliation(s)
- Manuel C F Pontes
- Department of Marketing, Rowan University, Glassboro, New Jersey, USA.
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298
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Paskovaty A, Pflomm JM, Myke N, Seo SK. A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. Int J Antimicrob Agents 2005; 25:1-10. [PMID: 15620820 DOI: 10.1016/j.ijantimicag.2004.09.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the 21st century, we face the problems of escalating antibiotic resistance, difficult-to-treat infections and slowed new drug development. Healthcare practitioners are increasingly recognising the importance of good antimicrobial stewardship. Various strategies such as formulary management, prior approval, clinical pathways, post-prescribing evaluation and intravenous to oral conversion have been used singly or in combination to improve prescribing and reduce costs. Combining a multifaceted approach with a full-time dedicated multidisciplinary team appears to be capable of yielding satisfactory clinical and economic outcomes and most importantly, sustaining efforts of antimicrobial stewardship. The multidisciplinary approach to antibiotic management should be tailored to fit the individual needs of an institution. More data are needed to document effects on curbing resistance.
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Affiliation(s)
- A Paskovaty
- Department of Pharmacy, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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299
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Ciesla G, Leader S, Stoddard J. Antibiotic prescribing rates in the US ambulatory care setting for patients diagnosed with influenza, 1997-2001. Respir Med 2004; 98:1093-101. [PMID: 15526810 DOI: 10.1016/j.rmed.2004.03.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To document the rate and cost of antibiotic prescribing for patients diagnosed only with influenza during US ambulatory care visits. Federal survey data for 1997-2001 were used to estimate outpatient trends for all patients and healthy people age 5-49 years. Cost estimates were based on Medicare payments and Red Book average wholesale prices in 2003. Antibiotic prescribing for influenza is widespread; 38% of visits led to an antibiotic prescription of which one-third were for broad spectrum antibiotics. Inappropriate antibiotics cost dollar 18.5 million annually and may contribute to resistance. Increased vaccination rates and viral testing could reduce these trends.
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Affiliation(s)
- Gabrielle Ciesla
- MedImmune, Inc., One MedImmune Way, Gaithersburg, MD 20878, USA.
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300
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Ho M, Hsiung CA, Yu HT, Chi CL, Chang HJ. Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan. Int J Antimicrob Agents 2004; 23:438-45. [PMID: 15120720 DOI: 10.1016/j.ijantimicag.2003.10.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2003] [Accepted: 10/31/2003] [Indexed: 11/18/2022]
Abstract
The Bureau of National Health Insurance (BNHI) of Taiwan issued a new reimbursement regulation effective from 1 February 2001 forbidding the use of antimicrobials in ambulatory patients with upper respiratory infections (URI) without evidence of bacterial infection. We evaluated the effect of this regulation by analysing changes in the types of infections diagnosed and the amount of antibiotics prescribed in 1999, 2000 and 2001. Between 1999 and 2001, antimicrobials for respiratory infections decreased from 18.0 to 9.97 DDD/1000 per day or by 44.6% (P=0.0000+). Antimicrobials for URI decreased from 8.32 in 1999 to 3.28 DDD/1000 per day in 2001 or by 60.6% (P=0.0000+); from 2000 to 2001 the decrease was 55.8%. Reduction of antimicrobials for URI from 1999 to 2001 accounted for 62.8% of the reduction of antimicrobials in respiratory infections or 51.3% of the total reduction of antimicrobials. Reduction in aminopenicillins was responsible for most of the decrease.
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Affiliation(s)
- Monto Ho
- National Health Research Institutes, 128 Yen-Chiu-Yuan Road Sec. 2, Taipei 11529, Taiwan, ROC
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