Systematic review of determinants influencing antibiotic prescribing for uncomplicated acute respiratory tract infections in adult patients at the emergency department

Patients' requests and physicians' prescribing behavior. A systematic review

BACKGROUND

Patients' requests is a frequently cited factor in the literature affecting doctors' prescribing decisions. This systematic review aims to consolidate quantitative findings, shedding light on the relationship between patient requests and the actions taken by general practitioners. A broader perspective was adopted by not limiting our investigation to specific medication categories. Instead, we treat the act of requesting as a communicative behavior, separate from the pharmacological context.

METHOD

A comprehensive search across various online databases was performed. Two authors independently contributed the screening phase. The selection of articles and the data extraction were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart.

RESULTS

Patient's request demonstrated to be a driving factor for physician's prescribing behavior not only when antibiotics are involved, but as a more generalized trend.

CONCLUSIONS

The study acknowledges the complexity of patient-provider communication, emphasizing the asymmetry in roles and the tension between patient empowerment and medical expertise. By uncovering the underlying mechanisms shaping doctors' responses to patient requests, this systematic review enhances our understanding of communication in healthcare settings.

PRACTICE IMPLICATIONS

Understanding the impact of patient requests on prescribing decisions highlights the importance of training healthcare providers in effective communication strategies that balance patient autonomy with clinical judgment. These insights can inform guidelines and interventions aimed at managing patient expectations, supporting more evidence-based prescribing practices and fostering better doctor-patient relationships.

Clinical evolution and medical resource utilization in adult patients with respiratory syncytial virus infection at a community hospital in Argentina

OBJECTIVE

To describe the hospital medical resources used in adults hospitalized with respiratory syncytial virus infection and to evaluate the association of comorbidities with resource utilization and clinical outcomes.

DESIGN

A retrospective cohort study was conducted using the electronic healthcare database of Hospital Alemán, Buenos Aires, Argentina. It included hospitalized patients aged 18 years or older who had a positive test for respiratory syncytial virus between September 2010 and December 2023. Data were analyzed using standard statistical methods following STROBE guidelines.

RESULTS

Among 72 hospitalized adults with confirmed respiratory syncytial virus infection, the mean length of hospital stay was 12.18 days (SD 12.91), and 27 (37.5%) patients required intensive care unit admission. Healthcare resource utilization was substantial, with 26% needing non-invasive ventilation and 11% requiring mechanical ventilation. Antibiotics (75%) and corticosteroids (68.05%) were commonly used, likely reflecting the severity of clinical presentation or the potential for bacterial coinfection. Cardiovascular comorbidities were significantly associated with severe disease outcomes and intensive care unit admission (OR 3.53, 95% CI: 1.00-12.54). Comparative analysis with 226 influenza patients showed respiratory syncytial virus patients had longer hospital stays and higher intensive care unit admission rates.

CONCLUSIONS

Respiratory syncytial virus infection in adults resulted in substantial medical resource utilization and significant intensive care unit admission and ventilation support requirements. Cardiovascular comorbidities might be associated with increased severity and intensive care unit admissions. The high rate of antibiotic use is noteworthy and warrants further investigation to understand prescribing patterns and optimize antimicrobial stewardship. Compared to influenza, respiratory syncytial virus appears to be associated with longer hospital stays and higher intensive care unit admissions, highlighting the need for tailored management strategies for respiratory syncytial virus in adult populations. Further research should focus on optimizing treatment protocols and preventive measures for respiratory syncytial virus.

Social determinants of health and risk of dementia among older men and women: A 12-year cohort study in Australia

INTRODUCTION

Social determinants of health (SDH) are recognized as contributing factors to cognitive disorders, but their collective influence on dementia risk remains unclear.

METHODS

A gender-disaggregated analysis was conducted on 12,896 community-dwelling older Australians (mean ± SD age: 75.2 ± 4.3 years; 54% women) without major cognitive impairment upon enrollment. Latent class analysis identified clusters from 72 SDH (70 individual-level and 2 neighborhood-level), while Cox proportional hazards regression estimated dementia risk over 12 years (median: 8.4) follow-up.

RESULTS

Four clusters were identified: least disadvantaged (Class 1: 31.5% men; 30.6% women), most disadvantaged (Class 2: 20.2% men; 19.4% women), high social support with Class 1 features (Class 3: 22.2% men; 24.1% women), and high social support with Class 2 features (Class 4: 26.1% men; 25.7% women). Compared to Class 1, men (HR: 1.49, 95% CI: 1.12-1.98) and women (HR: 1.56, 95% CI: 1.17-2.07) in Class 2, and women in Class 4 (HR: 1.66, 95% CI: 1.28-2.16) had a higher dementia risk.

DISCUSSION

Socioeconomic disadvantage was associated with incident dementia. Despite stronger social support, women's cognitive capacity appeared to be disproportionately impacted by adverse SDH.

HIGHLIGHTS

Four distinct multidimensional clusters were identified from a wide range of 72 social determinants of health. These clusters were associated with dementia risk differently in men and women. In both men and women, the most socioeconomically disadvantaged group had a higher risk of dementia. Despite stronger interpersonal social support, women had a greater risk of dementia. The addition of known dementia risk factors in cluster analysis did not change the findings, suggesting that social determinants of health independently predict dementia risk.

A Behavioral Analysis of Factors That Influence Antibiotic Prescribing in Hospitals: A Metasynthesis of Reviews

Antibiotic resistance is a global public health threat driven, in part, by antibiotic overprescription. Behavior change theories are increasingly used to try to modify prescriber behavior. A metasynthesis of 8 reviews was conducted to identify factors influencing antibiotic prescribing for adults in hospital settings and to analyze these factors using 4 behavior change frameworks. Forty-three factors were identified across 7 thematic categories and then mapped to the theoretical domains framework and capability-opportunity-motivation model of behavior. The behavior change wheel and behavior change techniques taxonomy were then used to identify appropriate interventions and their components. The domain "environmental context and resources" was coded the most often, followed by "social influences" and "beliefs about consequences," revealing that prominent sources of antibiotic prescribing behavior are "physical opportunity" and "social opportunity." Based on these results, suggested interventions include environmental prompts/cues, education on consequences of antibiotic overuse, social comparison and support, and incentives.

European society of clinical microbiology and infectious diseases guidelines for antimicrobial stewardship in emergency departments (endorsed by European association of hospital pharmacists)

SCOPE

This European Society of Clinical Microbiology and Infectious Diseases guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are (a) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? (b) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? (c) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? (d) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing?

METHODS

An expert panel was convened by European Society of Clinical Microbiology and Infectious Diseases and the guideline chair. The panel selected in consensus the four most relevant antimicrobial stewardship topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes and stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively.

RECOMMENDATIONS

The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e. withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very low and low certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.

Prescription patterns of antibiotics and associated factors among outpatients diagnosed with respiratory tract infections in Jinja city, Uganda, June 2022-May 2023

BACKGROUND

Most respiratory tract infections (RTIs) are viral and do not require antibiotics, yet their inappropriate prescription is common in low-income settings due to factors like inadequate diagnostic facilities. This misuse contributes to antibiotic resistance. We determined antibiotic prescription patterns and associated factors among outpatients with RTIs in Jinja City, Uganda.

METHODS

We conducted a retrospective observational study that involved data abstraction of all patient records with a diagnosis of RTIs from the outpatient registers for the period of June 1, 2022, to May 31, 2023. An interviewer-administered questionnaire capturing data on prescribing practices and factors influencing antibiotic prescription was administered to drug prescribers in the health facilities where data were abstracted and who had prescribed from June 1, 2022, to May 31, 2023. We used modified Poisson regression analysis to identify factors associated with antibiotic prescription.

RESULTS

Out of 1,669 patient records reviewed, the overall antibiotic prescription rate for respiratory tract infections (RTIs) was 79.8%. For specific RTIs, rates were 71.4% for acute bronchitis, 93.3% for acute otitis media, and 74.4% for acute upper respiratory tract infections (URTIs). Factors significantly associated with antibiotic prescription included access to Uganda Clinical Guidelines (Adjusted prevalence ratio [aPR] = 0.61, 95% CI = 0.01-0.91) and Integrated Management of Childhood Illness guidelines (aPR = 0.14, 95% CI = 0.12-0.87, P = 0.002), which reduced the likelihood of prescription. Prescribers without training on antibiotic use were more likely to prescribe antibiotics (aPR = 3.55, 95% CI = 1.92-3.98). Patients with common cold (aPR = 0.06, 95% CI = 0.04-0.20) and cough (aPR = 0.11, 95% CI = 0.09-0.91) were less likely to receive antibiotics compared to those with pneumonia.

CONCLUSION

The study reveals a high rate of inappropriate antibiotic prescription for RTIs, highlighting challenges in adherence to treatment guidelines. This practice not only wastes national resources but also could contribute to the growing threat of antibiotic resistance. Targeted interventions, such as enforcing adherence to prescription guidelines, could improve prescription practices and reduce antibiotic misuse in this low-income setting.

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

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.

Health Equity and Antibiotic Prescribing in the United States: A Systematic Scoping Review

We performed a scoping review of articles published from 1 January 2000 to 4 January 2022 to characterize inequities in antibiotic prescribing and use across healthcare settings in the United States to inform antibiotic stewardship interventions and research. We included 34 observational studies, 21 cross-sectional survey studies, 4 intervention studies, and 2 systematic reviews. Most studies (55 of 61 [90%]) described the outpatient setting, 3 articles were from dentistry, 2 were from long-term care, and 1 was from acute care. Differences in antibiotic prescribing were found by patient's race and ethnicity, sex, age, socioeconomic factors, geography, clinician's age and specialty, and healthcare setting, with an emphasis on outpatient settings. Few studies assessed stewardship interventions. Clinicians, antibiotic stewardship experts, and health systems should be aware that prescribing behavior varies according to both clinician- and patient-level markers. Prescribing differences likely represent structural inequities; however, no studies reported underlying drivers of inequities in antibiotic prescribing.

Antibiotic expectation, behaviour, and receipt among patients presenting to emergency departments with uncomplicated upper respiratory tract infection during the COVID-19 pandemic

OBJECTIVES

Pre-COVID-19 pandemic, patients who attended the emergency department (ED) for upper respiratory tract infection (URTI) were more likely to receive antibiotics if they expected them. These expectations could have changed with the change in health-seeking behaviour during the pandemic. We assessed the factors associated with antibiotics expectation and receipt for uncomplicated URTI patients in four Singapore EDs during the COVID-19 pandemic.

METHODS

We conducted a cross-sectional study on adult patients with URTI from March 2021 to March 2022 in four Singapore EDs and assessed the determinants of antibiotics expectation and receipt using multivariable logistic regression models. We also assessed the reasons patients expect antibiotics during their ED visit.

RESULTS

Among 681 patients, 31.0% expected antibiotics while 8.7% received antibiotics during their ED visit. Factors (adjusted odds ratio [95% confidence interval]) that significantly influenced expectation for antibiotics include: 1) prior consultation for current illness with (6.56 [3.30-13.11]) or without (1.50 [1.01-2.23]) antibiotics prescribed; 2) anticipation for COVID-19 test (1.56 [1.01-2.41]); and 3) poor (2.16 [1.26-3.68]) to moderate (2.26 [1.33-3.84]) knowledge on antibiotics use and resistance. Patients expecting antibiotics were 10.6 times (10.64 [5.34-21.17]) more likely to receive antibiotics. Those with tertiary education were twice (2.20 [1.09-4.43]) as likely to receive antibiotics.

CONCLUSION

In conclusion, patients with URTI who expected antibiotics to be prescribed remained more likely to receive it during the COVID-19 pandemic. This highlights the need for more public education on the non-necessity for antibiotics for URTI and COVID-19 to address the problem of antibiotic resistance.

A multi-institutional exploration of emergency medicine physicians' attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study

BACKGROUND

The COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians' attitudes and behaviours in four EDs in Singapore.

METHODS

We employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework.

RESULTS

We obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor.

CONCLUSIONS

Self-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Population-based assessment of factors influencing antibiotic prescribing for adults with dengue infection in Taiwan

Background

Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors.

Methods

57,301 adult dengue cases reported in Taiwan between 2008–2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan’s National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients.

Results

Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings.

Conclusions

In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing.

Antimicrobial resistance is a growing global public health threat. The non-specific clinical manifestations of dengue overlap with signs and symptoms of other febrile illnesses common to tropical and subtropical zones making differential diagnosis between dengue and bacterial infections difficult, hence, leading to potentially unnecessary antibiotic prescribing. However, our understanding of factors underlying antibiotic prescribing for dengue is rather limited. Taiwan has experienced periodic dengue outbreaks and has a comprehensive national health insurance database including reliable infectious diseases surveillance and prescribing records. The findings in Taiwan show that other than commonly known patient characteristics, provider and contextual factors play a significant role. Physician’s age and practice setting were significant factors influencing the decision to prescribe antibiotics, particularly in outpatient visits. The likelihood of prescribing an antibiotic to dengue patients was reduced by more than 50% in medical visits occurring after the dengue infection was confirmed. Understanding patient, provider and contextual factors in antibiotics prescription for dengue infections can provide insights for improved antibiotic stewardship and unnecessary antibiotic treatment for dengue.

Use of infection biomarkers in the emergency department

The use of infection biomarkers in the emergency department is discussed in terms of their possible contributions to diagnostic-prognostic uncertainties, appropriate antibiotic treatments, and triage and follow-up planning. Procalcitonin (PCT), C-reactive protein (CRP), proadrenomedullin (proADM), and presepsin are among the most discussed infection biomarkers for use in the emergency department. Due to the variable sensitivity results and cutoff values, there are insufficient data to recommend the widespread use of CRP and procalcitonin (PCT) for the diagnosis and prognosis of infection in the emergency department. However, these biomarkers can be used for appropriate antibiotic use in selected infection groups, such as community-acquired pneumonia, especially to reduce unnecessary antibiotic prescribing. With its prognostic superiority over other biomarkers and its contribution to prognostic score systems in community-acquired pneumonia (CAP), proADM can be used to predict hospitalization, preferably within the scope of clinical studies. Although presepsin has been shown to have some advantages over other biomarkers to rule out sepsis, there are insufficient data for its clinical use in the emergency department.