1
|
Erba L, Furlan L, Monti A, Marsala E, Cernuschi G, Solbiati M, Bracco C, Bandini G, Pecorino Meli M, Casazza G, Montano N, Sbrojavacca R, Costantino G. Short vs long-course antibiotic therapy in pyelonephritis: a comparison of systematic reviews and guidelines for the SIMI choosing wisely campaign. Intern Emerg Med 2021; 16:313-323. [PMID: 32566969 DOI: 10.1007/s11739-020-02401-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies. MATERIALS AND METHODS We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence. RESULTS We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs. CONCLUSIONS Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.
Collapse
Affiliation(s)
- Luca Erba
- Università Degli Studi Di Milano, Milan, Italy.
| | | | - Alice Monti
- Università Degli Studi Di Milano, Milan, Italy
| | | | - Giulia Cernuschi
- UOC Pronto Soccorso E Medicina D'Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Solbiati
- UOC Pronto Soccorso E Medicina D'Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Christian Bracco
- Department of Internal Medicine, Santa Croce and Carle General Hospital, Cuneo, Italy
| | - Giulia Bandini
- Medicina Interna, Università Degli Studi Di Firenze, AOU Careggi, Firenze, Italy
| | - Monica Pecorino Meli
- Dipartimento Delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento Di Scienze Biomediche E Cliniche "L. Sacco", Università Degli Studi Di Milano, Milan, Italy
| | - Nicola Montano
- Dipartimento Di Medicina Interna, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento Di Scienze Cliniche E Di Comunità, Università Degli Studi Di Milano, Milan, Italy
| | - Rodolfo Sbrojavacca
- Dipartimento Di Pronto Soccorso E Medicina D'Urgenza, Azienda Ospedaliera Universitaria Di Udine, Udine, Italy
| | - Giorgio Costantino
- UOC Pronto Soccorso E Medicina D'Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Dipartimento Di Scienze Cliniche E Di Comunità, Università Degli Studi Di Milano, Milan, Italy
| |
Collapse
|
2
|
Hecker MT, Fox CJ, Son AH, Cydulka RK, Siff JE, Emerman CL, Sethi AK, Muganda CP, Donskey CJ. Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting. PLoS One 2014; 9:e87899. [PMID: 24498394 PMCID: PMC3912125 DOI: 10.1371/journal.pone.0087899] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 12/30/2013] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention. METHODS The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18-65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2). RESULTS Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods. CONCLUSIONS A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.
Collapse
Affiliation(s)
- Michelle T. Hecker
- Department of Medicine, Division of Infectious Diseases, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Clinton J. Fox
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Andrea H. Son
- Department of Pharmacy, MetroHealth Medical Center, Cleveland, Ohio, United States of America
| | - Rita K. Cydulka
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Jonathan E. Siff
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Charles L. Emerman
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Ajay K. Sethi
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Christine P. Muganda
- Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Curtis J. Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| |
Collapse
|
3
|
Copp HL, Yiee JH, Smith A, Hanley J, Saigal CS. Use of urine testing in outpatients treated for urinary tract infection. Pediatrics 2013; 132:437-44. [PMID: 23918886 PMCID: PMC3876750 DOI: 10.1542/peds.2012-3135] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI). METHODS We studied children <18 years who had an outpatient UTI and a temporally associated antibiotic prescription from 2002 through 2007 by using a large claims database, Innovus i3. We evaluated urine-testing trends and performed multivariable logistic regression to assess for factors associated with urine culture use. RESULTS Of 40 603 treated UTI episodes in 28 678 children, urinalysis was performed in 76%, and urine culture in 57%; 32% of children <2 years had no urinalysis or culture performed for an antibiotic-treated UTI episode. Urine culture use decreased during the study period from 60% to 54% (P < .001). We observed variation in urine culture use with age (<2 years: odds ratio [OR] 1.0, 95% confidence interval [CI] 0.9-1.1; 2-5 years: OR 1.3, 95% CI 1.2-1.4; 6-12 years: OR 1.3, 95% CI 1.2-1.4, compared with 13-17 years); gender (boys: OR 0.8, 95% CI 0.8-0.9); and specialty (pediatrics: OR 2.6, 95% CI 2.5-2.8; emergency medicine, OR 1.2, 95% CI 1.1-1.3; urology: OR 0.5, 95% CI 0.4-0.6, compared with family/internal medicine). Recent antibiotic exposure (OR 1.1, 95% CI 1.1-1.2) and empirical broad-spectrum prescription (OR 1.2, 95% CI 1.1-1.2) were associated with urine culture use, whereas previous UTI and urologic anomalies were not. CONCLUSIONS Providers often do not obtain urine tests when prescribing antibiotics for outpatient pediatric UTI. Variation in urine culture use was observed based on age, gender, and physician specialty. Additional research is necessary to determine the implications of empirical antibiotic prescription for pediatric UTI without confirmatory urine testing.
Collapse
Affiliation(s)
- Hillary L. Copp
- Department of Urology, University of California, San Francisco, California
| | - Jenny H. Yiee
- Department of Urology, University of California, Los Angeles, California; and
| | - Alexandria Smith
- Department of Urology, University of California, Los Angeles, California; and,Rand Corporation, Santa Monica, California
| | - Janet Hanley
- Department of Urology, University of California, Los Angeles, California; and,Rand Corporation, Santa Monica, California
| | - Christopher S. Saigal
- Department of Urology, University of California, Los Angeles, California; and,Rand Corporation, Santa Monica, California
| | | |
Collapse
|
4
|
Eliakim-Raz N, Yahav D, Paul M, Leibovici L. Duration of antibiotic treatment for acute pyelonephritis and septic urinary tract infection— 7 days or less versus longer treatment: systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2013; 68:2183-91. [DOI: 10.1093/jac/dkt177] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
5
|
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE. Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011. [DOI: 10.1093/cid/cir102] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.
Collapse
Affiliation(s)
- Kalpana Gupta
- Department of Medicine, Veterans Affairs Boston Health Care System and Boston University School of Medicine, Boston, Massachusetts
| | - Thomas M. Hooton
- Department of Medicine, University of Miami Miller School of Medicine, University of Miami, Miami Florida
| | | | | | - Richard Colgan
- Department of Family and Community Medicine, University of Maryland, Baltimore, Maryland
| | - Loren G. Miller
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance
| | - Gregory J. Moran
- Department of Emergency Medicine and Division of Infectious Diseases Olive View-UCLA Medical Center, Slymar, California
| | - Lindsay E. Nicolle
- Department of Internal Medicine and Department of Medical Mirobiology University of Manitoba, Winnipeg, Canada
| | - Raul Raz
- Infectious Diseases Unit, Ha'Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - David E. Soper
- Departments of Obstetrics and Gynecology and Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
6
|
Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:e103-20. [PMID: 21292654 DOI: 10.1093/cid/ciq257] [Citation(s) in RCA: 1758] [Impact Index Per Article: 135.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
A Panel of International Experts was convened by the Infectious Diseases Society of America (IDSA) in collaboration with the European Society for Microbiology and Infectious Diseases (ESCMID) to update the 1999 Uncomplicated Urinary Tract Infection Guidelines by the IDSA. Co-sponsoring organizations include the American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases–Canada, and the Society for Academic Emergency Medicine. The focus of this work is treatment of women with acute uncomplicated cystitis and pyelonephritis, diagnoses limited in these guidelines to premenopausal, non-pregnant women with no known urological abnormalities or co-morbidities. The issues of in vitro resistance prevalence and the ecological adverse effects of antimicrobial therapy (collateral damage) were considered as important factors in making optimal treatment choices and thus are reflected in the rankings of recommendations.
Collapse
Affiliation(s)
- Kalpana Gupta
- Department of Medicine, Veterans Affairs Boston Health Care System and Boston University School of Medicine, Boston, Massachusetts
| | - Thomas M. Hooton
- Department of Medicine, University of Miami Miller School of Medicine, University of Miami, Miami Florida
| | | | | | - Richard Colgan
- Department of Family and Community Medicine, University of Maryland, Baltimore, Maryland
| | - Loren G. Miller
- Division of Infectious Diseases, Harbor-UCLA Medical Center, Torrance
| | - Gregory J. Moran
- Department of Emergency Medicine and Division of Infectious Diseases Olive View-UCLA Medical Center, Slymar, California
| | - Lindsay E. Nicolle
- Department of Internal Medicine and Department of Medical Mirobiology University of Manitoba, Winnipeg, Canada
| | - Raul Raz
- Infectious Diseases Unit, Ha'Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - David E. Soper
- Departments of Obstetrics and Gynecology and Medicine, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
7
|
Schneider JE, Peterson NA, Vaughn TE, Mooss EN, Doebbeling BN. Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects. Int J Technol Assess Health Care 2006; 22:58-66. [PMID: 16673681 DOI: 10.1017/s0266462306050847] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The overall objective of this article was to review the theoretical and conceptual dimensions of how the implementation of clinical practice guidelines (CPGs) is likely to affect treatment costs. METHODS An important limitation of the extant literature on the cost effects of CPGs is that the main focus has been on clinical adaptation. We submit that the process innovation aspects of CPGs require changes in both clinical and organizational dimensions. We identify five organizational factors that are likely to affect the relationship between CPGs and total treatment costs: implementation, coordination, learning, human resources, and information. We review the literature supporting each of these factors. RESULTS The net organizational effects of CPGs on costs depends on whether the cost-reducing properties of coordination, learning, and human resource management offset potential cost increases due to implementation and information management. CONCLUSIONS Studies of the cost effects of clinical practice guidelines should attempt to measure, to the extent possible, the effects of each of these clinical and organizational factors.
Collapse
Affiliation(s)
- John E Schneider
- University of Iowa and Iowa City VA Center for Research in the Implementation of Innovative Strategies in Practice, 52242, USA.
| | | | | | | | | |
Collapse
|
8
|
Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. ACTA ACUST UNITED AC 2006. [DOI: 10.1002/ebch.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
9
|
Abstract
BACKGROUND The development of resistance to antibiotics by many important human pathogens has been linked to exposure to antibiotics over time. The misuse of antibiotics for viral infections (for which they are of no value) and the excessive use of broad spectrum antibiotics in place of narrower spectrum antibiotics have been well-documented throughout the world. Many studies have helped to elucidate the reasons physicians use antibiotics inappropriately. OBJECTIVES To systematically review the literature to estimate the effectiveness of professional interventions, alone or in combination, in improving the selection, dose and treatment duration of antibiotics prescribed by healthcare providers in the outpatient setting; and to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialized register for studies relating to antibiotic prescribing and ambulatory care. Additional studies were obtained from the bibliographies of retrieved articles, the Scientific Citation Index and personal files. SELECTION CRITERIA We included all randomised and quasi-randomised controlled trials (RCT and QRCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of healthcare consumers or healthcare professionals who provide primary care in the outpatient setting. Interventions included any professional intervention, as defined by EPOC, or a patient-based intervention. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. MAIN RESULTS Thirty-nine studies examined the effect of printed educational materials for physicians, audit and feedback, educational meetings, educational outreach visits, financial and healthcare system changes, physician reminders, patient-based interventions and multi-faceted interventions. These interventions addressed the overuse of antibiotics for viral infections, the choice of antibiotic for bacterial infections such as streptococcal pharyngitis and urinary tract infection, and the duration of use of antibiotics for conditions such as acute otitis media. Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing. The exception was a study documenting a sustained reduction in macrolide use in Finland following the publication of a warning against their use for group A streptococcal infections. Interactive educational meetings appeared to be more effective than didactic lectures. Educational outreach visits and physician reminders produced mixed results. Patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated effectively reduced antibiotic use by patients and did not result in excess morbidity. Multi-faceted interventions combining physician, patient and public education in a variety of venues and formats were the most successful in reducing antibiotic prescribing for inappropriate indications. Only one of four studies demonstrated a sustained reduction in the incidence of antibiotic-resistant bacteria associated with the intervention. AUTHORS' CONCLUSIONS The effectiveness of an intervention on antibiotic prescribing depends to a large degree on the particular prescribing behaviour and the barriers to change in the particular community. No single intervention can be recommended for all behaviours in any setting. Multi-faceted interventions where educational interventions occur on many levels may be successfully applied to communities after addressing local barriers to change. These were the only interventions with effect sizes of sufficient magnitude to potentially reduce the incidence of antibiotic-resistant bacteria. Future research should focus on which elements of these interventions are the most effective. In addition, patient-based interventions and physician reminders show promise and innovative methods such as these deserve further study.
Collapse
Affiliation(s)
- S R Arnold
- University of Tennessee, Pediatrics, Le Bonheur Children's Medical Center, 50 N Dunlap St., Memphis, TN 38103, USA.
| | | |
Collapse
|
10
|
Blacklidge M, Kotagal UR, Lazaron L, Schoettker PJ, Kennedy MR, Stultz M, Muething S. Challenges to Performance-Based Assessment for Community Physicians. J Healthc Qual 2005; 27:20-7. [PMID: 17514846 DOI: 10.1111/j.1945-1474.2005.tb00573.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The Joint Commission on Accreditation of Healthcare Organizations requires accredited organizations to assess individual competency of physicians granted membership on the medical staff. Verification of the competency of physicians caring for children in the acute-care setting presents a particular challenge for the clinical privileging of community physicians. At Cincinnati Children's Hospital, a knowledge-based reappointment method was developed and implemented. Using a case-based self-test, the initial phase measured physicians' knowledge of evidence-based guidelines for three common pediatric inpatient diagnoses. Future methods for tracking individual performance of community-based generalists at the time of reappointment were explored through a physician survey. Response was positive. This process may help keep community physicians engaged as vital members of the hospital staff.
Collapse
|
11
|
BootsMiller BJ, Yankey JW, Flach SD, Ward MM, Vaughn TE, Welke KF, Doebbeling BN. Classifying the effectiveness of Veterans Affairs guideline implementation approaches. Am J Med Qual 2005; 19:248-54. [PMID: 15620076 DOI: 10.1177/106286060401900604] [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: 11/17/2022]
Abstract
Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods.
Collapse
Affiliation(s)
- Bonnie J BootsMiller
- Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246, USA.
| | | | | | | | | | | | | |
Collapse
|
12
|
Coenen S, Van Royen P, Michiels B, Denekens J. Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial. J Antimicrob Chemother 2004; 54:661-72. [PMID: 15282232 DOI: 10.1093/jac/dkh374] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To assess the effect of a tailored professional intervention, including academic detailing, on antibiotic prescribing for acute cough. METHODS In a cluster-randomized controlled before and after study 85 Flemish GPs included adult patients with acute cough consulting in the periods February-April 2000 and 2001. The intervention consisted of a clinical practice guideline for acute cough, an educational outreach visit and a postal reminder to support its implementation in January 2001. Antibiotic prescribing rates and patients' symptom resolution were the main outcome measures. RESULTS Thirty-six of 42 GPs received the intervention and 35 of 43 GPs served as controls; 1503 patients were eligible for analysis. Only in the intervention group were patients less likely to receive antibiotics after the intervention [OR(adj) (95% CI)=0.56 (0.36-0.87)]. Prescribed antibiotics were also more in line with the guideline in the intervention group [1.90 (0.96-3.75)] and less expensive from the perspective of the National Sickness and Invalidity Insurance Institute [MD(adj) (95% CI)= Euro -6.89 [-11.77-(-2.02)]]. No significant differences were found between the groups for the time to symptom resolution. CONCLUSIONS An (inter)actively delivered tailored intervention implementing a guideline for acute cough is successful in optimizing antibiotic prescribing without affecting patients' symptom resolution. Further research efforts should be devoted to cost-effectiveness studies of such interventions.
Collapse
Affiliation(s)
- Samuel Coenen
- Centre for General Practice, University of Antwerp, BE 2610 Antwerp, Belgium.
| | | | | | | |
Collapse
|
13
|
Muething S, Schoettker PJ, Gerhardt WE, Atherton HD, Britto MT, Kotagal UR. Decreasing overuse of therapies in the treatment of bronchiolitis by incorporating evidence at the point of care. J Pediatr 2004; 144:703-10. [PMID: 15192613 DOI: 10.1016/j.jpeds.2004.01.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the effect of evidence-based point-of-care algorithms and rules, based on guideline recommendations, on the overuse of therapies for bronchiolitis. Study design Pre-postintervention for infants <1 year of age admitted with a first-time episode of bronchiolitis. Data collected for guideline-eligible patients discharged between January 15, 2002, and March 27, 2002, were compared with data collected for guideline-eligible patients discharged from the hospital with a diagnosis of bronchiolitis during the same time period in the first 5 years after the original guideline implementation (1997 to 2001). The primary outcome of interest was use of bronchodilator therapy. Secondary outcomes included use of guideline order sets, resource utilization, length of stay, and readmission. RESULTS A total of 256 patients from 2002 were compared with 1272 historic patients. In 2002, the odds of receiving any bronchodilator, more than 1, more than 2, and more than 4 bronchodilators were all significantly less than predicted by the 1997 to 2001 year-to-year trend. The odds of receiving a nasopharyngeal wash for respiratory syncytial virus and a chest radiography (OR=0.680, CL=0.476, 0.973) were also significantly lower than what was predicted from use trends of previous years. CONCLUSIONS Evidence-based point-of-care instruments can have a significant effect on unwarranted treatment variation.
Collapse
Affiliation(s)
- Stephen Muething
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Titler MG, Herr K, Schilling ML, Marsh JL, Xie XJ, Ardery G, Clarke WR, Everett LQ. Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers. Appl Nurs Res 2004; 16:211-27. [PMID: 14608555 DOI: 10.1016/s0897-1897(03)00051-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.
Collapse
Affiliation(s)
- Marita G Titler
- Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1009, USA.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
BACKGROUND Clinical practice guidelines have proliferated in the past several decades, starting with only a handful in the 1980s to over 1000 approved through The National Guideline Clearinghouse in 2002. METHODS The purposes of this article to review research related to guideline adoption and impact and to make recommendations for assessing the outcomes of guidelines, using the CDC guideline process as an example. RESULTS Despite the national movement toward standardization of evidence-based practice, few studies have been conducted to assess the costs of guideline development and implementation, and some practice guidelines have been implemented without concomitant assessment on patient outcomes and costs and benefits of changes in care. CONCLUSIONS An immediate mandate is to ensure that when guidelines are promulgated, they include an evaluation plan, developed by the implementer of the guideline, which takes advantage of existing qualitative and quantitative data and programs (e.g., patient-centered care, quality assurance, risk management) not limited to expensive and sophisticated clinical trials.
Collapse
Affiliation(s)
- Elaine Larson
- Columbia University School of Nursing, 630 West 168th Street, New York, NY 10032, USA.
| |
Collapse
|
16
|
Hampel C, Gillitzer R, Pahernik S, Thüroff JW. [The disturbing development of resistance in urinary tract infections]. Urologe A 2003; 42:27-33. [PMID: 12574880 DOI: 10.1007/s00120-002-0270-7] [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: 10/20/2022]
Abstract
Despite recent caveats about the rapid development of resistance to fluoroquinolones in the treatment of urinary tract infections (UTI), the good tolerability, bioavailability and the broad antibiotic spectrum of fluoroquinolons explain their increased use. We investigated the changes of bacterial spectra and cross resistance profiles in ambulatory and hospitalized UTI patients. A total of 430 positive urine cultures and resistograms were classified according to patient status as either ambulatory or hospitalized and retrospectively analyzed. Cross-resistance profiles of the most effective antibiotics (cotrimoxazol, levofloxacin, amoxicillin/clavulanic acid) were made before an analysis of cost-effectiveness was performed. Whereas Escherichia coli remains the predominant cause of UTI in ambulatory patients, Enterococcus faecalis is the most frequently detected bacterium in the urine cultures of hospitalized patients. This is one reason for the unacceptably high rate of primary resistance of UTI bacteria against cephalosporins. Primary resistance to cotrimoxazol, amoxicillin/cavulanic acid and levofloxacin are impressive and tend to favor the use of levofloxacin. However, high cross-resistance rates reduce the usability of one antibiotic in case of the lack of effectiveness of the other. The broad use of potent antibiotics in hospitals has led to a higher primary resistance and cross-resistance of UTI bacteria in hospitalized patients than in ambulatory patients. The primary resistance of UTI causing bacteria is generally high and worrying. The new fluoroquinolone levofloxacin exhibits surprisingly high primary resistance rates and shares high cross-resistance with other antibiotics that are as effective but much cheaper. Thus, we consider that it should not be a first line treatment option for ambulatory UTI patients in the absence of any resistogram, in order to ensure cost-effectiveness and a slow down in the rapid development of resistance.
Collapse
Affiliation(s)
- C Hampel
- Urologische Klinik, Johannes-Gutenberg Universität, Mainz.
| | | | | | | |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Recurrent urinary tract infection is a common problem and can affect women of all ages, particularly the elderly and pregnant women. Obstetricians and gynaecologists need to have up-to-date knowledge of the diagnosis, pathophysiology and management of this condition. RECENT FINDINGS The diagnosis of urinary tract infection is made on the basis of symptoms and bacteriuria of more than 103 bacteria per ml. Host and bacterial virulence factors are important in the pathogenesis of recurrent urinary tract infections. General host factors predisposing to recurrent infection are genetic factors, ageing, the menopause, urogenital dysfunction, sexual behaviour, and previous pelvic surgery. Urinary tract infection is common in pregnancy, and recent studies have suggested an association with mental retardation and developmental delay. Women with recurrent urinary tract infection in pregnancy should be considered for long-term antibiotic prophylaxis. Intravaginal oestrogens and cranberry juice have been found to be effective for prevention, although more research is required. Women with recurrent urinary tract infection should have at least a 3-day course of trimethoprim or cotrimoxazole, or a 5-day course of beta-lactams or nitrofurantoin, with perhaps a 10-day course in the elderly. Women with frequent urinary tract infection (more than three episodes per year) should be offered prophylactic antibiotics, which can be patient-initiated, postcoital, or long-term low-dose therapy. In the future, vaccines against specific uropathogenic bacteria may be useful in urinary tract infection prophylaxis. SUMMARY More research is required, by all medical disciplines, on various aspects of urinary tract infection.
Collapse
Affiliation(s)
- Peter L Dwyer
- Department of Urogynaecology, Mercy Hospital for Women & Royal Women's Hospital, Melbourne, Australia.
| | | |
Collapse
|
18
|
|
19
|
Leigh AP, Nemeth MA, Keyserling CH, Hotary LH, Tack KJ. Cefdinir versus cefaclor in the treatment of uncomplicated urinary tract infection. Clin Ther 2000; 22:818-25. [PMID: 10945508 DOI: 10.1016/s0149-2918(00)80054-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This multicenter, double-blind, randomized, parallel-group study was conducted in Europe, South Africa, and Australia to compare the clinical and microbiologic efficacy and the tolerability of a cephalosporin antibiotic, cefdinir, with those of cefaclor in the treatment of uncomplicated urinary tract infection. METHODS Patients were randomized in a 1:1 ratio to 5 days of treatment with either cefdinir 100 mg BID or cefaclor 250 mg TID. RESULTS A total of 661 patients were randomized to treatment. They were 90% female, with a median age of 44 years. There were no clinically important differences between groups in terms of demographic characteristics or symptoms on admission. The most frequently isolated pathogens in admission urine cultures were Escherichia coli (383 patients), Proteus mirabilis (20 patients), Staphylococcus saprophyticus (14 patients), and Klebsiella pneumoniae (9 patients). Of the admission pathogens with documented susceptibility results, significantly more were resistant to cefaclor (6.7%) than to cefdinir (3.7%; P < 0.003). Significantly more admission isolates of E. coli were resistant to cefaclor (5.1%) than to cefdinir (2.0%; P < 0.007). A total of 383 patients were assessable for efficacy, 196 in the cefdinir group and 187 in the cefaclor group. Clinical cure rates and microbiologic response rates for cefdinir and cefaclor were statistically equivalent at 5 to 9 days posttherapy (test-of-cure visit), using a 95% CI approach. The rate of treatment-related adverse events was higher in cefdinir-treated patients (20.2%) than in cefaclor-treated patients (13.0%; P = 0.025), mainly due to the greater frequency of diarrhea in the former group. However, only 4 patients (1.2%) discontinued cefdinir treatment due to diarrhea. CONCLUSION Empiric therapy with cefdinir appears to be a reasonable choice for patients with uncomplicated urinary tract infection in whom cephalosporin treatment is indicated.
Collapse
Affiliation(s)
- A P Leigh
- Synthelabo, Le Plessis Robinson, France
| | | | | | | | | |
Collapse
|
20
|
Dickerson LM, Mainous AG, Carek PJ. The pharmacist's role in promoting optimal antimicrobial use. Pharmacotherapy 2000; 20:711-23. [PMID: 10853627 DOI: 10.1592/phco.20.7.711.35171] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Optimal use of antimicrobials is essential in the face of escalating antibiotic resistance, and requires cooperation from all sectors of the health care system. Although antibiotic-restriction policies in the hospital setting are important in altering microbial susceptibility patterns, an overall reduction in antibiotic prescriptions in the outpatient setting is more likely to significantly impact antibiotic resistance. Education of providers, application of clinical practice guidelines, audit and feedback activities, and multifaceted interventions all have had an effect in altering antibiotic prescribing in a research setting. Clinicians must alter antibiotic prescribing for the treatment of infectious diseases, and patients must change their perception of the need for these drugs. Pharmacists can play a major role through clinician education and focused clinical services. With cooperation of health care teams, the effectiveness of available antibiotics may be sustained and the threat of resistance minimized.
Collapse
Affiliation(s)
- L M Dickerson
- Department of Family Medicine, Medical University of South Carolina, Charleston 29406, USA
| | | | | |
Collapse
|
21
|
Abstract
It is possible to understand the pathophysiology, diagnostic laboratory methodology, and appropriate medical and surgical management of urinary tract infections in today's modern medical world. The foundation of success lies within an appropriate determination of the presence of mitigating complications, careful documentation of invading organisms, and judicious selection and administration of modern antimicrobial agents. Virtually all urinary tract infections begin in the lower system through bacterial exposure and adherence phenomena, creating simple uncomplicated infections in otherwise healthy hosts and serious complicated infections in others. Not all bacteriuria should be treated, and not all infections should be treated equally; knowing the difference is the secret.
Collapse
Affiliation(s)
- R U Anderson
- Department of Urology, Stanford University School of Medicine, California, USA.
| |
Collapse
|
22
|
Abstract
Acute uncomplicated urinary tract infection is one of the most common problems for which young women seek medical attention and accounts for considerable morbidity and health care costs. Acute cystitis or pyelonephritis in the adult patient should be considered uncomplicated if the patient is not pregnant or elderly, if there has been no recent instrumentation or antimicrobial treatment, and if there are no known functional or anatomic abnormalities of the genitourinary tract. Most of these infections are caused by E. coli, which are susceptible to many oral antimicrobials, although resistance is increasing to some of the commonly used agents. Review of the published data suggests that a 3-day regimen is more effective than a single-dose regimen for all antimicrobials tested. Regimens with trimethoprim-sulfamethoxazole seem to be more effective than those with beta lactams, regardless of the duration. Because of increasing resistance to trimethoprim-sulfamethoxazole, an alternative regimen such as nitrofurantoin (in a 7-day regimen), a fluoroquinolone, or an oral third-generation cephalosporin may be a better empiric choice in some areas. Acute pyelonephritis caused by highly virulent uropathogens in an otherwise healthy woman may be considered an uncomplicated infection. The optimal treatment duration for acute uncomplicated pyelonephritis has not been established, but 10- to 14-day regimens are recommended. We prefer to use antimicrobials that attain high renal tissue levels, such as a fluoroquinolone, trimethoprim-sulfamethoxazole, or an aminoglycoside, for pyelonephritis. Acute uncomplicated cystitis or pyelonephritis in healthy adult men is uncommon but is generally caused by the same spectrum of uropathogens with the same antimicrobial susceptibility profile as that seen in women.
Collapse
Affiliation(s)
- T M Hooton
- Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | | |
Collapse
|