Antibiotic Prescribing In Primary Care Research Articles

Successful improvement of antibiotic prescribing at Primary Care in Andalusia following the implementation of an antimicrobial guide through multifaceted interventions: An interrupted time-series analysis.

BackgroundMost effective strategies designed to improve antimicrobial prescribing have multiple approaches. We assessed the impact of the implementation of a rigorous antimicrobial guide and subsequent multifaceted interventions aimed at improving antimicrobial use in Primary Care.MethodsA quasi-experimental study was designed. Interventions aimed at achieving a good implementation of the guide consisted of the development of electronic decision support tools, local training meetings, regional workshops, conferences, targets for rates of antibiotic prescribing linked to financial incentives, feedback on antibiotic prescribing, and the implementation of a structured educational antimicrobial stewardship program. Interventions started in 2011, and continued until 2018. Outcomes: rates of antibiotics use, calculated into defined daily doses per 1,000 inhabitants-day (DID). An interrupted time-series analysis was conducted. The study ran from January 2004 until December 2018.ResultsOverall annual antibiotic prescribing rates showed increasing trends in the pre-intervention period. Interventions were followed by significant changes on trends with a decline over time in antibiotic prescribing. Overall antibiotic rates dropped by 28% in the Aljarafe Area and 22% in Andalusia between 2011 and 2018, at rates of -0.90 DID per year (95%CI:-1.05 to -0.75) in Aljarafe, and -0.78 DID (95%CI:-0.95 to -0.60) in Andalusia. Reductions occurred at the expense of the strong decline of penicillins use (33% in Aljarafe, 25% in Andalusia), and more precisely, amoxicillin clavulanate, whose prescription plummeted by around 50%. Quinolones rates decreased before interventions, and continued to decline following interventions with more pronounced downward trends. Decreasing cephalosporins trends continued to decline, at a lesser extent, following interventions in Andalusia. Trends of macrolides rates went from a downward trend to an upward trend from 2011 to 2018.ConclusionsMultifaceted interventions following the delivering of a rigorous antimicrobial guide, maintained in long-term, with strong institutional support, could led to sustained reductions in antibiotic prescribing in Primary Care.

A computerized decision support system (CDSS) for antibiotic prescription in primary care-Antibioclic: implementation, adoption and sustainable use in the era of extended antimicrobial resistance.

To describe the implementation and use of a computerized decision support system (CDSS) for antibiotic prescription in primary care in France (Antibioclic). The CDSS targets 37 infectious diseases and has been freely available on a website since 2011. Description and implementation of the architecture of a CDSS for antibiotic prescription in general practice. Analysis of the queries made between 2012 and 2018 on the CDSS by GPs. Analysis of two cross-sectional studies of users in 2014 and 2019. The number of queries increased from a median of 796/day [IQR, 578-989] in 2012 to 11 125/day [5592-12 505] in 2018. Unique users increased from 414/day [245-494] in 2012 to 5365/day [2891-5769] in 2018. Time taken to make a query was 2 min [1.9-2.1]. Among 3 542 347 queries in 2018, 78% were for adults. Six situations accounted for ≥50% of queries: cystitis; acute otitis media; acute sinusitis; community-acquired pneumonia; sore throat; and pyelonephritis. Queries concerned pathologies for which antibiotic prescription was necessary (64%), was conditional on additional clinical steps (34%) or was not recommended (2%). Most users (81%) were GPs, with median age of 38 years [31-52] and 58% were female. Among the 4016 GPs who responded to the surveys, the vast majority (96%) reported using the CDSS during the consultation, with 24% systematically using Antibioclic to initiate an antibiotic course and 93% having followed the CDSS recommendation for the latest prescription. Most GPs were comfortable using the CDSS in front of a patient. Antibioclic has been adopted and is widely used in primary care in France. Its interoperability could allow its adaptation and implementation in other countries.

Associations between declining antimicrobial use in primary care in Scotland and patient satisfaction and hospitalisation due to infection: a longitudinal study of greater than five million patients

Background. Scottish antimicrobial prescribing in the community has fallen since 2012, but this could have unintended consequences. The aim was to examine associations between changes in antibiotic prescribing in primary care and hospital admissions and patient satisfaction. Methods. Data for 877 Scottish general practices with 5.1 million patients were provided by NHS National Services Scotland. Practices were classified into four equal groups (quartiles) in terms of change in total antibiotic prescribing (rate/1000 registered patients in each quarter) 2012-2018. Changes in hospital admission with infection were examined comparing the four groups. Multivariate regression examined associations between change in antibiotic prescribing and patient satisfaction with the practice using national survey data. Results. Across Scotland, primary care antibiotic prescribing decreased by 15% from 194.1 (95%CI 193.8-194.4) in Q1 2012 to 165.3 (95%CI 165.0-165.6 ) in Q2 2012, with considerable variation between practices (non-significant increase of 0.22 prescriptions/1000/quarter [p=0.49] for the quartile of practices with least reduction in antibiotic prescribing, vs reduction of -2.95 prescriptions/1000/quarter [p<0.001] for quartile with the largest reduction). Rates of hospital admissions with infection increased over the time period but there were no significant association with changes in antibiotic prescribing. Patient satisfaction decreased over the period, but change in antibiotic prescribing was not associated with patient satisfaction. Conclusion. There have been clinically significant reductions in Scottish primary care antibiotic use since 2012, varying considerably between practices. Longitudinal analysis of Scotland-wide practice level data found no associations between practice-level reductions in primary care antibiotic prescribing and hospital admissions or patient satisfaction.

Serious bacterial infections and antibiotic prescribing in primary care: cohort study using electronic health records in the UK

ObjectiveThis study evaluated whether serious bacterial infections are more frequent at family practices with lower antibiotic prescribing rates.DesignCohort study.Setting706 UK family practices in the Clinical Practice Research Datalink from 2002...

Effect of antibiotic prescribing in primary care on antimicrobial resistance: a literature review 2020

Our aim is to review the literature and, where appropriate, investigating subsequent antibiotic resistance in individuals prescribed antibiotics in primary care. Data sources are observational and experimental studies identified through Medline, Embase, and Cochrane searches. Review methods Electronic searches using MeSH terms and text words identified 4373 papers. Results The review included 24 studies, 22 involved patients with symptomatic infection and two involved healthy volunteers, 19 were observational studies (of which two were prospective) and five were randomised trials. The observations concluded that individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop bacterial resistance to that antibiotic.

Conceptualising the Integration of Strategies by Clinical Commissioning Groups in England towards the Antibiotic Prescribing Targets for the Quality Premium Financial Incentive Scheme: A Short Report.

Background: In order to tackle the public health threat of antimicrobial resistance, improvement in antibiotic prescribing in primary care was included as one of the priorities of the Quality Premium (QP) financial incentive scheme for Clinical Commissioning Groups (CCGs) in England. This paper briefly reports the outcome of a workshop exploring the experiences of antimicrobial stewardship (AMS) leads within CCGs in selecting and adopting strategies to help achieve the QP antibiotic targets. Methods: We conducted a thematic analysis of the notes on discussions and observations from the workshop to identify key themes. Results: Practice visits, needs assessment, peer feedback and audits were identified as strategies integrated in increasing engagement with practices towards the QP antibiotic targets. The conceptual model developed by AMS leads demonstrated possible pathways for the impact of the QP on antibiotic prescribing. Participants raised a concern that the constant targeting of high prescribing practices for AMS interventions might lead to disengagement by these practices. Most of the participants suggested that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Conclusions: Our results suggest that national targets, rather than financial incentives are key for engaging stakeholders in quality improvement in antibiotic prescribing.

Machine Predictions and Human Decisions with Variation in Payoffs and Skill

Human decision-making differs due to variation in both incentives and available information. This constitutes a substantial challenge for the evaluation of whether and how machine learning predictions can improve decision outcomes. We propose a framework that incorporates machine learning on large-scale data into a choice model featuring heterogeneity in decision maker payoff functions and predictive skill. We apply this framework to the major health policy problem of improving the efficiency in antibiotic prescribing in primary care, one of the leading causes of antibiotic resistance. Our analysis reveals large variation in physicians' skill to diagnose bacterial infections and in how physicians trade off the externality inherent in antibiotic use against its curative benefit. Counterfactual policy simulations show that the combination of machine learning predictions with physician diagnostic skill results in a 25.4 percent reduction in prescribing and achieves the largest welfare gains compared to alternative policies for both estimated physician as well as conservative social planner preference weights on the antibiotic resistance externality.

Machine Predictions and Human Decisions with Variation in Payoffs and Skills

Human decision-making differs due to variation in both incentives and available information. This generates substantial challenges for the evaluation of whether and how machine learning predictions can improve decision outcomes. We propose a framework that incorporates machine learning on large-scale administrative data into a choice model featuring heterogeneity in decision maker payoff functions and predictive skill. We apply our framework to the major health policy problem of improving the efficiency in antibiotic prescribing in primary care, one of the leading causes of antibiotic resistance. Our analysis reveals large variation in physicians’ skill to diagnose bacterial infections and in how physicians trade off the externality inherent in antibiotic use against its curative benefit. Counterfactual policy simulations show the combination of machine learning predictions with physician diagnostic skill achieves a 25.4 percent reduction in prescribing and the largest welfare gains compared to alternative policies for estimated as well as plausible hypothetical weights on the antibiotic resistance externality.

The role of real-world data in the development of treatment guidelines: a case study on guideline developers\u2019 opinions about using observational data on antibiotic prescribing in primary care

BackgroundAntimicrobial resistance (AMR) is a prominent threat to public health. Although many guidelines have been developed over the years to tackle this issue, their impact on health care practice varies. Guidelines are often based on evidence from clinical trials, but these have limitations, particularly in the breadth and generalisability of the evidence and evaluation of the guidelines’ uptake. The aim of this study was to investigate how national and local guidelines for managing common infections are developed and explore guideline committee members’ opinions about using real-world observational evidence in the guideline development process.MethodsSix semi-structured interviews were completed with participants who had contributed to the development or adjustment of national or local guidelines on antimicrobial prescribing over the past 5 years (from the English National Institute for Health and Care Excellence (NICE)). Interviews were audio recorded and transcribed verbatim. Data was analysed thematically. This also included review of policy documents including guidelines, reports and minutes of guideline development group meetings that were available to the public.ResultsThree key themes emerged through our analysis: perception versus actual guideline development process, using other types of evidence in the guideline development process, and guidelines are not enough to change antibiotic prescribing behaviour. In addition, our study was able to provide some insight between the documented and actual guideline development process within NICE, as well as how local guidelines are developed, including differences in types of evidence used.ConclusionsThis case study indicates that there is the potential for a wider range of evidence to be included as part of the guideline development process at both the national and local levels. There was a general agreement that the inclusion of observational data would be appropriate in enhancing the guideline development process, as well providing a potential solution for monitoring guideline use in clinical practice, and improving the implementation of treatment guidelines in primary care.

Does practice characteristics explain the impact of a financial incentive on antibiotic prescribing?

Abstract Background About 80% of the antibiotics prescribed in England are from primary care practices. The Quality Premium (QP) initiative that offers financial rewards on the quality of specific health services commissioned is one of the NHS England interventions to reduce antimicrobial resistance through reduced prescribing. Evaluations of the initiative suggest a reduction in antibiotic prescribing in primary care. We investigated whether the effect of this financial incentive on antibiotic prescribing is explained by variations in practice characteristics that can contribute to differences in antibiotic prescribing. Methods We used monthly prescribing data for 6,600 practices in England from NHS Digital for the year from April 2015 when antibiotic improvement was included as a QP priority and the preceding year. We fitted an initial linear generalised estimating equations model examining the effect of the incentive on antibiotic items/STAR-PU prescribed, adjusting for seasonality and number of months since implementation. We examined the consistency of the effect after the initial model was adjusted for variations in workforce, prevalence of co-morbidities (asthma, COPD, cancer, chronic kidney disease, diabetes), and deprivation index. Results Antibiotics prescribed in primary care practices in England reduced by 0.20 items/STAR-PU (95% CI:0.19-0.21) after the implementation of the initiative. This reduction flattened off in the following months with a month-on-month increase of 0.013 items (95% CI:0.012-0.013). After adjusting for practice characteristics, the immediate and month-on-month impacts remained consistent with slight attenuation of the immediate impact (0.18, 95% CI:0.17-0.18). Subgroup analyses showed the effect of the initiative was significantly more among 20% top prescribers. Conclusions Variations in practice characteristics are not a major explanation for the impact of the quality premium initiative on antibiotic prescribing in primary care practices in England. Key messages Our findings on the targeted impact of a financial incentive scheme to improve antibiotics prescribing on high prescribers are important to policymakers and antibiotic stewardship programs. Variations in practice characteristics are not a major explanation for the impact of a financial incentive scheme on antibiotics prescribing in primary care practices in England.

How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation.

Many antimicrobial stewardship (AMS) interventions have been implemented in England, facilitating decreases in antibiotic prescribing. Nevertheless, there is substantial variation in antibiotic prescribing across England and some healthcare organizations remain high prescribers of antibiotics. This study aimed to identify ways to improve AMS interventions to further optimize antibiotic prescribing in primary care in England. Stakeholders representing different primary care settings were invited to, and 15 participated in, a focus group or telephone interview to identify ways to improve existing AMS interventions. Forty-five intervention suggestions were generated and 31 were prioritized for inclusion in an online survey. Fifteen stakeholders completed the survey appraising each proposed intervention using the pre-defined APEASE (i.e., Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity) criteria. The highest-rated nine interventions were prioritized as most promising and feasible, including: quality improvement, multidisciplinary peer learning, appointing AMS leads, auditing individual-level prescribing, developing tools for prescribing audits, improving inductions for new prescribers, ensuring consistent local approaches to antibiotic prescribing, providing online AMS training to all patient-facing staff, and increasing staff time available for AMS work with standardizing AMS-related roles. These prioritized interventions could be incorporated into existing national interventions or developed as stand-alone interventions to help further optimize antibiotic prescribing in primary care in England.

2073. Apples and Oranges: Comparing Toolkits to Track Antimicrobial Prescribing in Ambulatory Care Settings

BackgroundBetween 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department.MethodsThis was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings.ResultsBetween March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified.ConclusionRates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions.Disclosures All authors: No reported disclosures.

A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing.

This qualitative literature review aims to critically assess and analyse published literature to determine drivers influencing over-prescribing by general practitioners (GPs) in primary care, exploring their views and opinions, and also to determine how antibiotic prescribing can be improved and unnecessary prescribing reduced, thus reducing the threat to public health from antibiotic resistance. It is intended to develop new thinking in this area and add to existing knowledge concerning GPs' antibiotic prescribing behaviour. Thematic analysis following Braun and Clarke's 2006 framework was used to analyse 17 qualitative studies chosen from EBSCOhost databases, focusing on GPs' views of antibiotic prescribing in primary care, with specific search strategies and inclusion criteria to ensure study quality and trustworthiness. Three main themes and nine sub-themes were generated from the studies. The first main theme discussed GP factors related to over-prescribing, the main drivers being GP attitudes and feelings and anxiety/fear concerning prescribing. The second theme highlighted external factors, with pressures from time and financial issues as the main drivers within this theme. The final theme marked patient pressure, demand and expectation with lack of patient education as the major drivers affecting GP over-prescribing. The findings of this research show GPs' antibiotic prescribing in primary care is complex, being influenced by many internal and external factors. A multifaceted approach to interventions targeting the drivers identified could significantly reduce the level of antibiotic prescribing thus minimising the impact of antibiotic resistance and promoting a more efficient working environment for GPs and patients alike.

Effects of restrictive prescribing on antibiotic consumption in primary care in China, 2012–17: an interrupted time-series analysis

BackgroundThe overuse of antibiotics is a major public health problem worldwide, especially in low-income and middle-income countries. However, there are few polices specific to antibiotic stewardship in primary care, and their effectiveness is unclear. A restrictive-prescribing stewardship policy was introduced in Hubei province, China, in November, 2014. We aimed to evaluate the effects of this policy on antibiotic consumption in primary care in the region. MethodsMonthly antibiotic consumption data were extracted from the Hubei Medical Procurement Administrative Agency system from Sept 1, 2012, to Aug 31, 2017. An interrupted time-series analysis combined with Anatomical Therapeutic Chemical/Defined Daily Dose methodology and European Surveillance of Antimicrobial Consumption Quality Indictors was performed to evaluate the effects of the restrictive-prescribing stewardship policy on antibiotic consumption in primary care. The Durbin-Watson test was used to check for autocorrelation, and p values and coefficients were estimated by use of the generalised least squares method. FindingsOver the entire study period, a significant reduction (–32·58%, p<0·001) was observed in total antibiotic consumption, which occurred within 1 month after introduction of restrictive prescribing (r=–2·4518, p=0·005) and continued to 2017 (r=–0·1193, p=0·017). Specifically, the use of penicillins (r=–0·0553, p=0·035), cephalosporins (r=–0·0294, p=0·037), and macrolides/lincosamides/streptogramins (r=–0·0182, p=0·003) decreased from before to after the intervention. The restrictive intervention was also associated with an immediate decline in the contribution of β-lactamase-sensitive penicillins to total antibiotic use (r=–2·9126, p=0·001) and a decline from baseline in the use of oral antibiotics (r=–0·0815, p=0·018). However, an immediate increase in the contribution of third-generation and fourth-generation cephalosporins to total antibiotic use (r=5·0352, p=0·005) and an increase from baseline in the contribution of fluoroquinolones to total antibiotic use (r=0·0406, p=0·037) were observed after the intervention. Finally, restrictive prescribing was associated with an immediate increase in the ratio of broad-spectrum to narrow-spectrum antibiotic use (r=1·8747, p=0·001), although use of both types of antibiotics significantly declined from before to after the intervention (broad-spectrum antibiotics: r=–0·0423, p=0·017; narrow-spectrum antibiotics: r=–0·0223, p=0·006). InterpretationRestrictive antibiotic prescribing in primary care in China was effective in reducing total antibiotic consumption, especially use of penicillins, cephalosporins, and macrolides/lincosamides/streptogramins. However, the effects of the intervention on some other antibiotics were mixed. Stronger administrative regulation focusing on specific antibiotics, such as third-generation and fourth-generation cephalosporins, fluoroquinolones, and broad-spectrum antibiotics, is needed in the future. FundingNational Natural Science Foundation of China Youth Fund (grant number 71704058).

Analyzing data from the digital healthcare exchange platform for surveillance of antibiotic prescriptions in primary care in urban Kenya: A mixed-methods study.

BackgroundKnowledge of antibiotic prescription practices in low- and middle-income countries is limited due to a lack of adequate surveillance systems.ObjectiveTo assess the prescription of antibiotics for the treatment of acute respiratory tract infections (ARIs) in primary care.MethodAn explanatory sequential mixed-methods study was conducted in 4 private not-for-profit outreach clinics located in slum areas in Nairobi, Kenya. Claims data of patients who received healthcare between April 1 and December 27, 2016 were collected in real-time through a mobile telephone-based healthcare data and payment exchange platform (branded as M-TIBA). These data were used to calculate the percentage of ARIs for which antibiotics were prescribed. In-depth interviews were conducted among 12 clinicians and 17 patients to explain the quantitative results.ResultsA total of 49,098 individuals were registered onto the platform, which allowed them to access healthcare at the study clinics through M-TIBA. For 36,210 clinic visits by 21,913 patients, 45,706 diagnoses and 85,484 medication prescriptions were recorded. ARIs were the most common diagnoses (17,739; 38.8%), and antibiotics were the most frequently prescribed medications (21,870; 25.6%). For 78.5% (95% CI: 77.9%, 79.1%) of ARI diagnoses, antibiotics were prescribed, most commonly amoxicillin (45%; 95% CI: 44.1%, 45.8%). These relatively high levels of prescription were explained by high patient load, clinician and patient perceptions that clinicians should prescribe, lack of access to laboratory tests, offloading near-expiry drugs, absence of policy and surveillance, and the use of treatment guidelines that are not up-to-date. Clinicians in contrast reported to strictly follow the Kenyan treatment guidelines.ConclusionThis study showed successful quantification of antibiotic prescription and the prescribing pattern using real-world data collected through M-TIBA in private not-for-profit clinics in Nairobi.

Antibiotic prescription rate for upper respiratory tract infections in general practice - a Croatian study.

Aim Acute upper respiratory tract infections are the most common indication for antibiotic prescribing in primary care. The frequency of antibiotics prescribed to patients with upper respiratory tract infections has been studied. Methods A cross-sectional survey has been conducted from October to December 2017 with participation of 17 General Practices in Croatia. Visits of patients with symptoms of upper respiratory tract infections made the survey framework. A specially structured questionnaire was a tool for the assessment of reasons for encounters, clinical statuses and practitioners' decisions. According to the registered clinical status, two independent doctors classified patients using Centor criteria, which were used to evaluate appropriate indication for antibiotic prescription. Results The survey analysed 709 patients' visits. Seventy three percent of general practice visits due to acute respiratory tract infection were initial. Antibiotics had been prescribed in the total of 32.6% of cases. Analysing upper respiratory tract infections with Centor score 1 and 2, antibiotics had been prescribed in 22.8% cases of the first visit and in 31.7% of the second visit, and with the Centor score 3 and 4 antibiotics had been prescribed in 85.1% of cases during the initial visit, and 66.7% of cases during the second visit. Logistic regression analysis about the contribution of nonclinical variables to antibiotic prescribing showed that most often antibiotics had been prescribed on Mondays. The most prescribed group of antibiotics was the penicillin group (74.8%), followed by macrolides (17.6%) and cephalosporins (4.0%). Conclusion General practitioners prescribe antibiotics for acute respiratory tract infections more than recommended by evidence based medicine and professional criteria.

Pharmaceutical companies information and antibiotic prescription patterns: A follow-up study in Spanish primary care.

ObjectivesTo assess the impact of sources of drug information on antibiotic prescribing patterns (quantity and quality) among primary care physicians.MethodsWe conducted a cohort study on primary care physicians who were actively engaged in medical practice in 2010 in a region in north-west Spain (Galicia), fulfilling inclusion criteria (n = 2100). As the independent variable, we took the perceived utility of 6 sources of information on antibiotics, as measured by the validated KAAR-11 questionnaire. As dependent variables, we used: (1) a quality indicator (appropriate quality, defined as any case where 6 of the 12 indicators proposed by the European Surveillance of Antimicrobial Consumption Network [ESAC-Net] were better than the mean values for Spain); and, (2) a quantity indicator (high prescribing), defined as any case where defined daily doses (DDD) per 1 000 inhabitants per day of antibacterials for systemic use were higher than the mean values for Spain. The adjusted odds ratio for a change in the interquartile range (IqOR) for each sources of information on antibiotics was calculated using Generalized Linear Mixed Models.ResultsThe questionnaire response rate was 68%. Greater perceived utility of pharmaceutical sales representatives increases the risk of having high prescribing (1/IqOR = 2.50 [95%CI: 1.63–3.66]) and reduces the probability of having appropriate quality (1/IqOR = 2.28 [95%CI: 1.77–3.01]). Greater perceived utility of clinical guidelines increases the probability of having appropriate quality (1/IqOR = 1.25 [95%CI: 1.02–1.54]) and reduces the probability of high prescribing (1/IqOR = 1.25 [95%CI: 1.02–1.54]).ConclusionsSources of information on antibiotics are an important determinant of the quantity and quality of antibiotic prescribing in primary care. Commercial sources of information influence prescribing negatively, and clinical guidelines are associated with better indicators.

Lower Urinary Tract Infections: Management, Outcomes and Risk Factors for Antibiotic Re-prescription in Primary Care

SummaryBackgroundUrinary tract infections (UTIs) are major drivers of antibiotic prescribing in primary care. Inappropriate antibiotic prescribing for UTIs likely drives antibiotic resistance. We aimed to describe current investigation and antibiotic treatment to examine opportunities for improved antimicrobial stewardship.MethodsWe identified a cohort of all patients with lower UTI diagnosis between 2011 and 2015 in the 390 primary care practices contributing data to ResearchOne in England. We examined investigation, antibiotic treatment and antibiotic re-prescription within 28 days according to guideline-defined patient groups. We assessed risk factors for re-prescription using mixed-effect logistic regression.FindingsIn total, 494,675 UTIs were diagnosed in 300,354 patients. Median age was 54 years, and 83.3% were women. Same-day antibiotic was prescribed for 85.7% of UTIs; 56.8% were treated with trimethoprim, and urine sampling was undertaken in 25.0%. The antibiotic re-prescription rate was low (17,430, 4.1%) and increased slightly over time in men (from 5.2% in 2011 to 6.2% in 2015). Overall, 21.1% of pre-prescription were for the same antibiotic. The percentage of adults with recurrent UTIs ranged from 1.0% in 18–64 year-old men to 2.6% in women ≥ 65 years. The risk of antibiotic re-prescription increased with age, calendar year, recent antibiotic prescribing and treatment with antibiotic other than trimethoprim or nitrofurantoin.InterpretationMost patients diagnosed with lower UTI in primary care receive same-day empirical antibiotics with little diversity in choice of agent. The antibiotic re-prescription rate is low. Microbiological investigation and re-prescription of the same antibiotic given for the initial episode happened in one quarter of UTIs.FundingUK National Health Service Improvement.

Reducing antibiotic prescribing in primary care in England from 2014 to 2017: population-based cohort study

ObjectiveTo analyse individual-patient electronic health records to evaluate changes in antibiotic (AB) prescribing in England for different age groups, for male and female subjects, and by prescribing indications from 2014...

Social norm feedback reduces primary care antibiotic prescribing in a regression discontinuity study.

Reducing antibiotic prescribing is a priority for health authorities responsible for preventing antimicrobial resistance. Northern Ireland has high rates of antimicrobial use. We implemented a social norm feedback intervention and evaluated its impact. To estimate the size and duration of the effect of a social norm feedback letter to GPs who worked in the 20% of practices with the highest antimicrobial prescribing. The letter was sent in October 2017 to 221 GPs in 67 practices. To assess the effect of the intervention, we used a sharp non-parametric regression discontinuity (RD) design, with prescribing rates in the four calendar quarters following the intervention as the outcome variables. In the quarter following the intervention (October to December 2017) there was a change of -25.7 (95% CI = -42.5 to -8.8, P = 0.0028) antibiotic items per 1000 Specific Therapeutic group Age-sex Related Prescribing Units (STAR-PU). At 1 year, the coefficient was -58.7 (95% CI = -116.7 to -0.7, P = 0.047) antibiotic items per 1000 STAR-PU. The greatest change occurred soon after the intervention. Approximately 18900 fewer antibiotic items were prescribed than if the intervention had not been made (1% of Northern Ireland's annual primary care antibiotic prescribing). A social norm feedback intervention reduced antibiotic prescribing in the intervention practices. The diminishing effect over time suggests the need for more frequent feedback. The RD method allowed measurement of the effectiveness of an intervention that was delivered as part of normal business, without a randomized trial.