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Grigoryan L, Trautner BW. Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review. Infect Dis Clin North Am 2024; 38:277-294. [PMID: 38575491 DOI: 10.1016/j.idc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.
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Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston TX 77098, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, IQuESt (152), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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2
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Soucy JPR, Low M, Acharya KR, Ellen M, Hulth A, Löfmark S, Garber GE, Watson W, Moran-Gilad J, Davidovitch N, Amar T, McCready J, Orava M, Brownstein JS, Brown KA, Fisman DN, MacFadden DR. Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study. Microbiol Spectr 2024; 12:e0001724. [PMID: 38411087 PMCID: PMC10986525 DOI: 10.1128/spectrum.00017-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.
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Affiliation(s)
- Jean-Paul R. Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Low
- Chief Physician’s Office, Clalit Health Services, Tel Aviv, Israel
| | - Kamal R. Acharya
- Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anette Hulth
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sonja Löfmark
- The Public Health Agency of Sweden, Stockholm, Sweden
| | | | - William Watson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nadav Davidovitch
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Tamar Amar
- Department of Epidemiology, Biostatistics, and Community Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Janine McCready
- Division of Infectious Diseases, Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Matthew Orava
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kevin A. Brown
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - David N. Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek R. MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Sanchez GV, Kabbani S, Tsay SV, Bizune D, Hersh AL, Luciano A, Hicks LA. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2024; 30:951-962. [PMID: 37856146 DOI: 10.1089/tmj.2023.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Angelina Luciano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Acharya KR, Cohen A, Brankston G, Soucy JPR, Hulth A, Löfmark S, Brownstein JS, Davidovich N, Ellen ME, Fisman DN, Moran-Gilad J, Steinman A, MacFadden DR, Greer AL. An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel. Animals (Basel) 2024; 14:626. [PMID: 38396594 PMCID: PMC10885889 DOI: 10.3390/ani14040626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.
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Affiliation(s)
- Kamal R. Acharya
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Adar Cohen
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 7610001, Israel; (A.C.); (A.S.)
| | - Gabrielle Brankston
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Jean-Paul R. Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (J.-P.R.S.); (D.N.F.)
| | - Anette Hulth
- Public Health Agency of Sweden, 171 82 Stockholm, Sweden; (A.H.); (S.L.)
| | - Sonja Löfmark
- Public Health Agency of Sweden, 171 82 Stockholm, Sweden; (A.H.); (S.L.)
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Nadav Davidovich
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel; (N.D.); (J.M.-G.)
| | - Moriah E. Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - David N. Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (J.-P.R.S.); (D.N.F.)
| | - Jacob Moran-Gilad
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel; (N.D.); (J.M.-G.)
| | - Amir Steinman
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 7610001, Israel; (A.C.); (A.S.)
| | | | - Amy L. Greer
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
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Last K, Simon A, Gärtner BC, Becker SL, Papan C. Attitudes of primary care physicians towards antimicrobial stewardship and the impact of a multi-part training course - a pilot study. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc24. [PMID: 38025891 PMCID: PMC10665713 DOI: 10.3205/dgkh000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background A plethora of antimicrobial stewardship (AMS) programs has been initiated during the past years, focusing on hospital settings. Primary-care physicians have seldom been addressed, although the majority of antibiotic prescriptions are issued for outpatients. We sought to investigate attitudes of primary-care physicians and the impact of a customized training course. Methods Primary-care physicians in southwest Germany were invited to a multi-part training course on AMS in the primary-care setting. Participants were asked to answer a questionnaire about their attitude and factors that hinder them from implementing AMS or enable them to perform AMS. In addition, a knowledge assessment exam at the beginning and end of the training was conducted on selected infectious diseases/syndromes. Results In total, 36 primary-care physicians participated in the training course. The predominant age group was 51-60 years old (36%; 13/36). The majority, 23/35 (66%), indicated never having had AMS training, while 22/35 (63%) acknowledged partly implementing AMS activities in their daily routine. The primary barrier was lack of expertise, while the main motives were reducing antimicrobial resistance and optimizing patient care. The provision of guidelines was regarded as more important than feedback on their prescription behavior. Exam performance improved from the initial to the final exam on all topics. Conclusion Customized AMS training courses are a feasible and potentially complimentary tool to address antibiotic misuse in the primary-care setting.
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Affiliation(s)
- Katharina Last
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Arne Simon
- Pediatric Oncology, Saarland University Medical Center, Homburg, Germany
| | - Barbara C. Gärtner
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Sören L. Becker
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
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Carney G, Maclure M, Patrick DM, Fisher A, Stanley D, Bassett K, Dormuth CR. A cluster randomized trial assessing the impact of personalized prescribing feedback on antibiotic prescribing for uncomplicated acute cystitis to family physicians. PLoS One 2023; 18:e0280096. [PMID: 37523381 PMCID: PMC10389722 DOI: 10.1371/journal.pone.0280096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE To evaluate the impact of personalized prescribing portraits on antibiotic prescribing for treating uncomplicated acute cystitis (UAC) by Family Physicians (FPs). DESIGN Cluster randomized control trial. SETTING The intervention was conducted in the primary care setting in the province of BC between December 2010 and February 2012. PARTICIPANTS We randomized 4 833 FPs by geographic location into an Early intervention arm (n = 2 417) and a Delayed control arm (n = 2 416). INTERVENTION The Education for Quality Improvement in Patient Care (EQIP) program mailed to each FP in BC, a 'portrait' of their individual prescribing of antibiotics to women with UAC, plus therapeutic recommendations and a chart of trends in antibiotic resistance. MAIN OUTCOME MEASURES Antibiotic prescribing preference to treat UAC. RESULTS Implementing exclusion criteria before and after a data system change in the Ministry of Health caused the arms to be unequal in size-intervention arm (1 026 FPs, 17 637 UAC cases); control arm (1 352 FPs, 25 566 UAC cases)-but they were well balanced by age, sex and prior rates of prescribing antibiotics for UAC. In the early intervention group probability of prescribing nitrofurantoin increased from 28% in 2010 to 38% in 2011, a difference of 9.9% (95% confidence interval [CI], 9.1% to 10.7. Ciprofloxacin decreased by 6.2% (95% CI: 5.6% to 6.9%) and TMP-SMX by 3.7% (95% CI: 3.1% to 4.2%). Among 295 FPs who completed reflective surveys, 52% said they were surprized by the E. coli resistance statistics and 57% said they planned to change their treatment of UAC. CONCLUSION The EQIP intervention demonstrated that feedback of personal data to FPs on their prescribing, plus population data on antibiotic resistance, with a simple therapeutic recommendation, can significantly improve prescribing of antibiotics. Trial registration: ISRCTN 16938907.
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Affiliation(s)
- Greg Carney
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Malcolm Maclure
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - David M Patrick
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Anat Fisher
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dana Stanley
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Ken Bassett
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Colin R Dormuth
- Therapeutics Initiative, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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Konishi T, Fujiogi M, Sato M, Michihata N, Matsui H, Nishioka K, Tanabe M, Seto Y, Yasunaga H. Impact of the National Action Plan for Antimicrobial Resistance on Antibiotic Use for Mastitis Using a Japanese Nationwide Database. Breast Care (Basel) 2023; 18:122-129. [PMID: 37261132 PMCID: PMC10228258 DOI: 10.1159/000529381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/24/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Mastitis is the inflammation of the mammary gland that mainly occurs during the lactation period and requires antibiotic treatment with little evidence for its efficacy. We investigated the effect of the National Action Plan for antimicrobial resistance aiming for appropriate antimicrobial stewardship on broad-spectrum antibiotics administration for mastitis despite the lack of a disease-specific antimicrobial agents manual. METHODS Using a large nationwide database, an interrupted time-series analysis was performed using data from 34,340 female patients who received antibiotics for mastitis between April 2012 and March 2020. This study compared the trend of outcomes before and after the publication date of the National Action Plan (April 2016). The outcomes were the proportion of broad-spectrum and first-choice narrow-spectrum antibiotic administration and surgical drainage within 30 days after the administration. RESULTS Broad-spectrum antibiotics were administered in 70% of the cases before and 67% of the cases after the National Action Plan publication date. The trend of broad-spectrum antibiotics administration significantly changed at the publication (-2.6% [95% confidence interval, -3.9% to -1.3%], p < 0.001) and the administration decreased after the publication (1.9% annual decrease, Ptrend < 0.001). The trend of first-choice antibiotics administration also changed at the publication (1.3% [0.1-2.4%], p = 0.028) and the administration increased after the publication (1.3% annual increase, Ptrend < 0.001). The occurrence of surgical drainage was stable during the study period. CONCLUSION Despite the lack of a disease-specific antimicrobial manual, the publication of the National Action Plan improved antimicrobial stewardship for mastitis without any impact on a surgical treatment course.
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Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Science, Technology, and Innovation Governance Education and Research Program, Graduate School of Public Policy, The University of Tokyo, Tokyo, Japan
| | - Michimasa Fujiogi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Division of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Misuzu Sato
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kotoe Nishioka
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Yang J, Cui Z, Liao X, He X, Wang L, Wei D, Wu S, Chang Y. Effects of a feedback intervention on antibiotic prescription control in primary care institutions based on a Health Information System: a cluster randomized cross-over controlled trial. J Glob Antimicrob Resist 2023; 33:51-60. [PMID: 36828121 DOI: 10.1016/j.jgar.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/16/2022] [Accepted: 02/07/2023] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES Overuse and misuse of antibiotics are major factors in the development of antibiotic resistance in primary care institutions of rural China. In this study, the effectiveness of a Health Information System-based, automatic, and confidential antibiotic feedback intervention was evaluated. METHODS A randomized, cross-over, cluster-controlled trial was conducted in primary care institutions. All institutions were randomly divided into two groups and given either a three-month intervention followed by a three-month period without any intervention or vice versa. The intervention consisted of three feedback measures: a real-time pop-up warning message of inappropriate antibiotic prescriptions on the prescribing physician's computer screen, a 10-day antibiotic prescription summary, and distribution of educational manuals. The primary outcome was the 10-day inappropriate antibiotic prescription rate. RESULTS There were no significant differences in inappropriate antibiotic prescription rates (69.1% vs. 72.0%) between two groups at baseline (P = 0.072). After three months (cross-over point), inappropriate antibiotic prescription rates decreased significantly faster in group A (12.3%, P < 0.001) compared to group B (4.4%, P < 0.001). At the end point, the inappropriate antibiotic prescription rates decreased in group B (15.1%, P < 0.001) while the rates increased in group A (7.2%, P < 0.001). The characteristics of physicians did not significantly affect the rate of antibiotic or inappropriate antibiotic prescription rates. CONCLUSION A Health Information System-based, real-time pop-up warnings, a 10-day prescription summary, and the distribution of educational manuals, can effectively reduce the rates of antibiotic and inappropriate antibiotic prescriptions.
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Affiliation(s)
- Junli Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Zhezhe Cui
- Guangxi Key Laboratory of Major Infectious Disease Prevention and Control and Biosafety Emergency Response, Guangxi Center for Disease Control and Prevention, Nanning, China
| | - Xingjiang Liao
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Xun He
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China.
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, China
| | - Du Wei
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Shengyan Wu
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, China; Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, China.
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Cox S, Lo-A-Foe K, van Hoof M, Dinant GJ, Oudhuis G, Savelkoul P, Cals J, de Bont E. Physician-Targeted Interventions in Antibiotic Prescribing for Urinary Tract Infections in General Practice: A Systematic Review. Antibiotics (Basel) 2022; 11:1560. [PMID: 36358215 PMCID: PMC9686805 DOI: 10.3390/antibiotics11111560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 07/30/2023] Open
Abstract
Urinary tract infections (UTIs) are the most common reason for women to consult a general practitioner (GP). While UTIs are self-limiting in half of cases, most women are prescribed antibiotics, often in discordance with established guidelines. Researchers have employed different interventions to improve GPs' prescribing behavior, especially for respiratory infections, but it is uncertain whether these are effective for UTI care. Therefore, we performed a systematic review, including (cluster) randomized clinical trials investigating the effect of interventions targeted at GPs to improve antibiotic prescriptions for UTI. From September to December 2021 we searched the Medline, Web of Science, and CENTRAL databases, ultimately including ten studies describing eleven trials. We determined the effect of the interventions on the decision to prescribe and on the choice of antibiotic. Results showed that most studies employed multifaceted interventions, most frequently including audit & feedback and/or educational meetings. Seven out of nine trials that recorded first-choice prescriptions saw an increased proportion of first-choice antibiotics in the intervention groups compared to control groups. The employed interventions also caused a decreased proportion of at least one broad-spectrum antibiotic in five out of six studies that measured broad-spectrum antibiotic prescriptions. However, the total number of antibiotic prescriptions for UTIs increased in four out of eight studies. Therefore, while effective at influencing GPs' prescribing behavior, future interventions should also focus on improving the decision to prescribe at all.
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Affiliation(s)
- Stefan Cox
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Kelly Lo-A-Foe
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Minke van Hoof
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Guy Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Jochen Cals
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Eefje de Bont
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
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Sheppard D. Short-course antibiotic therapy: The next frontier in antimicrobial stewardship. CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2022; 48:496-501. [PMID: 38173469 PMCID: PMC10763651 DOI: 10.14745/ccdr.v48i1112a01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ensuring appropriate use of antibiotics is critical to preserving their effectiveness through limiting the development and spread of antimicrobial resistance. Evidence is accumulating that shorter courses of antibiotics are as effective as traditional longer regimens for many common infections and can reduce the risk of adverse events. Despite the availability of evidence and guidelines supporting short-course antibiotic therapy for these conditions, prolonged use of antibiotics remains common. This article will review the origins and evolution of our approach regarding antimicrobial prescription duration, the evidence for the use of short-course therapy for selected infections, barriers to the uptake of this practice and potential approaches that can be taken to reduce inappropriately long antibiotic use.
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Affiliation(s)
- Donald Sheppard
- Antimicrobial Resistance Task Force, Public Health Agency of Canada, Ottawa, ON
- Department of Microbiology and Immunology, Faculty of Medicine, McGill University, Montréal, QC
- Infectious Disease and Immunity in Global Health, Research Institute of McGill University Health Center, Montréal, QC
- McGill Interdisciplinary Initiative in Infection and Immunity, Montréal, QC
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Wang W, Yu S, Zhou X, Wang L, He X, Zhou H, Chang Y. Antibiotic prescribing patterns at children's outpatient departments of primary care institutions in Southwest China. BMC PRIMARY CARE 2022; 23:269. [PMID: 36289470 PMCID: PMC9607730 DOI: 10.1186/s12875-022-01875-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inappropriate use of antibiotics in children is common in many countries. The purpose of the study was to explore patterns of antibiotic prescribing in children's outpatient clinics in primary care institutions in a province of southwest China. METHODS We obtained electronic prescription data from 75 primary care institutions in Guizhou province in 2020. The classification of incorrect spectrum of antibiotics, unnecessary use and combined use of antibiotics was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the USA Centers for Disease Control and Prevention. Potential risk factors for inappropriate use of antibiotics were identified using bivariate analyses. The generalized estimation equation was used to identify independent predictors of inappropriate use of antibiotics. RESULTS A total of 158,267 antibiotic prescriptions were retrieved. Acute upper respiratory tract infections were the most common diseases, accounting for 74.9% of all prescriptions. The main antibiotic group used was penicillins (63.7%), followed by cephalosporins (18.8%). Of 137,284 visits, 18.3% of antibiotic prescriptions were appropriate and the percentage of unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics was 76.9, 2.4 and 2.4%, respectively. Physicians with lower professional titles and more than 40 years of work duration were relatively more likely to prescribe inappropriate antibiotics. CONCLUSION The inappropriate use of antibiotics in children is still prominent in primary care institutions of southwest China. The education and training of physicians and caregivers in these institutions should be strengthened.
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Affiliation(s)
- Wenju Wang
- grid.413458.f0000 0000 9330 9891School of Public Health, Guizhou Medical University, Guiyang, Guizhou Province China
| | - Shitao Yu
- Guiyang Public Health Clinical Center, Guiyang, Guizhou Province China
| | - Xunrong Zhou
- grid.443382.a0000 0004 1804 268XSecond Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou Province China
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, Guizhou Province China
| | - Xun He
- grid.413458.f0000 0000 9330 9891School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province China
| | - Hanni Zhou
- grid.413458.f0000 0000 9330 9891School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province China
| | - Yue Chang
- grid.413458.f0000 0000 9330 9891School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province China
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Educational Activities for Students and Citizens Supporting the One-Health Approach on Antimicrobial Resistance. Antibiotics (Basel) 2021; 10:antibiotics10121519. [PMID: 34943732 PMCID: PMC8698298 DOI: 10.3390/antibiotics10121519] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
Antibiotic resistance is one of the biggest threats to global health, food security and development. Urgent action is needed at all levels of society to reduce the impact and spread of antibiotic resistance. For a more sustaining approach, education in children, college students, citizens and caregivers are essential. The One-Heath approach is a collaborative, multisectoral and transdisciplinary strategy in which, no single organizations or sector can address the issue of antimicrobial resistance at the human-environment interface alone. Within this strategy, education plays a central role. In this scoping review, we highlighted a range of learning activities on antibiotic resistance as part of the One-Health approach. In particular, those applications that can be introduced to a wide audience to help arrest the current crisis for the next generation. The review identifies a high number of teaching opportunities: board and role-play games, round tables, musicals, e-learning and environmental experiments to couple with more curricula and formal education to inform a diverse group of audiences.
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