Antibiotic Use In Primary Care Research Articles

Can financial rewards for stewardship in primary care curb antibiotic resistance?

Antibiotic use in primary care remains highly frequent, variable, and is often unnecessary. Hence, in principle, effective outpatient antibiotic stewardship might be an impactful intervention. Countries such as the Netherlands and Sweden where antibiotic stewardship has been applied in the outpatient setting also have some of the lowest rates of antibiotic resistance in Europe. However, for a variety of reasons, antibiotic stewardship in primary care has been challenging in most other world regions.

Impact of Prior Antibiotic Use in Primary Care on Escherichia coli Resistance to Third Generation Cephalosporins: A Case-Control Study.

Research is lacking on the reversibility of antimicrobial resistance (AMR). Thus, we aimed to determine the influence of previous antibiotic use on the development and decay over time of third generation cephalosporin (3GC)-resistance of E. coli. Using the database of hospital laboratories of the Autonomous Province of Bolzano/Bozen (Italy), anonymously linked to the database of outpatient pharmaceutical prescriptions and the hospital discharge record database, this matched case-control study was conducted including as cases all those who have had a positive culture from any site for 3GC resistant E. coli (3GCREC) during a 2016 hospital stay. Data were analyzed by conditional logistic regression. 244 cases were matched to 1553 controls by the date of the first isolate. Male sex (OR 1.49, 95% CI 1.10–2.01), older age (OR 1.11, 95% CI 1.02–1.21), the number of different antibiotics taken in the previous five years (OR 1.20, 95% CI 1.08–1.33), at least one antibiotic prescription in the previous year (OR 1.92, 95% CI 1.36–2.71), and the diagnosis of diabetes (OR 1.57, 95% CI 1.08–2.30) were independent risk factors for 3GCREC colonization/infection. Patients who last received an antibiotic prescription two years or three to five years before hospitalization showed non-significant differences with controls (OR 0.97, 95% CI 0.68–1.38 and OR 0.85, 95% CI 0.59–1.24), compared to an OR of 1.92 (95% CI 1.36–2.71) in those receiving antibiotics in the year preceding hospitalization. The effect of previous antibiotic use on 3GC-resistance of E. coli is highest after greater cumulative exposure to any antibiotic as well as to 3GCs and in the first 12 months after antibiotics are taken and then decreases progressively.

Evaluation of a multimodal intervention to promote rational antibiotic use in primary care

BackgroundIncreasing antimicrobial resistance is a serious societal challenge affecting outpatient, inpatient and veterinary care. The German One-Health project, RAI (Rational use of Antibiotics via Information and Communication) addresses all three sectors. In the outpatient sector, General Practitioners (GPs) are the main prescribers of antibiotics and were therefore, targeted for this study. A multimodal intervention focusing on Acute Respiratory Tract infections (ARI) was designed and implemented. The aim of this study was to evaluate acceptance, rating and the self-reported impact of the intervention among GPs.MethodsThe intervention offered six tools: a GP training on rational antibiotic use, an app for self-monitoring, a leaflet and a set of posters (both for use as information materials in waiting rooms) and both digital and printed information prescriptions (material for ‘prescribing’ information instead of an antibiotic to the patient). The tools could be used according to individual preferences. The intervention was conducted between August 2016 and July 2017. Following the intervention, a three pages anonymous questionnaire was sent to all 271 participants. Items covered socio-demographic and professional background, use and judgement of the intervention tools (6 point Likert scale), impact of the intervention tools (4 point Likert scale).ResultsThe response rate was 39% (n = 107). On average, respondents used 3.1 of the six available tools, with printed information prescriptions used most frequently (79%). Digital information prescriptions were used more frequently by men than by women (OR 2.8; 95% CI 1.16–7.24; p = 0.02). Eighty-seven percent of respondents stated that information prescriptions supported doctor-patient communication. In a comparison of the overall impression of the different intervention tools the GP training on rational antibiotic use was rated best (1.67 on a 6 point scale with 1 = highest, 6 = lowest) and most often noted as having had a “strong” or “very strong” impact on personal antibiotic prescribing behavior.ConclusionsThe multimodal intervention addressing education and communication was well accepted among GPs and could help in fostering rational use of antibiotics in primary care.

Knowledge, attitudes and practices relating to antibiotic use and resistance among prescribers from public primary healthcare facilities in Harare, Zimbabwe

Background Overuse of antibiotics is one of the main drivers for antimicrobial resistance (AMR). Globally, most antibiotics are prescribed in the outpatient setting. This survey aimed to explore attitudes and practices with regards to microbiology tests, AMR and antibiotic prescribing among healthcare providers at public primary health clinics in Harare, Zimbabwe. Methods This cross-sectional survey was conducted in nine primary health clinics located in low-income suburbs of Harare between October and December 2020. In Zimbabwe, primary health clinics provide nurse-led outpatient care for acute and chronic illnesses. Healthcare providers who independently prescribe antibiotics and order diagnostic tests were invited to participate. The survey used self-administered questionnaires. A five-point Likert scale was used to determined attitudes and beliefs. Results A total of 91 healthcare providers agreed to participate in the survey. The majority of participants (62/91, 68%) had more than 10 years of work experience. Most participants reported that they consider AMR as a global (75/91, 82%) and/or national (81/91, 89%) problem, while 52/91 (57%) considered AMR to be a problem in their healthcare facilities. A fifth of participants (20/91, 22%) were unsure if AMR was a problem in their clinics. Participants felt that availability of national guidelines (89/89, 100%), training sessions on antibiotic prescribing (89/89, 100%) and regular audit and feedback on prescribing (82/88, 93%) were helpful interventions to improve prescribing. Conclusions These findings support the need for increased availability of data on AMR and antibiotic use in primary care. Educational interventions, regular audit and feedback, and access to practice guidelines may be useful to limit overuse of antibiotics.

Evaluation of the Quality of Antibiotic Prescribing in Primary Care: A Multicenter Longitudinal Study From Shenzhen, China.

Background: Currently, there is no comprehensive evaluation of the quality of antibiotic prescribing in China’s primary care facilities based on longitudinal data. Methods: We randomly selected 11 community health centers in Shenzhen, China, and collected all outpatient prescriptions of these centers from 2010 to 2015. To evaluate the quality of antibiotic prescribing, we used six quality indicators for analysis, including number of antibiotics per 100 consultations, ratio between broad-spectrum and narrow-spectrum antibiotics (B/N ratio), percentage of first-line antibiotics recommended by guidelines, percentage of oral antibiotics with a duration exceeding the guideline recommendation, and new pediatric-specific indicators such as percentage of antibiotics with amoxicillin (A index) and ratio between amoxicillin and broad-spectrum antibiotics (A/B ratio). Results: During the study period, 571,362 outpatient consultations resulted in antibiotic prescriptions, which contained 706,411 antibiotics. The overall number of antibiotics per 100 consultations decreased significantly from 93.50 in 2010 to 19.98 in 2015 (p = 0.004), but the B/N ratio showed an upward trend over time (p = 0.009). In different populations and different common infections, the number of antibiotics used decreased to varying degrees, while the B/N ratio increased to varying degrees, with the most obvious change in children <5 years. The percentage of first-line antibiotics for common infections was not high, ranging from 3.45 to 44.25% during 2014–2015. The percentage of oral antibiotics with an exceeded duration ranged from 0.70 to 19.39%. Moreover, the A index and A/B ratio in children remained low for a long time, which was 0.76% and 0.01 in 2015. Conclusion: A review of antibiotic prescribing in Shenzhen, China, showed a substantial reduction in antibiotic use in primary care. However, problems such as widespread use of broad-spectrum antibiotics, insufficient use of first-line antibiotics and low use of amoxicillin were prevalent. Improving and optimizing the quality of antibiotic prescribing, particularly in children prescriptions, will be the focus of future antibiotic stewardship in China.

Impact of the COVID-19 Pandemic on Antibiotic Prescribing for Common Infections in The Netherlands: A Primary Care-Based Observational Cohort Study.

In 2020, the COVID-19 pandemic brought dramatic changes in the delivery of primary health care across the world, presumably changing the number of consultations for infectious diseases and antibiotic use. We aimed to assess the impact of the pandemic on infections and antibiotic prescribing in Dutch primary care. All patients included in the routine health care database of the Julius General Practitioners’ Network were followed from March through May 2019 (n = 389,708) and March through May 2020 (n = 405,688). We extracted data on consultations for respiratory/ear, urinary tract, gastrointestinal and skin infections using the International Classification of Primary Care (ICPC) codes. These consultations were combined in disease episodes and linked to antibiotic prescriptions. The numbers of infectious disease episodes (total and those treated with antibiotics), complications, and antibiotic prescription rates (i.e., proportion of episodes treated with antibiotics) were calculated and compared between the study periods in 2019 and 2020. Fewer episodes were observed during the pandemic months than in the same months in 2019 for both the four infectious disease entities and complications such as pneumonia, mastoiditis and pyelonephritis. The largest decline was seen for gastrointestinal infections (relative risk (RR), 0.54; confidence interval (CI), 0.51 to 0.58) and skin infections (RR, 0.71; CI, 0.67 to 0.75). The number of episodes treated with antibiotics declined as well, with the largest decrease seen for respiratory/ear infections (RR, 0.54; CI, 0.52 to 0.58). The antibiotic prescription rate for respiratory/ear infections declined from 21% to 13% (difference −8.0% (CI, −8.8 to −7.2)), yet the prescription rates for other infectious disease entities remained similar or increased slightly. The decreases in primary care infectious disease episodes and antibiotic use were most pronounced in weeks 15–19, mid-COVID-19 wave, after an initial peak in respiratory/ear infection presentation in week 11, the first week of lock-down. In conclusion, our findings indicate that the COVID-19 pandemic has had profound effects on the presentation of infectious disease episodes and antibiotic use in primary care in the Netherlands. Consequently, the number of infectious disease episodes treated with antibiotics decreased. We found no evidence of an increase in complications.

Awareness of Appropriate Antibiotic Use in Primary Care for Influenza-Like Illness: Evidence of Improvement from UK Population-Based Surveys.

Influenza-like illnesses (ILI) account for a significant portion of inappropriate antibiotic use. Patient expectations for antibiotics for ILI are likely to play a substantial role in ‘unnecessary’ antibiotic consumption. This study aimed to investigate trends in awareness of appropriate antibiotic use and antimicrobial resistance (AMR). Three sequential online surveys of independent representative samples of adults in the United Kingdom investigated expectations for, and consumption of, antibiotics for ILI (May/June 2015 (n = 2064); Oct/Nov 2016 (n = 4000); Mar 2017 (n = 4000)). Respondents were asked whether they thought antibiotics were effective for ILI and about their antibiotic use. Proportions and 95% confidence intervals (CI) were calculated for each question and interactions with respondent characteristics were tested using logistic regression. Over the three surveys, the proportion of respondents who believed antibiotics would “definitely/probably” help an ILI fell from 37% (95% CI 35–39%) to 28% (95% CI 26–29%). Those who would “definitely/probably” visit a doctor in this situation fell from 48% (95% CI 46–50%) to 36% (95% CI 34–37%), while those who would request antibiotics during a consultation fell from 39% (95% CI 37–41%) to 30% (95% CI 29–32%). The percentage of respondents who found the information we provided about AMR “new/surprising” fell from 34% (95% CI 32–36%) to 28% (95% CI 26–31%). Awareness improved more among black, Asian and minority ethnic (BAME) than white people, with little other evidence of differences in improvements between subgroups. Whilst a degree of selection bias is unavoidable in online survey samples, the results suggest that awareness of AMR and appropriate antibiotic use has recently significantly improved in the United Kingdom, according to a wide range of indicators.

Applying Digital Information Delivery to Convert Habits of Antibiotic Use in Primary Care in Germany: Mixed-Methods Study

BackgroundAntimicrobial resistance is an important global health issue. In Germany, the national agenda supports various interventions to convert habits of antibiotic use. In the CHANGE-3 (Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care) study, digital tools were applied for information delivery: tablet computers in primary care practices, e-learning platforms for medical professionals, and a public website to promote awareness and health literacy among primary care physicians, their teams, and their patients.ObjectiveThis study is embedded in the process evaluation of the CHANGE-3 study. The aim of this study was to evaluate the acceptance and uptake of digital devices for the delivery of health-related information to enhance awareness and change habits of antibiotic use in primary care in Germany.MethodsThis study used a convergent-parallel mixed-methods design. Audio-recorded semistructured telephone interviews were conducted with physicians, nonphysician health professionals, and patients in the CHANGE-3 program. Pseudonymized verbatim transcripts were coded using thematic analysis. In-depth analysis was performed based on the inductive category of information provision via digital information tools. Identified themes were related to the main postulates of Diffusion of Innovations theory (DIT) to provide an explanatory frame. In addition, data generated through a structured survey with physicians and nonphysician health professionals in the program were analyzed descriptively and integrated with the qualitative data to explore the complementarity of the findings.ResultsFindings regarding the acceptance and uptake of digital devices were related to three postulates of DIT: innovation characteristics, communication channels, and unanticipated consequences. Participants considered the provided digital educative solutions to be supportive for promoting health literacy regarding conversion of habits of antibiotic use. However, health care professionals found it challenging to integrate these solutions into existing routines in primary care and to align them with their professional values. Low technology affinity was a major barrier to the use of digital information in primary care. Patients welcomed the general idea of introducing health-related information in digital formats; however, they expressed concerns about device-related hygiene and the appropriateness of the digital tools for older patients.ConclusionsPatients and medical professionals in German primary care are reluctant to use digital devices for information and education. Using a Diffusion of Innovations approach can support assessment of existing barriers and provide information about setting-specific preconditions that are necessary for future tailoring of implementation strategies.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN) 15061174; http://www.isrctn.com/ISRCTN15061174.

Effects of restrictive-prescribing stewardship on antibiotic consumption in primary care in China: an interrupted time series analysis, 2012\u20132017

BackgroundThe overuse of antibiotics has been a major public health problem worldwide, especially in low- and middle- income countries (LMIC). However, there are few policies specific to antibiotic stewardship in primary care and their effectiveness are still unclear. A restrictive-prescribing stewardship targeting antibiotic use in primary care has been implemented since December 2014 in Hubei Province, China. This study aimed to evaluate the effects of the restrictive-prescribing stewardship on antibiotic consumption in primary care so as to provide evidence-based suggestions for prudent use of antibiotics.MethodsMonthly antibiotic consumption data were extracted from Hubei Medical Procurement Administrative Agency (HMPA) system from Sept 1, 2012, to Aug 31, 2017. Quality Indictors of European Surveillance of Antimicrobial Consumption (ESAC QIs) combined with Anatomical Therapeutic Chemical (ATC) classification codes and DDD per 1000 inhabitants per day (DID) methodology were applied to measure antibiotic consumption. An interrupted time series analysis was performed to evaluate the effects of restrictive-prescribing stewardship on antibiotic consumption.ResultsOver the entire study period, a significant reduction (32.58% decrease) was observed in total antibiotic consumption, which declined immediately after intervention (coefficient = − 2.4518, P = 0.005) and showed a downward trend (coefficient = − 0.1193, P = 0.017). Specifically, the use of penicillins, cephalosporins and macrolides/lincosamides/streptogramins showed declined trends after intervention (coefficient = − 0.0553, P = 0.035; coefficient = − 0.0294, P = 0.037; coefficient = − 0.0182, P = 0.003, respectively). An immediate decline was also found in the contribution of β-lactamase-sensitive penicillins to total antibiotic use (coefficient = − 2.9126, P = 0.001). However, an immediate increase in the contribution of third and fourth-generation cephalosporins (coefficient = 5.0352, P = 0.005) and an ascending trend in the contribution of fluoroquinolones (coefficient = 0.0406, P = 0.037) were observed after intervention. The stewardship led to an immediate increase in the ratio between broad- and narrow-spectrum antibiotic use (coefficient = 1.8747, P = 0.001) though they both had a significant downward trend (coefficient = − 0.0423, P = 0.017; coefficient = − 0.0223, P = 0.006, respectively). An immediate decline (coefficient = − 1.9292, P = 0.002) and a downward trend (coefficient = − 0.0815, P = 0.018) were also found in the oral antibiotic use after intervention, but no significant changes were observed in the parenteral antibiotic use.ConclusionsRestrictive-prescribing stewardship in primary care was effective in reducing total antibiotic consumption, especially the use of penicillins, cephalosporins and macrolides/lincosamides/streptogramins. However, the intervention effects were limited regarding the use of combinations of penicillins with ß-lactamase inhibitors, the third and fourth-generation cephalosporins, fluoroquinolones and parenteral antibiotics. Stronger administrative regulations focusing on specific targeted antibiotics, especially the use of broad-spectrum antibiotics and parenteral antibiotics, are in urgent need in the future.

Effects of 13-valent pneumococcal conjugate vaccination of adults on lower respiratory tract infections and antibiotic use in primary care: secondary analysis of a double-blind randomized placebo-controlled study

ObjectivesThe efficacy of 13-valent pneumococcal conjugate vaccine (PCV13) in adults to prevent community-acquired pneumonia (CAP) and lower respiratory tract infections (LRTI) not requiring hospitalization is unknown. We determined the effect of PCV13 on CAP, LRTI and antibiotic use in the primary care setting. MethodsCommunity-dwelling immunocompetent adults over 65 years of age were randomized to PCV13 or placebo as part of the double-blind Community-Acquired Pneumonia immunization Trial in Adults (CAPiTA). CAP and LRTI episodes and antibiotic prescription data were extracted from general practitioner information systems of 40 426 individuals. Vaccine efficacy (VE) of PCV13 was determined using Poisson regression with robust standard errors, comparing CAP and non-CAP LRTI episodes, LRTI-specific and total antibiotic prescriptions. ResultsIn all, 20 195 participants received PCV13 and 20 231 received placebo. A total of 1564 and 1659 CAP episodes occurred in the PCV13 and placebo group, respectively; VE 5.5% (95% CI –2.6% to 13.0%). Non-CAP LRTI episodes occurred 7535 and 7817 times in the PCV13 and placebo groups, respectively; VE 3.4% (95% CI –2.0% to 8.5%). A total of 8835 and 9245 LRTI-related antibiotic courses were prescribed in the PCV13 and placebo arms, respectively; VE 4.2% (95% CI –1.0% to 9.1%). Antibiotic courses for any indication were prescribed 43 386 and 43 309 times, respectively; VE –0.4% (–4.9% to 3.9%). ConclusionsPCV13 vaccination in the elderly is unlikely to cause a relevant reduction in the incidence of CAP, LRTI, LRTI-related antibiotic use or total antibiotic use in primary care.

Broad Spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy

IntroductionThe overuse of antibiotics is causing worldwide spread of antimicrobial resistance (AMR). Compared with other countries, Italy has both high antibiotic consumption rates and high rates of AMR. Due to...

AntibioGame®: A serious game for teaching medical students about antibiotic use

IntroductionMeasures for controlling antimicrobial resistance are urgently required. We describe here AntibioGame®, a serious game for improving the training of medical students in antibiotic use in primary care. ObjectiveWe aimed to design a serious game for antibiotics teaching and to evaluate its usability and playability by medical students. MethodsWe used various gamification techniques (e.g. use of mascots, avatars, rewards, leader board) and cartoon graphics in the design of AntibioGame®. This game implements clinical case templates built from a list of learning goals defined by a medical team through an analysis of clinical practice guidelines. The game was evaluated by asking medical students to rate their satisfaction and the usability and playability of the game on an electronic form and through group discussions. The electronic form was derived from the MEEGA + scale, a five-point Likert scale including 32 items for assessing both usability and playability. ResultsAntibioGame® is a case-based game in which students play the role of a doctor meeting patients in consultation and helping other health professionals to solve their problems, as in real life. The scenarios are realistic and cover situations frequently encountered in primary care. The 57 medical students enrolled found the game attractive, usable, fun, and appropriate for learning. Game quality was considered “good” (score = 60 on the MEEGA + scale). All the students said they would recommend the game, 96 % liked it and 81 % would use it for revision. ConclusionAntibioGame® is a promising tool for improving knowledge in antibiotic prescription that could easily be included in multifaceted programs for training medical students.

A Multinational European Study of Patient Preferences for Novel Diagnostics to ManageAntimicrobial Resistance.

BackgroundNovel diagnostics are needed to manage antimicrobial resistance (AMR). Patient preferences are important in determining whether diagnostic tests are successful in practice, but there are few data describing the test attributes which matter most to patients. We elicited patients’ preferences for attributes of diagnostic tests that could be used to reduce unnecessary antibiotic use in primary care across seven European countries.MethodsWe used an online stated preference survey, including a discrete choice experiment (DCE). The DCE explored how patients make trade-offs between three key attributes of diagnostic tests: the speed that results were available, confidence in the test results, and how convenient it is to take the test. Individuals were eligible to complete the survey if they had taken antibiotics within the last 2 years and were resident in Germany, Italy, Spain, France, Greece, the Netherlands or the United Kingdom (UK).ResultsIn total, 988 respondents completed the survey. The DCE responses illustrated that speed was the least important attribute in most countries. Responses from Germany and the Netherlands indicated that confidence was most important in these countries. Responses from the UK, France, Spain and Italy showed convenience as the most important attribute in these countries. Two attributes, confidence and convenience, were jointly favoured by respondents in Greece.ConclusionPatients in different European countries do not have the same preferences for the attributes of diagnostic tests to manage AMR in primary care. Failure to account for such differences during test development could reduce test uptake, result in continued overuse of antibiotics, and hamper marketisation.Electronic supplementary materialThe online version of this article (10.1007/s40258-019-00516-0) contains supplementary material, which is available to authorized users.

Selection and co-selection of antibiotic resistances among Escherichia coli by antibiotic use in primary care: An ecological analysis.

BackgroundThe majority of studies that link antibiotic usage and resistance focus on simple associations between the resistance against a specific antibiotic and the use of that specific antibiotic. However, the relationship between antibiotic use and resistance is more complex. Here we evaluate selection and co-selection by assessing which antibiotics, including those mainly prescribed for respiratory tract infections, are associated with increased resistance to various antibiotics among Escherichia coli isolated from urinary samples.MethodsMonthly primary care prescribing data were obtained from National Health Service (NHS) Digital. Positive E. coli records from urine samples in English primary care (n = 888,207) between April 2014 and January 2016 were obtained from the Second Generation Surveillance System. Elastic net regularization was used to evaluate associations between prescribing of different antibiotic groups and resistance against amoxicillin, cephalexin, ciprofloxacin, co-amoxiclav and nitrofurantoin at the clinical commissioning group (CCG) level. England is divided into 209 CCGs, with each NHS practice prolonging to one CCG.ResultsAmoxicillin prescribing (measured in DDD/ 1000 inhabitants / day) was positively associated with amoxicillin (RR 1.03, 95% CI 1.01–1.04) and ciprofloxacin (RR 1.09, 95% CI 1.04–1.17) resistance. In contrast, nitrofurantoin prescribing was associated with lower levels of resistance to amoxicillin (RR 0.92, 95% CI 0.84–0.97). CCGs with higher levels of trimethoprim prescribing also had higher levels of ciprofloxacin resistance (RR 1.34, 95% CI 1.10–1.59).ConclusionAmoxicillin, which is mainly (and often unnecessarily) prescribed for respiratory tract infections is associated with increased resistance against various antibiotics among E. coli causing urinary tract infections. Our findings suggest that when predicting the potential impact of interventions on antibiotic resistances it is important to account for use of other antibiotics, including those typically used for other indications.

Influence of primary care antibiotic prescribing on incidence rates of multidrug-resistant Gram-negative bacteria in hospitalised patients.

Use of antibiotics can give rise to the selection of resistant bacteria. It remains unclear whether antibiotic use in primary care can influence bacterial resistance incidence in patients when hospitalised. The aim of this study is to explore the impact of prior community antibiotic usage on hospital-detected multidrug-resistant Gram-negative (MRGN) incidence rate. This pharmacoepidemiological study was case-control in design, and was carried out in the Antrim Area Hospital (N. Ireland) in two phases. In phase 1, the controls were matched according to: age, gender, admission ward, date of admission, and age-adjusted Charlson co-morbidity index score. During the second phase, controls were selected randomly from the total population of admissions to the hospital over the 2-year study period. In phase 1, multivariate analysis revealed that prior exposure to the second- and third-generation cephalosporins (p = 0.004) and fluoroquinolones (p = 0.023) in primary care was associated with an increased likelihood of MRGN detection in inpatients. In phase 2, an independent relationship between an increased risk of identification of MRGN, while hospitalised was associated with: prolonged hospitalisation (p < 0.001), being elderly (p < 0.001), being female (p = 0.007), and having genitourinary disease (p < 0.001). This study provides clear evidence which supports the need to optimise antibiotic use in primary care to help reduce MRGN incidence in hospitalised patients.

OP85 Persistence Leads To Ongoing Decreases In Primary Care Antibiotic Use

IntroductionAustralia has had high rates of antibiotic use in primary care. Consumer and health professional knowledge and practices in the community vary. In 2012, NPS MedicineWise implemented a five-year national educational program for consumers, general practitioners (GPs) and pharmacies to reduce antibiotic use in Australia.MethodsFor consumers, a social marketing approach was used focusing on the winter months. Strategies leveraged collectivism, nudge theory, celebrity endorsement and co-creation and used multiple communication channels. For health professionals, interventions were most intense in 2012 with additional activities implemented each year including face-to-face educational visiting, audits, comparative prescribing feedback, case studies and point-of-care materials. Surveys were conducted periodically to evaluate changes in knowledge and awareness. Pharmaceutical Benefits Scheme (PBS) claims data were analyzed. Organization for Economic Co-operation and Development data was used to compare Australian antibiotic per capita consumption to other countries. Time series analyses were used to estimate the cumulative program effect comparing observed and expected monthly dispensing volumes of antibiotics commonly prescribed for upper respiratory tract infections (URTIs), had interventions not occurred.ResultsBetween 2012 and 2017, GP antibiotic PBS prescriptions reduced by 18.4 percent. Antibiotic defined daily doses per 1000 inhabitants reduced from 23.7 in 2012 to 18.4 in 2016, similar to Norway (18.6 in 2016) and the UK (18.7). Time series modelling estimated 24.8 percent fewer GP antibiotic URTI prescriptions by 2017 versus no program. Consumer survey results indicated increased awareness of antibiotic resistance (50 percent in 2011, 74 percent in 2017) and the minority expect/request antibiotics for URTIs (22 percent in 2017).ConclusionsA five-year national educational program with multiple and repeated interventions for health professionals and consumers has resulted in ongoing reductions in antibiotic use in primary care.

Association between antibiotic prescribing and deprivation in Wales: A multilevel analysis

IntroductionThe most recent Welsh Antimicrobial Resistance Programme (WARP) report on antibiotic use in primary care found significant variations between Health Boards and hospitals in gross antibiotic use in 2014. The aim of this study was to evaluate the association between socioeconomic deprivation and antibiotic prescribing volumes.&#x0D; Objectives and ApproachWelsh General Practitioner (GP) antibiotic prescribing data for years 2013 to 2016 for patients’ resident in Wales were extracted from the Secure Anonymised Information Linkage GP tables. Deprivation was assessed by linking prescribing events to the Welsh Index of Multiple Deprivation (WIMD) score for the patient’s neighbourhood area. The association between deprivation area and antibiotic prescribed (items per 1000 persons per day) was stratified according to the patient’s age, sex, prescription year and antibiotic class. A three-level multilevel Poisson regression model of 1.58 million patients nested within 349 GP practices, nested with 67 GP clusters, was specified to assess the associations&#x0D; ResultsJust over 7.97 million antibiotic items were prescribed between 2013 and 2016. Patients in the most deprived WIMD quintile had an overall prescription rate that was 25.2% higher than those in the least deprived WIMD quintile. The final model revealed that residing in the most deprived WIMD quintile (incidence rate ratio [IRR] = 1.1769, 95% confidence interval [CI] 1.1768 to 1.1770, being female (IRR = 1,2699, 95% CI 1.2698 to 1.2700), being aged $\geq$90 (IRR = 2.0687, 95% CI 2.0683 to 2.0690), and prescription year being 2013 were associated with significantly higher rate of antibiotics prescription. There were significant primary cares clustering of antibiotics prescription in Wales.&#x0D; Conclusion/ImplicationsThis study provides evidence that patients in areas of higher socioeconomic deprivation are more likely to be prescribed antibiotics in primary care in Wales. Population health prevention strategies aimed at reducing high antibiotic prescription rates should consider targeting areas of high deprivation.

Patterns of dispensed non-medical prescriber prescriptions for antibiotics in primary care across England: a retrospective analysis.

To describe the patterns of dispensed non-medical prescriber (NMP) prescriptions for antibiotics in primary care across England between 2011 and 2015. A retrospective analysis of dispensed antibiotic prescriptions, written by NMPs and medical prescribers between 2011 and 2015 in primary care in England, obtained from the National Health Service Business Services Authority. Between 2011 and 2015, the number of NMPs (mainly nurses but also pharmacists and small numbers of allied health professionals) in England, who have independent prescribing capability, has risen by over one-third to nearly 30000. Most of these prescribers provide a broad range of services in primary care. The rate of dispensed NMP prescriptions for antibiotics over this period has increased, as has the percentage of all primary care antibiotics dispensed that were prescribed by NMPs, which is currently nearly 8%. The most commonly dispensed NMP antibiotic prescriptions were penicillin, sulphonamides, trimethoprim, macrolides, tetracyclines and nitrofurantoin. Increasing numbers of NMPs are working in primary care in England and managing infections. Antibiotics prescribed by this group align with surveillance reports of antibiotic use in primary care. With the numbers of NMPs being set to rise further, they form an important group to involve in antimicrobial stewardship efforts.

Personalized Prescription Feedback Using Routinely Collected Data to Reduce Antibiotic Use in Primary Care

ImportanceFeedback interventions using routinely collected health data might reduce antibiotic use nationwide without requiring the substantial resources and structural efforts of other antibiotic stewardship programs.ObjectiveTo determine if quarterly antibiotic prescription feedback over 2 years reduces antibiotic use when implemented in a complex health care system.Design, Setting, and ParticipantsPragmatic randomized trial using routinely collected claims data on 2900 primary care physicians with the highest antibiotic prescription rates in Switzerland.InterventionsPhysicians were randomized to quarterly updated personalized antibiotic prescription feedback over 2 years (n = 1450) or usual care (n = 1450). Feedback was provided both by mail and online from October 2013 to October 2015 and was supported by an initial 1-time provision of evidence-based guidelines.Main Outcomes and MeasuresThe primary outcome was the prescribed defined daily doses (DDD) of any antibiotic to any patient per 100 consultations in the first year analyzed by intention-to-treat. We further analyzed prescriptions of specific antibiotics, age groups, and sex for the first and second year to investigate persistency of effects over time.ResultsThe 2900 physicians had 10 660 124 consultations over 2 years of follow-up, prescribed 1 175 780 packages of antibiotics with 10 290 182 DDD. Physicians receiving feedback prescribed the same amount of antibiotics to all patients in the first year (between-group difference, 0.81%; 95% CI, −2.56% to 4.30%; P = .64) and second year (between-group difference, −1.73%; 95% CI, −5.07% to 1.72%; P = .32) compared with the control group. Prescribing to children aged 6 to 18 years was −8.61% lower in the feedback than in the control group in the first year (95% CI, −14.87% to −1.90%; P = .01). This difference diminished in the second year (between-group difference, −4.10%; 95% CI, −10.78% to 3.07%; P = .25). Physicians receiving feedback prescribed fewer antibiotics to adults aged 19 to 65 years in the second year (between-group difference, −4.59%; 95% CI, −7.91% to −1.16%; P < .01). Prescribing to other patient groups or of specific antibiotic types was not significantly different between groups.Conclusions and RelevanceThis nationwide antibiotic stewardship program with routine feedback on antibiotic prescribing was not associated with a change of antibiotic use. In older children, adolescents, and younger adults less antibiotics were prescribed, but not consistently over the entire intervention period.Trial Registrationclinicaltrials.gov Identifier: NCT01773824

Reduction in antibiotic prescribing for respiratory tract infections in Swedish primary care- a retrospective study of electronic patient records.

BackgroundSwedish studies on antibiotic use in primary care have been based on one-week registrations of infections. In order to study adherence to guidelines, analyses based on large databases that provide information on diagnosis linked prescriptions, are needed. This study describes trends in management of infections in Swedish primary care particularly with regards to antibiotic prescribing and adherence to national guidelines.MethodsA descriptive study of Sweden’s largest database regarding diagnosis linked antibiotic prescription data, the Primary care Record of Infections in Sweden (PRIS), for the years 2008, 2010 and 2013.ResultsAlthough the consultation rate for all infections remained around 30% each year, antibiotic prescribing rates decreased significantly over the years from 53.7% in 2008, to 45.5% in 2010, to 38.6% in 2013 (p = .032). The antibiotic prescribing rate for respiratory tract infections (RTIs) decreased from 40.5% in 2008 to 24.9% in 2013 while those for urinary tract infections and skin and soft tissue infections were unchanged. For most RTI diagnoses there was a decrease in prescription rate from 2008 to 2013, particularly for the age group 0–6 years. Phenoxymethylpenicillin (PcV) was the antibiotic most often prescribed, followed by tetracycline. Tonsillitis and acute otitis media were the two RTI diagnoses with the highest number of prescriptions per 1000 patient years (PY). For these diagnoses an increase in adherence to national guidelines was seen, with regards to treatment frequency, choice of antibiotics and use of rapid antigen detection test. The frequency in antibiotic prescribing varied greatly between different Primary Healthcare Centres (PHCCs).ConclusionFalling numbers of consultations and decreased antibiotic prescription rates for RTIs have reduced the antibiotic use in Swedish primary care substantially. Overprescribing of antibiotics could still be suspected due to large variability in prescribing frequency, especially for acute bronchitis and sinusitis. Continuous evaluation of diagnosis linked prescribing data and feedback to doctors is essential in order to achieve a more prudent antibiotic use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-016-2018-9) contains supplementary material, which is available to authorized users.