Survey of clinical pharmacists' knowledge of appropriateness of antimicrobial therapy for upper respiratory infections and acute bronchitis

Antibiotic use for acute upper respiratory tract infections in a veteran population

OBJECTIVE

To evaluate the effect of age, symptom duration, symptom presentation, presenting location, and type of acute upper respiratory tract infection (URI) on the receipt of inappropriate antibiotic prescriptions in adult patients.

METHODS

A retrospective cross-sectional study was conducted within a U.S. Department of Veterans Affairs health system. A total of 500 adult patients with acute URI during a 1-year study period were randomly selected and evaluated for receipt of antibiotic prescriptions. Patients were excluded if they had an indication for antibiotics based on Centers for Disease Control and Prevention criteria, concomitant infection, or unreviewable patient record. Patients were grouped and compared by age, symptom duration, symptom presentation (purulence of secretions), presenting location, and type of URI.

RESULTS

Overall, antibiotics were prescribed to 77% (219 of 283) of patients included in the study. Patients with purulent symptoms received a higher proportion of antibiotic prescriptions compared with those without purulent symptoms (P < 0.01). Patients seen in routine primary care received a lower proportion of antibiotic prescriptions compared with those seen in the emergency department or urgent care/primary care walk-in clinic (P < 0.01). No significant difference was observed in the proportion of antibiotic prescriptions based on symptom duration (P = 0.99) or age (P = 0.19). Patients with acute sinusitis or bronchitis received a higher proportion of antibiotics than those with acute pharyngitis or nonspecific URI (P < 0.01).

CONCLUSION

Despite evidence-based practice guidelines for the rational use of antibiotics in patients with upper respiratory tract infections, these conditions are being treated inappropriately. Patient and provider factors play a role in the receipt of antibiotics. Further efforts, including those by pharmacists, are needed to improve the use of antibiotics for acute URI in adult patients.

Identification of upper respiratory tract pathogens using electrochemical detection on an oligonucleotide microarray

Bacterial and viral upper respiratory infections (URI) produce highly variable clinical symptoms that cannot be used to identify the etiologic agent. Proper treatment, however, depends on correct identification of the pathogen involved as antibiotics provide little or no benefit with viral infections. Here we describe a rapid and sensitive genotyping assay and microarray for URI identification using standard amplification and hybridization techniques, with electrochemical detection (ECD) on a semiconductor-based oligonucleotide microarray. The assay was developed to detect four bacterial pathogens (Bordetella pertussis, Streptococcus pyogenes, Chlamydia pneumoniae and Mycoplasma pneumoniae) and 9 viral pathogens (adenovirus 4, coronavirus OC43, 229E and HK, influenza A and B, parainfluinza types 1, 2, and 3 and respiratory syncytial virus. This new platform forms the basis for a fully automated diagnostics system that is very flexible and can be customized to suit different or additional pathogens. Multiple probes on a flexible platform allow one to test probes empirically and then select highly reactive probes for further iterative evaluation. Because ECD uses an enzymatic reaction to create electrical signals that can be read directly from the array, there is no need for image analysis or for expensive and delicate optical scanning equipment. We show assay sensitivity and specificity that are excellent for a multiplexed format.

Correlates of parental antibiotic knowledge, demand, and reported use

BACKGROUND

Clinicians cite parental misconceptions and requests for antibiotics as reasons for inappropriate prescribing.

AIMS

To identify misconceptions regarding antibiotics and predictors of parental demand for antibiotics and to determine if parental knowledge and attitudes are associated with use.

METHODS

Survey of parents in 16 Massachusetts communities. Domains included antibiotic-related knowledge, attitudes about antibiotics, antibiotic use during a 12-month period, demographics, and access to health information. Bivariate and multivariate analyses evaluated predictors of knowledge and proclivity to demand antibiotics. A multivariate model evaluated the associations of knowledge, demand, and demographic factors with parent-reported antibiotic use.

RESULTS

A total of 1106 surveys were returned (response rates: 54% and 32% for commercially-insured and Medicaid-insured families). Misconceptions were common regarding bronchitis (92%) and green nasal discharge (78%). Two hundred sixty-five (24%) gave responses suggesting a proclivity to demand antibiotics. Antibiotic knowledge was associated with increased parental age and education, having more than 1 child, white race, and receipt of media information on resistance. Factors associated with a proclivity to demand antibiotics included decreased knowledge, pressure from day-care settings, lack of alternatives offered by clinicians, and lack of access to media information. Among all respondents, reported antibiotic use was associated with younger child age and day-care attendance. Among Medicaid-insured children only, less antibiotic knowledge and tendency to demand antibiotics were associated with higher rates of antibiotic use.

CONCLUSIONS

Misconceptions regarding antibiotic use are widespread and potentially modifiable by clinicians and media sources. Particular attention should be paid to Medicaid-insured patients in whom such misconceptions may contribute to inappropriate prescribing.

Prescription behaviours of office-based doctors to standardized common cold patients in Korea

PURPOSE

To investigate real pictures of prescription behaviours of office-based doctors in Korea, especially focusing on the prescription of oral antibiotics and injections.

METHODS

Prescription information was collected from 18 standardized patients (SPs) with the symptoms of the common cold who visited doctors' office.

RESULTS

For these patients antibiotics were prescribed by 96 doctors (64.7%) out of 148 and the rate of antibiotic prescription increased with age of doctors, increasing number of medicines, and cost of medicines. Analgesics were most frequently prescribed (91.8%), and gastrointestinal drugs (81.6%), antitussivies (61.2%), antithistamines (61.2%), decongestants (59.2%), mucolytics (51.0%) and proteolytic enzymes (32.7%) followed. More than half of the doctors intended to give injections to the patients, which was higher among internists and doctors prescribed more medicines.

CONCLUSIONS

Antibiotics and injections were frequently prescribed for mild common colds in Korea. Action to ensure judicious use of antibiotics and injection is urgent.

The patient's role in the spread and control of bacterial resistance to antibiotics

As the ultimate consumers, patients play an important role in the emergence, spread and control of bacterial resistance to antibiotics. Improved knowledge of antibiotics and the problem of resistance, as well as a better understanding of beliefs, pressures/concerns, and expectations, from both the patient's and physician's perspectives, are fundamental for controlling antibiotic use. There is growing evidence to suggest that empowering patients through implementation of patient-centered health-care strategies, such as shared decision-making, in conjunction with educational initiatives help to change attitudes and behavior, and improve access to and completion of appropriate antimicrobial therapy. This, in turn, may help to control the development and spread of resistance to antibiotics.

The pharmacist's role in promoting optimal antimicrobial use

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.