Antibiotic Prescribing In Primary Care Research Articles

P1337 Diabetes increases relapses and recurrences of acute urinary tract infections in adult women but does not evoke a differ-ence in the pattern of antibiotic prescriptions in primary care

Carbapenem-resistant Acinetobacter baumannii isolates producing carbapenem-hydrolysing oxacillinases are emerging worldwide. These enzymes are divided into four phylogenetic subgroups: OXA-23-like, OXA-51-like, OXA-24-like and OXA-58-like. A PCR-based approach linked to pyrosequencing analysis was developed to identify the genes for these β-lactamases. Carbapenem-hydrolysing oxacillinases were rapidly and unambiguously identified in a collection of carbapenem-resistant clinical isolates of A. baumannii and Acinetobacter junii. Pyrosequencing may provide a rapid tool for identification of OXA variants, thus avoiding delays inherent in classical sequencing methods.

Use of the bacteriology laboratory to decrease general practitioners’ antibiotic prescribing

Objective: Use of the bacteriology laboratory to guide antibiotic prescribing in primary care is often considered inappropriate due to difficulties of access in a relevant time scale. The overnight analysis offered to general practitioners in the Grampian area of Scotland for the past 6 years (ABLE), and which had previously been shown to reduce antibiotic prescribing by two-thirds in a randomized controlled trial, was audited to see if it was being used correctly in general practice, that is to reduce unnecessary antibiotic prescribing. Methods: 699 consultations were audited. Of these, 357 were ABLE patients. The other 342 were chosen because an antibiotic had been prescribed. Results: Only 36.7% (140) of the ABLE patients were prescribed an antibiotic, 65.7% being given a delayed action script. All but 10 were culture positive. ABLE patients had a greater proportion of urinary tract infections than the non-ABLE patients, but less lower-respiratory and skin or soft-tissue infection. The antibiotics prescribed reflected the differences in infection type. The repeat visit rate and repeat antibiotic prescription rate were almost identical between the two groups.Conclusion: While the overall use of ABLE in Grampian is low, its use seems to be appropriate in that it is successfully being used to identify bacterial infection and reduce unnecessary antibiotic prescribing.

Research Letter

<h3>Introduction</h3> The learning healthcare system (LHS) underpinned by data analysis and feedback to clinical care providers is thought to improve quality of care. The work aimed to implement an LHS for antibiotic prescribing in primary care in England. <h3>Method</h3> Deidentified patient-level data from general practices were processed and analysed at regular intervals (fortnightly increments). A dashboard application was developed and implemented displaying analytical graphics to give periodic feedback to clinicians, tailored to each clinical site. Benchmarking parameters were established by the analysis of two large national primary care datasets allowing peer-to-peer comparisons. To date, the dashboard is available to 70 English practices. <h3>Conclusions</h3> Successful implementation and uptake of the secure technical LHS infrastructure for the analysis and feedback to clinicians of their antibiotic prescribing demonstrate a great appetite for this type of frequent prescribing review in primary care, combining advanced data analytics with tailored feedback.

Modifying Antibiotic Prescribing in Primary Care

a result of inactive empirical antibiotic therapy as well as increasing economic costs for the community. Data on the association between the appropriateness of empirical antibiotic therapy and paitent outcomes is sparse for primary health care, compared with data from hospital settings, but anecdotal experience indicates that poor early antibiotic choice may be associated with progression of infection leading to hospitalization. In view of the above concerns, it appears reasonable that efforts be expended to improve the adequacy of antibiotic prescribing in the primary care setting. In this issue of Clinical Infectious Diseases, Rautakorpi et al. [7] describe a remarkable effort to improve antibiotic use in the Finnish primary health care setting. It has long been known that antibiotic prescribing is taken seriously in Scandinavia; indeed, almost one-third of all primary health care centers in Finland expressed a willingness to participate in this study. A multifaceted intervention was initiated over a 2-year period, primarily targeting physicians, although the authors hint at enhanced education for patients. One physician from each participating health care center spent 6.5 days in a “train the trainer” program. Their primary goal was to improve compliance among their colleagues with antibiotic prescribing guidelines for 6 common infections—otitis media, sinusitis, pharyngitis, acute bronchitis, bacterial skin infections, and urinary tract infections. Feedback on the study results, which acted as an important stimulus for ongoing adherence, was given to the physicians once a year. The intervention was successful on some, but not all, counts. There were significant improvements in compliance with first-line antibiotic treatment recommendations for sinusitis (from 35% to 51%; ), acute bronchitis (from 4% to P ! .001 9%; ), and urinary tract infec

Acute Infections in Primary Care: Accuracy of Electronic Diagnoses and Electronic Antibiotic Prescribing

ObjectiveTo maximize effectiveness, clinical decision-support systems must have access to accurate diagnostic and prescribing information. We measured the accuracy of electronic claims diagnoses and electronic antibiotic prescribing for acute respiratory infections (ARIs) and urinary tract infections (UTIs) in primary care. DesignA retrospective, cross-sectional study of randomly selected visits to nine clinics in the Brigham and Women's Practice-Based Research Network between 2000 and 2003 with a principal claims diagnosis of an ARI or UTI (N = 827). MeasurementsWe compared electronic billing diagnoses and electronic antibiotic prescribing to the gold standard of blinded chart review. ResultsClaims-derived, electronic ARI diagnoses had a sensitivity of 98%, specificity of 96%, and positive predictive value of 96%. Claims-derived, electronic UTI diagnoses had a sensitivity of 100%, specificity of 87%, and positive predictive value of 85%. According to the visit note, physicians prescribed antibiotics in 45% of ARI visits and 73% of UTI visits. Electronic antibiotic prescribing had a sensitivity of 43%, specificity of 93%, positive predictive value of 90%, and simple agreement of 64%. The sensitivity of electronic antibiotic prescribing increased over time from 22% in 2000 to 58% in 2003 (p for trend < 0.0001). ConclusionClaims-derived, electronic diagnoses for ARIs and UTIs appear accurate. Although closing, a large gap persists between antibiotic prescribing documented in the visit note and the use of electronic antibiotic prescribing. Barriers to electronic antibiotic prescribing in primary care must be addressed to leverage the potential that computerized decision-support systems offer in reducing costs, improving quality, and improving patient safety.

The relationship between primary care antibiotic prescribing and bacterial resistance in adults in the community: a controlled observational study using individual patient data

To examine the relationship between primary care prescribed antibiotics and the development of antibiotic resistance in perineal flora contaminating unselected urinary isolates from a large sample of asymptomatic adults representative of the general community. Escherichia coli isolates contaminating urine samples were obtained from asymptomatic adults aged >16 years registered with general practices in the former Avon and Gloucestershire health authority areas. Data on antibiotic exposure during the 12 months prior to providing the urine samples were collected from the primary care electronic and paper medical records. The main outcome measure was resistance to amoxicillin or trimethoprim or both. Two thousand nine hundred and forty-three adults submitted urine samples. Susceptibility among E. coli isolates and antibiotic prescribing data were available from 618 patients. We found no evidence of an association between resistance and patients' exposure to any antibiotic prescribed in primary care in the previous 12 months [adjusted odds ratio (OR) 1.12, 95% confidence interval 0.77-1.65, P = 0.52]. Secondary analyses demonstrated greater resistance in patients exposed to antibiotics within 2 months (adjusted OR 1.95, 1.08-3.49, P = 0.03), a dose-response relationship to increasing exposure to trimethoprim in the previous 12 months (adjusted OR 1.01, 1.01-1.02, P = 0.001) and that individuals who had been prescribed any beta-lactam antibiotic in the previous 12 months had amoxicillin MICs more than twice (adjusted 95% CI 1.23-3.31, P = 0.009) that of those who had not been prescribed any beta-lactams. Whether or not adults receive a prescription for any antibiotic during a 12 month period does not appear to influence the antimicrobial resistance of perineal flora. However, the temporal and dose-response relationships found may be suggestive of a causative association and should be the focus of further research.

Trends in primary care antibiotic prescribing in England 1994–1998

To investigate the changing decisions to prescribe antibiotics as manifest in the patterns of prescriptions dispensed in England, and to investigate antibiotic prescribing in different types of practice. Antibiotic prescribing data and practice characteristics collected for every practice in England for the years 1994/5-1997/8. Morbidity data for common infections was also obtained from published sources. Antibiotic prescribing was related to practice characteristics, with high prescribing in deprived and single-handed practices in particular. There was a fall in antibiotic prescribing in all types of practice of practice over the period of the study. Morbidity data from other sources shows a fall in diagnosed morbidity from some infectious diseases over the same period. There were no differences in choice of antibiotic in different types of practice. The fall in antibiotic prescribing is universal across all kinds of practices and is possibly related to the fall in diagnoses. It is uncertain whether this reflects true morbidity.

Is it possible to decrease antibiotic prescribing in primary care? An analysis of outcomes in the management of patients with sore throats.

The aim of this study was to assess whether it was possible to change clinical practice through the introduction of an evidence-based protocol for the management of sore throats. The impact of the changed clinical practice on patients was also assessed. An observational study was carried out comparing management of patients with sore throats in a semi-rural general practice (14 000 patients), before and after the introduction of an evidence-based protocol, using a multidisciplinary approach. All patients over the age of 2 years presenting with sore throats as their chief presenting complaint were included in the study which ran for two 6-month periods: February-July 1997 (n = 435) and February-July 1998 (n = 350). Antibiotic prescribing rates, consultation and reconsultation rates, duration of sore throat, analgesia requirements and satisfaction were assessed. Antibiotic prescribing was significantly reduced in period 2 (56% compared with 19%). Consultation rates decreased by 19% in period 2. Median number of days to recovery of sore throats was the same in both groups. Reconsultation rates and dissatisfaction rates were the same in both groups. Using a multidisciplinary approach, it is possible to reduce antibiotic prescribing for sore throats significantly without adversely affecting outcome.

Idoneidad de la prescripción antibiótica en atención primaria en la Comunidad Autónoma Vasca

To study the variability and suitability of antibiotic prescription in primary care in the Basque Country. Prospective, descriptive study. Basque Country health care centres both within and not in the reformed network. 3182 infections from consultations for infectious disease were studied through sampling stratified by health area during February, March and April 1998. The appropriateness of antibiotics (ATB) prescription was compared with some standards after an extensive bibliographic review. 68.6% of consultations were infections not needing ATB (infections of respiratory airways, acute bronchitis, flu and gastro-enteritis). ATB were used in 28.5% of these cases (CI: 26.6-30.5), especially in acute bronchitis (90.7%) (CI: 87.3-93.4). Unnecessary prescription supposes 39.7% of total antibiotic prescription (CI: 37.2-42.1%), which means unnecessary annual expenditure of 1155 million pesetas. In 31.4% of the infections that require ATB treatment, in 23.7% inappropriate treatment was chosen (CI: 21-26.7%). Overall appropriateness of treatment was 72.2% (CI: 70.6-73.8). Working in the reformed system was linked to better prescription in all cases. Paediatricians prescribed better in the case of infections not susceptible to ATB treatment. ATB prescription is not consistent with the available scientific evidence. Incorrect treatments occur especially in benign and self-limiting processes. A local policy of ATB use that includes multi-disciplinary collaboration and effective ongoing training is necessary.

Endocrine Aspects of Acute Illness

Respiratory tract infections (RTI) are among the most common acute conditions leading to GP consultations and to antibiotic prescribing in primary care, even though 70% are viral, and many others are minor self-limiting bacterial infections.^1-4 Between 0.5% and 1.1% of adults have community-acquired pneumonia every year in the UK, most of whom are managed in primary care.^4,5 The decision to prescribe antibiotics for an acute RTI in primary care is often based on clinical symptoms, which have low sensitivity and specificity, and high inter-observer variability.^2,4 In primary care, it is very difficult to differentiate between diagnoses without additional tests.⁶ Unnecessary antibiotic prescribing may not aid recovery, exposes patients to potential adverse effects, may encourage repeat attendance and contributes to antibiotic resistance.^2,7 One strategy aiming to reduce antibiotic prescribing in primary care is the use of biomarkers (e.g. C-reactive protein [CRP]).² In the correct clinical context (e.g. in previously healthy people, not those with chronic lung disease) and as an adjunct to clinical assessment, a biomarker may help in the management of an RTI.² In order to be used during the consultation, the results of a biomarker test must be rapidly available (e.g. ‘point-of-care’ [POC] testing).⁴ POC testing for CRP has recently been recommended as part of a national clinical guideline on the diagnosis and management of pneumonia.⁴ Here, we review the rationale for POC CRP testing and its advantages and disadvantages.