High Antibiotic Prescribing Research Articles

Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK

BackgroundSince the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of ‘prudent healthcare’ championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted.MethodsA PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest.ResultsA sum of £86.9 million was spent on respiratory care in 2012–13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment.ConclusionsThis exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored.

Antibiotics prescribed to febrile under-five children outpatients in urban public health services in Burkina Faso

Appropriate use of antibiotics remains critical for success in achieving MDG4. The aim of this study was to investigate antibiotics prescribing practices to febrile under-five children outpatients in urban public health services in a low income country. Methods: From March to April 2013, a cross-sectional epidemiological study of care facilities visit by under-five age, for febrile illness, was carried out in urban health services in Bobo-Dioulasso, Burkina Faso. Patient demographics, diagnoses and medications were recorded. We calculated for each diagnoses several indicators for antibiotics use. Results: Our study showed an over-prescription of antibiotics at the university teaching hospital (78.08%) and at the first level facilities (57.71%) for under-five outpatients for febrile illness. There was evidence of high antibiotic prescription in children with diarrhea (more than 9 on 10 at university teaching hospital of diarrhea cases and 60% at the first level facilities), in children with Upper respiratory tract infections (respectively 60% and 85.2% of cases at university teaching hospital and at the first level facilities) and in children with malaria (respectively 47.5% and 17.6% of cases at university teaching hospital and at the first level facilities). Overuse, misuse and inappropriately prescribed antibiotic coexisted in our results: at university teaching hospital 90.9% of diarrhea cases, 60% of URTI cases, 47.5% of malaria cases received antibiotic prescription; at first level heath care facilities 85.2% of URTI, 17.6% of malaria cases received an prescribed antibiotic and 11.8% of LRTI did not received a prescribed antibiotic. Developing countries have poor access to newer antibiotics and irrational antibiotics use remains a global problem. Overuse and misuse of antibiotics combat, rigorous infectious diseases diagnosis, antimicrobial resistance consequences education of users and health professional’s prescribers, and improved surveillance of antimicrobial resistance, must be strengthened.

Rational prescribing in paediatrics in a resource-limited setting

IntroductionThere is evidence of inappropriate medication use, causing unnecessary costs for health systems, particularly those with limited resources. Overprescription is commonly reported and can lead to antibiotic resistance. Prescribing patterns...

Identifying streptococcal throat infections in primary care: more guidance but uncertainty remains

Commentary on: Little P, Hobbs FR, Mant D, et al. Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study. Br J Gen Pract 2012;62:787–94.[OpenUrl][1][CrossRef][2][PubMed][3] Acute...

In vitro susceptibility of urogenital Chlamydia trachomatis strains in a country with high azithromycin consumption rate

Although Chlamydia trachomatis resistance is not of great concern due to its excellent sensitivity to the currently recommended first-line antibiotics (azithromycin and doxycycline), clinical treatment failures have been reported and some of them were linked to laboratory proved resistance. The aim of this study was to determine in vitro susceptibility to azithromycin and doxycycline for 24 urogenital chlamydial strains isolated in Croatia-a country with the highest consumption of azithromycin in Europe and with very high antibiotic prescription rates. Fourteen isolates from cervical swabs, nine from male urethral swabs, and one isolate from expressed prostatic secretion were tested in McCoy cell culture system. All strains were susceptible to azithromycin and doxycycline with minimal inhibitory concentration for azithromycin and doxycycline ranging from 0.064 to 0.125 μg/mL and 0.016 to 0.064 μg/mL, and minimal chlamydicidal concentration ranging from 0.064 to 2.0 μg/mL and 0.032 to 1.0 μg/mL, respectively. Since we still lack information on whether C. trachomatis is evolving in vivo in response to antibiotic selection pressure, this kind of surveillance for resistance is essential in detecting shifts in antimicrobial susceptibilities.

Antibiotic prescribing for upper respiratory infections: European primary paediatricians’ knowledge, attitudes and practice

Young children are the highest receivers of antibiotics in the European Union, with the majority of antibiotics given for children with minor upper respiratory infections (URIs). The study aims to examine paediatricians' reported views influencing community antibiotic prescribing. European primary care paediatricians and participants of the European Academy of Paediatrics Research in Ambulatory Setting Network were asked to complete a Web-based survey on knowledge, attitudes and practice of antibiotic prescribing for URIs. The survey was completed by 685 respondents from 21 countries, 397 network participants (response rate 65%) and 288 paediatricians. Overall, 43.5% of respondents overestimated the risks associated with not prescribing antibiotics and the clinical benefit of antibiotics in otitis media and tonsillitis (strong believers in the benefits of antibiotics phenotype). Strong believers are also more likely to be high prescribers of antibiotics. Paediatricians from a low or medium European Surveillance of Antimicrobial Consumption country category prescribe less antibiotics than those from a higher category. There is a clear need for an educational intervention focused on European primary care paediatricians based on the risk-benefit analysis associated with the antibiotic prescribing for minor URIs, to reduce inappropriate prescribing.

Prescripción extrahospitalaria de antibióticos en Aragón y sus diferencias por género y edad

BackgroundThe objective of the study is to describe the use of antibiotics among outpatients, the pattern of sub-group prescribing, as well as to analyse age- and gender-specific patterns of use, and to identify high users. MethodsA retrospective, observational study was designed, in which the rate of patients treated with antibiotics in Aragon (Spain) in 2008 was calculated. Data were extracted from the Aragon Pharmaceutical Consumption Database, a complete register of all dispensed prescriptions in Aragon in 2008. Defined Daily Dose (DDD) per 1000 inhabitants per day (DID) was calculated, and the number of patients who had received an antibacterial drug was analysed. ResultsThe antibiotic prescription rate in 2008 in Aragón was 339.81 per 1000 inhabitants (303.54 and 375.34 per 1000 for men and women, respectively). The DID was 23.72. Population prevalence of antimicrobial use changed markedly between different age groups and between genders. Children (0-4 years) had the highest rate. Females, in general, used antibiotics more than males. Penicillins was the most used antibacterial group in all age groups, except for people of advanced age (>80 years), where quinolones were the most frequently used. Most of the individuals defined as high users (using more than 60 DDDs/year) were in the 60-80 years age group. ConclusionWe observed a high antibiotic prescription rate in Aragon, particularly in children. There are differences between men and women in the use of antibiotics.

Initiating a transfusion protocol for free diep flap breast reconstruction in North Bristol NHS Trust

Initiating a transfusion protocol for free diep flap breast reconstruction in North Bristol NHS Trust

Outpatient Antibiotic Prescribing and Nonsusceptible Streptococcus pneumoniae in the United States, 1996-2003

Streptococcus pneumoniae infections have become increasingly complicated and costly to treat with the spread of antibiotic resistance. We evaluated the relationship between antibiotic prescribing and nonsusceptibility among invasive pneumococcal disease (IPD) isolates. Outpatient antibiotic prescription data for penicillins, cephalosporins, macrolides, and trimethoprim-sulfamethoxazole were abstracted from the IMS Health Xponent database to calculate the annual number of prescriptions per capita. We analyzed IPD data from 7 of the Centers for Disease Control and Prevention's Active Bacterial Core surveillance sites (population, 18.6 million) for which data were available for the entire time period under study (1996-2003). Logistic regression models were used to assess whether sites with high antibiotic prescribing rates had a high proportion of nonsusceptible and serotype 19A IPD. Yearly prescribing rates during the period 1996-2003 for children <5 years of age decreased by 37%, from 4.23 to 2.68 prescriptions per capita per year (P < .001), and those for persons ≥5 years of age decreased by 42%, from 0.98 to 0.57 prescriptions per capita per year (P < .001); increases in azithromycin prescribing were noted for both groups. Sites with high rates of antibiotic prescribing had a higher proportion of IPD nonsusceptibility than did low-prescribing sites (P = .003 for penicillin, P < .001 for every other antibiotic class). Cephalosporin and macrolide prescribing were associated with penicillin and multidrug nonsusceptibility and serotype 19A IPD (P < .001). In sites where antibiotic prescribing is high, the proportion of nonsusceptible IPD is also high, suggesting that local prescribing practices contribute to local resistance patterns. Cephalosporins and macrolides seem to be selecting for penicillin- and multidrug-resistant pneumococci, as well as serotype 19A IPD. Antibiotic use is a major factor contributing to the spread of antibiotic resistance; strategies to reduce antibiotic resistance should continue to include judicious use of antibiotics.

Alta exposición a antibióticos en la población y sus diferencias por género y edad

Purpose To determine antibiotic use and its distribution by age and gender, as well as the most prescribed therapeutic group. Design Observational descriptive with retrospective data. Settings and participants Population from the Lleida (Spain) Health Region receiving antibiotic prescriptions from 2002 to 2007. Measurements Daily Dose Per Inhabitant (DID) was calculated, as well as the number of patients under treatment. The study variables were: age, gender, number of patients under antibiotic treatment and pharmacological group. Results Mean prevalence of patients receiving antibiotics was 36.93% (33.51% in men and 40.42% in women). The DID in Lleida during 2007 is 23.52. The majority (56%) had received antibiotics once a year. The antibiotic consumption prevalence has a “V” shape with higher values among children and old people. There is an annual exposure to antibiotics in 58.8% of the 0 to 4 years-old age group. The most prescribed antibiotic is amoxicillin/clavulanic. Conclusions We observe a high antibiotic prescription rate among children and older people, the high consumption in childhood being of note. There is also a higher use of antibiotics among women and changing of prescription towards broad spectrum antibiotics.

Why do paediatricians prescribe antibiotics? Results of an Italian regional project

BackgroundTo investigate determinants of antibiotic prescription in paediatric care, as a first step of a multilevel intervention to improve prescribing for common respiratory tract infections (RTIs) in a northern Italian region with high antibiotic prescription rate.MethodsA two-step survey was performed: in phase I, knowledge, and attitudes were explored involving all family and hospital paediatricians of Emilia-Romagna and a sample of parents. In phase II, patient care practices were explored in a stratified random sample of visits, both in hospitals and family physician's clinics; parent expectations were investigated in a sub-sample of these visits.ResultsOut of overall 4352 visits for suspected RTIs, in 38% of children an antibiotic was prescribed. Diagnostic uncertainty was perceived by paediatricians as the most frequent cause of inappropriate prescription (56% of 633 interviewed paediatricians); but, rapid antigen detecting tests was used in case of pharyngitis/pharyngotonsillitis by 36% and 21% of family and hospital paediatricians only. More than 50% of paediatricians affirmed to not adopt a "wait and see strategy" in acute otitis. The perceived parental expectation of antibiotics was not indicated by paediatricians as a crucial determinant of prescription, but this perception was the second factor most strongly associated to prescription (OR = 12.8; 95% CI 10.4 - 15.8), the first being the presence of othorrea. Regarding parents, the most important identified factors, potentially associated to overprescribing, were the lack of knowledge of RTIs and antibiotics (41% of 1029 parents indicated bacteria as a possible cause of common cold), and the propensity to seek medical care for trivial infections (48% of 4352 children accessing ambulatory practice presented only symptoms of common cold).ConclusionA wide gap between perceived and real determinants of antibiotic prescription exists. This can promote antibiotic overuse. Inadequate parental knowledge can also induce inappropriate prescription. The value of this study is that it simultaneously explored determinants of antimicrobial prescribing in an entire region involving both professionals and parents.

Which practices are high antibiotic prescribers? A cross-sectional analysis

Substantial variation in antibiotic prescribing rates between general practices persists, but remains unexplained at national level. To establish the degree of variation in antibiotic prescribing between practices in England and identify the characteristics of practices that prescribe higher volumes of antibiotics. Cross-sectional study. 8057 general practices in England. A dataset was constructed containing data on standardised antibiotic prescribing volumes, practice characteristics, patient morbidity, ethnicity, social deprivation, and Quality and Outcomes Framework achievement (2004-2005). Data were analysed using multiple regression modelling. There was a twofold difference in standardised antibiotic prescribing volumes between practices in the 10th and 90th centiles of the sample (0.48 versus 0.95 antibiotic prescriptions per antibiotic STAR-PU [Specific Therapeutic group Age-sex weightings-Related Prescribing Unit]). A regression model containing nine variables explained 17.2% of the variance in antibiotic prescribing. Practice location in the north of England was the strongest predictor of high antibiotic prescribing. Practices serving populations with greater morbidity and a higher proportion of white patients prescribed more antibiotics, as did practices with shorter appointments, non-training practices, and practices with higher proportions of GPs who were male, >45 years of age, and qualified outside the UK. Practice and practice population characteristics explained about one-sixth of the variation in antibiotic prescribing nationally. Consultation-level and qualitative studies are needed to help further explain these findings and improve our understanding of this variation.

Socially responsible antibiotic choices in primary care: a qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics

There is considerable variation within and between countries in general medical practitioners' (GPs') prescribing of broad-spectrum antibiotics such as fluroquinolones, and resistance to these agents is increasing worldwide. Urgently promoting cautious fluroquinolone prescribing in primary care may limit increase in resistance. We therefore interviewed 40 GPs in order to explore the reasons for their choice of prescribed antibiotic, in particular their decision to prescribe fluroquinolones. We used a grounded theory approach to data collection and analysis, incorporating purposive and theoretical sampling, based on high and average fluroquinolone prescribing. Interviews were conducted with 26 GPs from practices known to be high prescribers of fluroquinolone antibiotics and 14 from average fluroquinolone prescribing practices. Chosing to prescribe a broad-spectrum antibiotic such as a fluroquinolone, rather than a narrow-spectrum antibiotic, related to a number of clinical considerations, perceptions of patient expectations and organizational influences. GPs from high fluroquinolone prescribing practices were more likely to prioritize patients' immediate needs, whereas GPs from average prescribing practices were more likely to consider longer term issues. GPs from both high and average fluroquinolone prescribing practices justified their antibiotic choices on the basis of a desire to do their best for their patients and society. Choosing to prescribe powerful, broad-spectrum antibiotics such as fluroquinolones, as well as choosing to keep these agents in reserve, was justified on the basis of social responsibility. Strategies to change fluroquinolone and broad-spectrum antibiotic prescribing will need to take into account clinicians' perceptions of social responsibility.

Antibiotic prescribing for childhood febrile illness by primary care doctors in Malaysia

Fever in children, a mostly benign and self-limiting illness, is often viewed with consternation by the care givers. It results in early consultation and excessive use of antipyretics and antibiotics. In this study, we document the prescribing practice of doctors from three primary care settings in Malaysia and identify the predictors of antibiotic prescription. Interview of care givers bringing febrile children (age </= 12 years) to three primary care settings: public primary care clinics, private general practice clinics and a university-based primary care clinic. Data from 649 children were analysed. Mean age of children 4.1 years and 55% were boys. One-third of the children had prior consultation for the same episode of fever. About 80% of the febrile children were diagnosed to have upper respiratory tract infection, viral fever and gastroenteritis. Overall antibiotic prescribing rate was 36.6% (public primary care clinic 26.8%, private general practice clinic 70.0% and university-based primary care clinic 32.2%). Independent predictors of antibiotic prescription were: clinic setting, longer duration of fever (>7 days), higher temperature (>38 degrees C) and the diagnosis of upper respiratory tract infections. After controlling for demographic and clinical factors, antibiotic prescription in private general practice clinic was seven times higher than public primary care clinic (odds ratio 7.1, 95% confidence interval 4.0-12.7), and 1.6 times higher than university-based primary care clinic (odds ratio 1.6, 95% confidence interval 1.0-2.5). Differences in the patients' demographic and clinical characteristics could not adequately explain the high antibiotic prescribing rate in private general practice clinics. This inappropriately high antibiotic prescribing for febrile children in private general practice clinics is a suitable target for future intervention.

Did local enhancement of a national campaign to reduce high antibiotic prescribing affect public attitudes and prescribing rates?

Objectives: Due to concerns about both costs and drug resistance, reducing antibiotic prescribing is a strategic aim for the UK National Health Service. A nationwide public education campaign launched in October 1999 (CATNAP) addressed this. The objectives were 1) to assess public attitudes to antibiotic use in a district with high antibiotic prescribing where a nationwide public education campaign was locally enhanced, 2) to assess the impact of the campaign on prescribing of antibiotics locally.Design: 1) Questionnaire survey to test the hypothesis that public attitudes would be equivalent before and after local enhancement of the national campaign. 2) Prescribing data analysis to assess the impact of the campaign on prescribing of antibiotics.Setting: London Borough of Barking and Dagenham.Outcome measures: 1) Differences in public attitudes to antibiotic prescribing pre and post the locally enhanced campaign. 2) Changes in prescribing rates pre and post the locally enhanced campaignResults: 1) Response rates in questionnaire study: 45% (442/982) initially, 42% (815/1941) at follow-up. Responses to all general questions were equivalent in both surveys. There was considerable misunderstanding amongst the population about the effectiveness of antibiotics, particularly in relation to viral infections, colds, sore throats and coughs. The proportion of responders who believed that children should be prescribed antibiotics for a fever was not equivalent in the two surveys, it decreased from 56 to 49%, the limit of the one-sided confidence interval was 13.5%. 2) The rate of change in prescriptions dispensed between 1998/9 and 1999/2000 was not significantly different from that expected, based on the previous four years, in either England and Wales or Barking and Dagenham.Conclusion: Using this study design and this method of locally enhancing a public education campaign, the locally enhanced campaign did not appear to influence the public's attitudes towards antibiotic prescribing in an area of high prescribing. Assessment of the attitudes of those who had definitely been exposed to the campaign and greater promotion of the campaign and its messages to, and by, GPs might be more likely to produce a demonstrable change in attitudes.

Understanding variation in quality improvement: the treatment of sore throats in primary care.

In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.

The more time spent on listening, the less time spent on prescribing antibiotics in general practice.

To analyse the variation between primary care centres (PCCs) with regard to prescribing antibiotics and to investigate whether the variation can be explained by factors related to patient satisfaction and to socio-demographic characteristics of the populations in the catchment areas of the PCCs. The frequency of prescription of antibiotics by GPs at the PCCs was used as the dependent variable in a multivariate regression analysis. Questionnaire data for patient satisfaction and register data for socio-demographic characteristics were used as explanatory variables. The study was set in a county in south-east Sweden, and 6734 patients consulting GPs at 39 out of the 41 PCCs in the county participated. Variables correlating with the frequency of antibiotics prescription at PCC level and with patient satisfaction were the main outcome measures. A seven-fold variation in the extent of the prescription of antibiotics between the PCCs was observed. In the multivariate analysis, a high antibiotic prescription rate relates to high overall patient satisfaction with GP consultation as well as to the share of males in the listed population but to low satisfaction with the time spent by the GP on listening to the patient. A high frequency of prescription of antibiotics at a PCC may reflect a general disposition among GPs to give priority to maintaining good relations with the patients. However, a low level of prescription may be consistent with patient satisfaction if more time is spent on listening to and informing the patients. Thus more time spent on listening to the patients may reduce the prescription of antibiotics without reducing patient satisfaction.

Relationship Between Asthma Medication and Antibiotic Use

Increasing morbidity due to asthma and antimicrobial resistance among human pathogens are both major public-health concerns. Numerous studies describe the overuse of antibiotics in general populations and underuse of anti-inflammatory medications by asthmatic patients. However, little is known about the relationship between asthma medication and antibiotic use in asthmatics. Specifically, we tested the hypothesis that higher use of bronchodilator and anti-inflammatory medication by asthmatics, as a marker of problematic asthma, is associated with greater antibiotic use. We also test the hypothesis that physicians who are low prescribers of anti-inflammatory medications are high prescribers of antibiotics. We conducted a retrospective cohort study evaluating asthma medication and antibiotic use by children and adults with asthma and the prescribing of these medications by primary-care physicians. Subjects were continuously enrolled asthma patients aged 6 to 55 years receiving care in an urban, group-model, health maintenance organization. None. Main outcome measures were (1) antibiotic use by asthmatics stratified by low, moderate, and high bronchodilator use; (2) antibiotic use by asthmatics stratified by no, intermittent, and long-term anti-inflammatory use; and (3) correlation between physician-level anti-inflammatory agent to bronchodilator ratio (AIF:BD) and their rate of antibiotic prescribing. We found that (1) high bronchodilator users received 1.72 antibiotics per person-year (95% confidence interval [CI], 1.62 to 1.83), whereas low bronchodilator users received 1.23 antibiotics per person-year (95% CI, 1.19 to 1.27; p < 0.0001); (2) long-term users of anti-inflammatory agents received 1.85 antibiotics per person-year (95% CI, 1.76 to 1.95), whereas those not receiving an anti-inflammatory agent received 0.95 antibiotics per person-year (95% CI, 0.90 to 1.00; p < 0.0001); and (3) despite variations in physician AIF:BDs and antibiotic prescribing, respectively, these measures were not correlated. Antibiotic use and asthma medication use are positively associated in a cohort of asthma patients. Greater effort is needed to define the appropriate role of antibiotics in asthma management.

High prescribers of antibiotics among general practitioners--relation to prescribing habits of other drugs and use of microbiological diagnostics.

General practitioners' (GPs') prescriptions of antibiotics have shown large variations and may not always be rational. We analysed GPs' prescriptions and use of microbiological diagnostics in Viborg County during a 6-month period in 1992 based on Danish Health Service data. In a logistic regression model we tried to identify potential predictors for a high prescriber of antibiotics, i.e. the GPs with the highest number of prescriptions per patient (upper quartile). Two categories were calculated for the predictor variables, dividing the distribution by the median value. The most liberal GP wrote 15 times as many prescriptions for antibiotics per patient as the most restrictive GP. A strong predictor for high prescribing of antibiotics was the number of prescriptions for other drugs per patient [odds ratio (OR) 12.3, 95% CI: 2.8-54.4] after adjustment for age and sex. High use of throat swabs was a strong negative predictor of high prescribing of antibiotics (OR 0.2, 95% CI: 0.1-0.8) while high use of cultures (OR 2.4, 95% CI: 0.8-6.9) and of urinary susceptibility tests (OR 3.1, 95% CI: 1.1-9.3) were positive predictors. The GP's general attitude to pharmacotherapy seems important for antimicrobial chemotherapy, and if use of antibiotics should be reduced, targeted strategies should be aimed at high prescribers.