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Dillen H, Wouters J, Snijders D, Wynants L, Verbakel JY. Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis. J Antimicrob Chemother 2024; 79:498-511. [PMID: 38113395 PMCID: PMC10904728 DOI: 10.1093/jac/dkad383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship. OBJECTIVES To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries. METHODS On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed. RESULTS We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible. CONCLUSIONS Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.
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Affiliation(s)
- Hannelore Dillen
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
| | - Jo Wouters
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Daniëlle Snijders
- Faculty of Medicine, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Laure Wynants
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, 1 Peter Debyeplein, Maastricht, 6229 HA, The Netherlands
- Department of Development and Regeneration, KU Leuven, 49 Herestraat, Leuven, 3000, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, 7 Kapucijnenvoer, Leuven, 3000, Belgium
- NIHR Community Healthcare MedTech and IVD cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
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2
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Thänert R, Sawhney SS, Schwartz DJ, Dantas G. The resistance within: Antibiotic disruption of the gut microbiome and resistome dynamics in infancy. Cell Host Microbe 2022; 30:675-683. [PMID: 35550670 PMCID: PMC9173668 DOI: 10.1016/j.chom.2022.03.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/28/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Abstract
Intestinal host-microbiota interactions during the first year of life are critical for infant development. Early-life antibiotic exposures disrupt stereotypical gut microbiota maturation and adversely affect childhood health. Furthermore, antibiotics increase the abundance of resistant bacteria and enrich the resistome-the compendium of antibiotic resistance genes-within the gut microbiota. Here, we discuss acute and persistent impacts of antibiotic exposure during infancy on pediatric health, the gut microbiome, and, particularly, the resistome. Reviewing our current understanding of antibiotic resistance acquisition and dissemination within and between microbiomes, we highlight open questions, which are imperative to resolve in the face of rising bacterial resistance.
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Affiliation(s)
- Robert Thänert
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sanjam S Sawhney
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Drew J Schwartz
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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3
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Soares N, Mitchell R, McGoff T, Bailey T, Wellman GS. Taste Perceptions of Common Pediatric Antibiotic Suspensions and Associated Prescribing Patterns in Medical Residents. J Pediatr Pharmacol Ther 2022; 27:316-323. [DOI: 10.5863/1551-6776-27.4.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Palatability of medication is an important factor for adherence, especially in pediatric populations that tend to use oral suspensions for antibiotic therapy. Our study is the first to evaluate the impact of taste on prescribing patterns of antibiotic suspensions. The objective was to determine if taste testing common antibiotic suspensions altered prescribing patterns of medical residents, through data extracted from the electronic health record.
METHODS
After assessing 5 “primer” tastes (sweet, salty, bitter, sour, umami [savory]), residents were randomized to sample 6 antibiotic suspensions to rate their taste perception. A 12-month retrospective and prospective analysis of outpatient prescribing practices of the residents followed, and the results were compared to the resident cohort randomized to no taste test.
RESULTS
The 43 residents prescribed 207 liquid antibiotic prescriptions for 176 patients, with no difference in patient characteristics between residents in the taste test versus non–taste test group. Although amoxicillin was most preferable and amoxicillin-clavulanate least, the only significant finding was a greater prescribing rate of cefdinir among those who had tasted it and an inverse relationship between cephalexin taste preference and percentage prescribing amoxicillin in the taste group. Residents who tasted were poor in identifying primer tastes, but this did not impact prescribing patterns.
CONCLUSIONS
Among 6 commonly prescribed antibiotic suspensions, amoxicillin remains a highly preferred taste among prescribers. Interestingly, after the taste test there was a significantly greater prescribing rate of cefdinir among those who had tasted it and somewhat lower prescribing rate for amoxicillin-clavulanate.
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Affiliation(s)
- Neelkamal Soares
- Department of Pediatric and Adolescent Medicine (NS), Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Rachel Mitchell
- Ferris State University College of Pharmacy (RM, TB, GSW), Big Rapids, MI
| | - Theresa McGoff
- Department of Biomedical Informatics (TM), Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Teresa Bailey
- Ferris State University College of Pharmacy (RM, TB, GSW), Big Rapids, MI
| | - Gregory S. Wellman
- Ferris State University College of Pharmacy (RM, TB, GSW), Big Rapids, MI
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Pickering AN, Walter EL, Dawdani A, Decker A, Hamm ME, Gellad WF, Radomski TR. Primary care physicians' approaches to low-value prescribing in older adults: a qualitative study. BMC Geriatr 2022; 22:152. [PMID: 35209856 PMCID: PMC8867785 DOI: 10.1186/s12877-022-02829-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Low-value prescribing may result in adverse patient outcomes and increased medical expenditures. Clinicians’ baseline strategies for navigating patient encounters involving low-value prescribing remain poorly understood, making it challenging to develop acceptable deprescribing interventions. Our objective was to characterize primary care physicians’ (PCPs) approaches to reduce low-value prescribing in older adults through qualitative analysis of clinical scenarios. Methods As part of an overarching qualitative study on low-value prescribing, we presented two clinical scenarios involving potential low-value prescribing during semi-structured interviews of 16 academic and community PCPs from general internal medicine, family medicine and geriatrics who care for patients aged greater than or equal to 65. We conducted a qualitative analysis of their responses to identify salient themes related to their approaches to prescribing, deprescribing, and meeting patients’ expectations surrounding low-value prescribing. Results We identified three key themes. First, when deprescribing, PCPs were motivated by their desire to mitigate patient harms and follow medication safety and deprescribing guidelines. Second, PCPs emphasized good communication with patients when navigating patient encounters related to low-value prescribing; and third, while physicians emphasized the importance of shared decision-making, they prioritized patients’ well-being over satisfying their expectations. Conclusions When presented with real-life clinical scenarios, PCPs in our cohort sought to reduce low-value prescribing in a guideline-concordant fashion while maintaining good communication with their patients. This was driven primarily by a desire to minimize the potential for harm. This suggests that barriers other than clinician knowledge may be driving ongoing use of low-value medications in clinical practice.
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Affiliation(s)
- Aimee N Pickering
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Center for Research on Healthcare, 3609 Forbes Avenue, 2nd Floor, Pittsburgh, PA, 15213, USA.
| | - Eric L Walter
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alicia Dawdani
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Decker
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Megan E Hamm
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas R Radomski
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Center for Pharmaceutical Policy and Prescribing, Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Beilfuss S, Linde S, Norton B. Accountable care organizations and physician antibiotic prescribing behavior. Soc Sci Med 2022; 294:114707. [PMID: 35030393 DOI: 10.1016/j.socscimed.2022.114707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 12/30/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Physician accountable care organization (ACO) affiliation has been found to reduce cost and improve quality across metrics that are directly measured by the Medicare ACO programs. However, little is known about potential spillover effects from this program onto non-measured physician behavior such as antibiotic prescribing. METHODS Using a two-part structural selection model that accounts for selection into treatment (ACO group), and non-treatment (control group), we compare physician antibiotic prescribing across these groups with adjustment for volume, patient, physician and institutional characteristics. We also estimate heterogeneous treatment responses across specialties, focusing on physicians with a primary specialty of internal medicine, family or general practice, nurse practitioners, as well as general and orthopedic surgeons. RESULTS We find that ACO affiliation helps reduce antibiotic prescribing by 20.4 (95%CI = -26.65 to -14.16, p-value<0.001) prescriptions (about 19.5%) per year. We show that each additional hospital and practice affiliation increases prescriptions by 1.6 (95%CI = 1.27 to 1.95, p-value<0.001) and 1.7 (95%CI = 1.00 to 2.47, p-value<0.001), respectively. However, the use of electronic health records and high-quality medical training is associated with a decrease in antibiotic use of 7.9 (95%CI = -8.79 to -7.07, p-value<0.001) and 3.6 (95%CI = -4.47 to -2.73, p-value<0.001) claims, respectively. The treatment effects are found to vary with specialty, where internal medicine physicians experience an average decrease of 23.6 (95%CI = -29.98 to -17.20, p-value<0.001), family and general practice physicians a decrease of 22.1 (95%CI = -28.37 to -15.77, p-value<0.001), nurse practitioners a decrease of 7.1 (95%CI = -13.99 to -0.77, p-value = 0.028), general surgeons a decrease of 9.6 (95%CI = -16.02 to -3.25, p-value = 0.003), and orthopedic surgeons a reduction of 8.1 (95%CI = -14.84 to -1.42, p-value = 0.018) in their antibiotic prescribing per year. CONCLUSIONS In assessing the impact of Medicare ACO programs it is important to account for spillover effects. Our study finds that ACO affiliation has had a measurable impact on physician antibiotic prescribing.
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Affiliation(s)
- Svetlana Beilfuss
- Eastern Michigan University, Department of Economics, Address: 703 Pray, Harrold, Ypsilanti, MI, 48197, USA.
| | - Sebastian Linde
- Medical College of Wisconsin, Department of Medicine, Division of General Internal Medicine, Address: 9200 West Wisconsin Avenue, Milwaukee, WI, 53226, United States; Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Brandon Norton
- Purdue University, Department of Economics, Krannert School of Management, Address: 403 West State Street, West Lafayette, IN, 47907-2056, United States.
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Increasing Adherence to Acute Otitis Media Treatment Duration Guidelines using a Quality Improvement Approach. Pediatr Qual Saf 2021; 6:e501. [PMID: 34934881 PMCID: PMC8677959 DOI: 10.1097/pq9.0000000000000501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022] Open
Abstract
This quality improvement initiative aimed to improve American Academy of Pediatrics acute otitis media (AOM) guideline adherence in pediatric urgent care sites by increasing the percentage of patients 2 years and older with AOM who received a short duration (7 days or fewer) of antibiotics from a baseline of 7% to a goal of 50%. METHODS This quality improvement initiative was conducted in a network of seven urgent care sites affiliated with a large academic children's hospital. The interventions focused on clinician and family education, clinical decision support, and a discharge template that defaulted to a 7-day duration of antibiotics for patients 2 years and older diagnosed with AOM. The outcome measure was the percentage of patients receiving 7 days or fewer of antibiotics. The process measure was the percentage of prescriptions originating from the new discharge template. A repeat visit for AOM within 30 days from the initial visit was the balancing measure. RESULTS The percentage of patients diagnosed with AOM receiving a short antibiotic course increased from a baseline of 7% to a new centerline mean of 67%, which exceeded the goal. This project resulted in 10,138 antibiotic days being avoided. Eighty-two percent of short-course prescriptions originated from the discharge template. Repeat visits for AOM within 1 month of the initial visit did not increase. CONCLUSIONS A quality improvement initiative combining education and clinical decision support improved adherence to AOM treatment duration guidelines and avoided unnecessary antibiotic exposure in a pediatric urgent care network without increasing treatment failures.
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Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid. Infect Control Hosp Epidemiol 2021; 43:582-588. [PMID: 33975663 DOI: 10.1017/ice.2021.177] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe risk factors associated with inappropriate antibiotic prescribing to children. DESIGN Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. PARTICIPANTS Population-based sample of pediatric Medicaid patients and providers. METHODS Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. RESULTS Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07-1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1-4.2), age 0-2 years (OR, 1.39; 95% CI, 1.37-1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28-1.33). CONCLUSIONS Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.
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Norlin C, Fleming-Dutra K, Mapp J, Monti J, Shaw A, Bartoces M, Barger K, Emmer S, Dolins JC. A Learning Collaborative to Improve Antibiotic Prescribing in Primary Care Pediatric Practices. Clin Pediatr (Phila) 2021; 60:230-240. [PMID: 33764189 PMCID: PMC9357460 DOI: 10.1177/00099228211001623] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An American Academy of Pediatrics State Chapter organized a 6-month, mostly online quality improvement learning collaborative to improve antibiotic prescribing and patient education for upper respiratory infection (URI) and acute otitis media (AOM). Practices submitted data on quality measures at baseline, monthly, and 4 months post-project. Fifty-three clinicians from 6 independent, private primary care pediatric practices participated. Use of first-line antibiotics for AOM increased from 63.5% at baseline to 80.4% 4 months post-project. Use of safety-net antibiotic prescriptions (SNAP) for AOM increased from 4.5% to 16.9%. Educating patients about management for URI increased from 66.1% to 88.0% and for AOM from 20.4% to 85.6%. Practices maintained high performance for not prescribing antibiotics for URI (94.4% to 96.2%). Leveraging local relationships and national resources, this replicable antibiotic stewardship project engaged independent private practices to improve patient education for URI and AOM and prescribing and use of SNAP for AOM.
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Affiliation(s)
- Chuck Norlin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Katherine Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeff Mapp
- Pediatric Associates of Richmond, Richmond, VA
| | - Jennifer Monti
- Division of Chapter Quality Improvement Initiatives, American Academy of Pediatrics, Itasca, IL
| | - Allison Shaw
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL
| | - Monina Bartoces
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Suzanne Emmer
- Division of Chapter Quality Improvement Initiatives, American Academy of Pediatrics, Itasca, IL
| | - Judith C. Dolins
- Community & Chapter Affairs and Quality Improvement, American Academy of Pediatrics
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