Inappropriate Prescribing Research Articles

Appropriateness of antimicrobial prescribing for oral and dental conditions in Australian hospitals: 2013 to 2022

ObjectivesDentists manage a variety of oral infections in clinical practice. Inappropriate antimicrobial prescribing by dentists occurs frequently and antimicrobial stewardship strategies should include dentistry. The aim of this retrospective analysis of the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) dataset, was to describe the types of oral and dental indications where antimicrobials were prescribed, and assess the guideline compliance and appropriateness of the antimicrobials in Australian hospitals. MethodsData from the Hospital NAPS was extracted for oral and dental indications from 2013 to 2022. The types of oral and dental indications presented, and the corresponding antimicrobials prescribed were assessed for compliance according to national prescribing guidelines, and appropriateness according to the NAPS structured algorithm. ResultsA total of 8,001 prescriptions for 7,477 patients were identified, from 433 hospitals. Antifungal, antibiotic and antiviral agents accounted for 84.5 %, 15.4 % and 0.03 % of prescriptions respectively. A greater proportion of antibiotics were prescribed in regional and rural areas compared to antifungals. The prescriptions assessed as compliant were 80.0 % and 44.7 % of antifungals and antibiotics respectively. Prescriptions assessed as appropriate were 84.4 % of antifungals, and 65.3 % of antibiotic prescriptions. ConclusionsA wide variety of antimicrobials were used with moderate levels of compliance and appropriateness. Future interventions should include targeted education, utilisation of prescribing guidelines, and tools to diagnose and manage oral and dental conditions. Consideration can be given to adjustment of the Hospital NAPS tool to cater for oral conditions and include the provision of dental treatment in the management of these infections. Clinical significanceA wide variety of oral and dental conditions are presented in Australian hospital settings, managed by a range of antibiotics and antifungals, with moderate levels of compliance to guidelines and appropriateness. Antimicrobial stewardship strategies should target and support dentistry in hospital settings.

Influences on androgen deprivation therapy prescribing before surgery in high-risk prostate cancer.

To understand how best to further reduce the inappropriate use of pre-surgical androgen deprivation therapy (ADT), we investigated the determinants (influences) of ADT prescribing in urologists in two European countries using an established behavioural science approach. Additionally, we sought to understand how resource limitations caused by COVID-19 influenced this practice. Identification of key determinants, of undistributed and disrupted practice, will aid development of future strategies to reduce inappropriate ADT prescribing in current and future resource-limited settings. We conducted semi-structured qualitative interviews with urologists practicing in Italy and the UK from February to July 2022. Interviews focussed on undisrupted (usual) practice and disrupted practice (changes made during COVID-19 restrictions). Codes were generated inductively and were mapped to the 14 domains of the Theoretical Domains Framework. Relevant domains of influence were identified, and the similarities and differences between the UK and Italy were distinguished. We identified 10 domains that were influential to ADT prescribing in the UK and eight in Italy. The role of guidance and evidence, the cancer care setting, the patients and the urologist's beliefs and experiences were identified as areas that were influential to ADT prescribing before surgery. Twenty-one similarities and 22 differences between the UK and Italy, for usual and COVID-19 practice, were identified across these 10 domains. Similarities and differences influencing ADT prescribing prior to surgery should be considered in behavioural strategy development and tailoring to reduce inappropriate ADT use. We gained an understanding of usual, undistributed care and resource-limited or disrupted care due to COVID-19 in two European countries. This gives an indication of how influences on ADT prescribing may change in future resource-limited circumstances and where efforts can be focused now and in future.

Adopting STOPP/START Criteria Version 3 in Clinical Practice: A Q&A Guide for Healthcare Professionals.

The growing complexity of geriatric pharmacotherapy necessitates effective tools for mitigating the risks associated with polypharmacy. The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria have been instrumental in optimizing medication management among older adults. Despite their large adoption for improving the reduction of potentially inappropriate medications (PIM) and patient outcomes, the implementation of STOPP/START criteria faces notable challenges. The extensive number of criteria in the latest version and time constraints in primary care pose practical difficulties, particularly in settings with a high number of older patients. This paper critically evaluates the challenges and evolving implications of applying the third version of the STOPP/START criteria across various clinical settings, focusing on the European healthcare context. Utilizing a "Questions & Answers" format, it examines the criteria's implementation and discusses relevant suitability and potential adaptations to address the diverse needs of different clinical environments. By emphasizing these aspects, this paper aims to contribute to the ongoing discourse on enhancing medication safety and efficacy in the geriatric population, and to promote more person-centred care in an aging society.

Sex differences in patterns of potentially inappropriate prescribing and adverse drug reactions in hospitalized older people: Findings from the SENATOR trial.

Older women experience more adverse drug reactions (ADRs) than older men. However, the underlying basis for this sex difference is unclear. Sex (biological status) and/or gender (sociocultural constructs) influences on patterns of inappropriate prescribing in multimorbid older adults may be one reason for this ADR sex difference. In this secondary analysis, we examined whether incident ADR sex differences could be related to concurrent sex differences in potentially inappropriate prescribing. A retrospective secondary analysis of sex differences in the prevalence of potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs), and ADRs among the 1537 participants (47.2% female, median [IQR] age 78 [72-84] years) was undertaken in the SENATOR clinical trial database, conducted in six large European medical centers. We looked specifically for male/female differences relating to PIMs and PPOs (defined by STOPP/START version 2 criteria) identified within 48 h of acute hospitalization. We also assessed sex differences for ADRs identified at 14 days from admission or discharge, whichever came first. ADRs were assessed by blinded endpoint adjudication panel consensus. During hospitalization, significantly more females experienced ≥1 ADR compared to males (28% and 21%, respectively; odds ratio 1.40, 95% CI 1.10-1.78, p < 0.005). Nine of the 11 STOPP-criteria PIMs showing a significant sex difference occurred more often in females. Of the four START-criteria PPOs showing a significant sex difference, all occurred more often in females. Some sex-associated PIMs reflect higher prevalence of related conditions in older women. We conclude that specific STOPP-criteria PIMs and START-criteria PPOs were identified more frequently in older women than older men during acute hospitalization, possibly contributing to higher ADR incidence in older women. Prescribers should appreciate sex differences in exposure to potentially inappropriate prescribing and ADR risk, given the preponderance of older women over older men in most clinical settings.

Exploiting relationship directionality to enhance statistical modeling of peer-influence across social networks.

Risky-prescribing is the excessive or inappropriate prescription of drugs that singly or in combination pose significant risks of adverse health outcomes. In the United States, prescribing of opioids and other "risky" drugs is a national public health concern. We use a novel data framework-a directed network connecting physicians who encounter the same patients in a sequence of visits-to investigate if risky-prescribing diffuses across physicians through a process of peer-influence. Using a shared-patient network of 10661 Ohio-based physicians constructed from Medicare claims data over 2014-2015, we extract information on the order in which patients encountered physicians to derive a directed patient-sharing network. This enables the novel decomposition of peer-effects of a medical practice such as risky-prescribing into directional (outbound and inbound) and bidirectional (mutual) relationship components. Using this framework, we develop models of peer-effects for contagion in risky-prescribing behavior as well as spillover effects. The latter is measured in terms of adverse health events suspected to be related to risky-prescribing in patients of peer-physicians. Estimated peer-effects were strongest when the patient-sharing relationship was mutual as opposed to directional. Using simulations we confirmed that our modeling and estimation strategies allows simultaneous estimation of each type of peer-effect (mutual and directional) with accuracy and precision. We also show that failing to account for these distinct mechanisms (a form of model mis-specification) produces misleading results, demonstrating the importance of retaining directional information in the construction of physician shared-patient networks. These findings suggest network-based interventions for reducing risky-prescribing.

Multidisciplinary medication review during older patient hospitalization according to STOPP/START criteria reduces potentially inappropriate prescriptions: MoPIM cohort study

PurposeMultimorbidity and polypharmacy in older adults converts the detection and adequacy of potentially inappropriate drug prescriptions (PIDP) in a healthcare priority. The objectives of this study are to describe the clinical decisions taken after the identification of PIDP by clinical pharmacists, using STOPP/START criteria, and to evaluate the degree of accomplishment of these decisions.MethodsMulticenter, prospective, non-comparative cohort study in patients aged 65 and older, hospitalized because of an exacerbation of their chronic conditions. Each possible PIDP was manually identified by the clinical pharmacist at admission and an initial decision was taken by a multidisciplinary clinical committee. At discharge, criteria were re-applied and final decisions recorded.ResultsFrom all patients (n = 674), 493 (73.1%) presented at least one STOPP criteria at admission, significantly reduced up to 258 (38.3%) at discharge. A similar trend was observed for START criteria (36.7% vs. 15.7%). Regarding the top 10 most prevalent STOPP criteria, the clinical committee initially agreed to withdraw 257 (34.2%) prescriptions and to modify 93 (12.4%) prescriptions. However, the evaluation of final clinical decisions revealed that 503 (67.0%) of those STOPP criteria were ultimately amended. For the top 10 START criteria associated PIDP, the committee decided to initiate 149 (51.7%) prescriptions, while a total of 198 (68.8%) were finally introduced at discharge.ConclusionsThe clinical committee, through a pharmacotherapy review, succeeded in identifying and reducing the degree of prescription inadequacy, for both STOPP and START criteria, in older patients with high degree of multimorbidity and polypharmacy.Trial RegistrationNCT02830425.

Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients.

We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing. A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48h. First, 41% of 15.896 hospitalized patients received antimicrobials over 20days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94). After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.

Factors associated with potentially inappropriate prescribing in elderly patients with various degrees of chronic kidney disease.

This study aimed to compare the prevalence of potentially inappropriately prescribed drugs in hemodialysis patients and patients with chronic kidney disease who did not require renal replacement therapy, as well as to identify risk factors associated with potentially inappropriate prescribing. The study was designed as a cross-sectional study conducted at the Department of Nephrology, Clinical Center in Nis, Serbia. The patients were divided into two groups: (1) patients on hemodialysis treatment and (2) patients with various degrees of chronic kidney disease without renal replacement therapy. The presence or absence of potentially inappropriate prescribing was determined using the 2015 AGS Beers criteria. The study included a total of 218 patients aged 65 years and over. The number of patients with potentially inappropriate prescribed drugs did not differ significantly (chi-square = 0.000, p = 1.000) between patients on hemodialysis (27 of 83, i.e., 32.5%) and patients with various degrees of chronic kidney disease without renal replacement therapy (44 of 135, i.e., 32.6%). Factors associated with potentially inappropriate prescribing in hemodialysis patients were the number of drugs (hazard ratio [HR] = 1.919, 95% confidence interval [CI]: 1.325-2.780) and number of comorbidities (HR = 1.743, 95% CI: 1.109-2.740). The number of drugs (HR = 1.438, 95% CI: 1.191-1.736) was the only independent factor associated with increased risk of potentially inappropriate prescribing in patients without renal replacement therapy. Our study showed that potentially inappropriate prescribing is a relatively frequent phenomenon present in about a third of patients in both study groups. The number of prescribed drugs was the main factor associated with the increased risk of potentially inappropriate prescribing in both groups.

Check of APpropriaTeness of Antimicrobial therapy In Nursing homes (CAPTAIN):a point prevalence study in Belgium.

The overall prevalence of antimicrobial therapy (AMT) in nursing homes is well described. However, less is known about the appropriateness of AMT in nursing home residents. Therefore, the Check of APpropriaTeness of antimicrobial therapy in nursing homes (CAPTAIN) study aimed to assess both prevalence and appropriateness of AMT in Belgian nursing homes. In a prospective, observational, point prevalence study, researchers documented prevalence and identified potentially inappropriate prescriptions (PIPs) by evaluating accordance of AMT with national guidelines. The severity of inappropriateness was assessed by a modified Delphi expert panel. Eleven nursing homes, including 1178 residents, participated in this study. On the survey day, 8.0% of residents took systemic AMT, primarily for urinary tract infections (54.2%), respiratory tract infections (36.5%), and skin and skin-structure infections (6.3%). About half of these prescriptions were used in prophylaxis (52.1%). Registration of indication and stop date was missing in 58.3% and 56.3% of AMTs, respectively. In 89.6% of the systemic AMTs, at least one discordance with national guidelines was identified, resulting in a total of 171 PIPs, with 49 unique PIPs. Of all unique PIPs, 26.5% were assessed with a high severity score (≥4). According to the expert panel, most inappropriate practice was starting AMT for cough without other symptoms. Inappropriate timing of time-dependent AMTs was common, but assessed as 'moderately severe'. One-third of systemic AMT exceeded the recommended duration. AMT in nursing homes is often not prescribed according to national guidelines, highlighting the need for future interventions to promote the rational use of AMT in this setting.

Identification of seniors at risk (ISAR) score and potentially inappropriate prescribing: a retrospective cohort study.

Potentially inappropriate prescribing (PIP) is usually associated with a higher risk of adverse health outcomes. It is therefore important to identify PIP in older adults. However, there are no clear prioritisation strategies to select patients requiring prescription reviews. The aim of this study was to assess the association between the identification of seniors at risk (ISAR) score and the number of PIPs. A 12-month retrospective hospital-basedstudy was conducted. PIPs, including potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), were detected using the STOPP/START tool. Multivariate linear regressions were conducted to identify factors associated with the number of PIPs. Sensitivity, specificity, Youden index, and ROC curve were calculated to determine the predictive power of ISAR score. This study included 266 records. The analysis led to the detection of 420 PIMs and 210 PPOs, with a prevalence of 80.1% and 54.9%, respectively. Multivariate linear regression revealed that the ISAR score (p = 0.041), and the number of medications (p < 0.001) were determinants of PIP. The number of medications remained the sole determinant of the number of PIMs (p < 0.001), while living in a nursing home was the only determinant of the number of PPOs (p = 0.036). The study showed that the ISAR score and the number of medications were independently associated with the number of PIPs. Considering the use of the ISAR score and the number of medications may be useful strategies to prioritise patients for whom prescribing appropriateness should be assessed using explicit criteria.

Appropriateness of Antibiotic Prescriptions in Emergency Departments in the United States, 2016-2021

Background: Inappropriate antibiotic prescribing contributes to antimicrobial resistance, a global health threat. Prior studies have used ICD-9-CM codes to estimate inappropriate prescribing rates in ambulatory settings, including emergency departments (EDs), though the last national estimates date back to 2010-2015 (Hersh et al, CID 2021). Using the most recent publicly available data, we estimated inappropriate antibiotic prescribing rates in EDs across all conditions. For further characterization, we estimated rates of inappropriate antibiotic prescribing with and without codes that could be plausible indications for which antibiotics are prescribed. Methods: We analyzed 2016-2021 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of EDs, subsetting to visits with ≥1 oral antibiotic prescription. Using ICD-10-CM codes (Chua et al, BMJ 2019), we calculated proportions of visits with inappropriate antibiotic prescribing; inappropriate antibiotic prescribing and ≥1 plausible antibiotic-inappropriate indication (e.g., viral infection); and inappropriate prescribing without plausible antibiotic-inappropriate indications. Among visits with plausible antibiotic-inappropriate indications, we subcategorized these further (e.g. viral infection, ophthalmologic conditions). Among visits without plausible antibiotic-inappropriate indications, we determined the most common diagnosis codes. We conducted analyses overall and separately among children (0-17 years), adults (18-64 years), and older adults (≥65 years). Results: Demographic characteristics by age group are shown in Table 1. Antibiotic prescription rates overall and for children, adults, and older adults were 18.6%, 17.8%, 19.1%, and 18.0%, respectively. Inappropriate prescription rates were 27.6%, 23.7%, 29.8%, and 24.6%, respectively. Inappropriate antibiotic prescription rates with plausible indications were 14.9%, 16.7%, 15.0%, and 12.6%, while inappropriate antibiotic prescription rates without plausible indications were 12.7%, 7.0%, 14.9%, and 12.0%, respectively (Figure 1). Rates of subcategories of inappropriate prescribing with plausible antibiotic indications overall and by age group are shown in Figure 2, with the most common diagnoses for potential signs and symptoms of infection in Table 2. The most common diagnoses for inappropriate prescribing without plausible indications are in Table 3. Conclusions: Inappropriate antibiotic prescriptions in EDs are common with a substantial proportion without plausible conditions. Most inappropriate prescriptions with plausible antibiotic-inappropriate indications are associated with potential signs and symptoms of infection without a more definitive diagnosis code, suggesting either diagnostic uncertainty or poor coding quality. Future work should distinguish between these two possibilities to determine whether stewardship efforts should focus on educational strategies to avoid unnecessary empiric antibiotic prescribing in the setting of diagnostic uncertainty, improving coding quality, or both.

Rational Use of Proton Pump Inhibitors among Patients Admitted in a Tertiary Care Hospital

Background: The prevalent usage of proton pump inhibitors (PPIs) is a testament to the effectiveness of this class of medications, but it also introduces risk associated with inappropriate prescriptive and consumptive practices. Because of the negative effect of incorrect usage and overdose of PPIs, it is very important for physicians to only prescribe these drugs when needed. However, recent studies showed some concerns about long-term PPIs consumption. The rational prescription of medications is vital to ensuring the optimal use of medical resources, providing effective therapy and minimizing adverse drug reactions. Methods: This observational study was conducted in the department of Pharmacology and therapeutics, Sylhet M.A.G. Osmani medical college, Sylhet, in collaboration with the department of Medicine, Surgery, Gastroenterology, Obstetrics and gynaecology, Sylhet M.A.G. Osmani medical college hospital, Sylhet, from July 2022 to June 2023. The sample size for this study was 600. Usage of PPIs was considered to be appropriate on the basis NICE guidelines and recommendations by Scarpignato et al. (2016) committees on behalf of three Italian scientific societies. Result: For 600 PPIs prescriptions, total 705 case sheets were reviewed. The mean age of the study patients was 42.94±17.16 years. Female were found more 359(59.8%) than male 241(40.2%). Out of 600 patients, based on the indications of PPI usage, 287 (47.8%) of prescriptions were found appropriate, whereas inappropriate prescriptions were found in 313 (52.2%) cases. Out of 287 patients who were prescribed PPIs in an appropriate indication, 175 (61%) patients were given PPIs in an appropriate dose, whereas inappropriate dose was found in 112 (39%) of patients. Again, among 175 patients who were prescribed PPIs for appropriate dose, 24 (13.7%) patients were given PPIs in an appropriate frequency, whereas inappropriate frequency was found in 151 (86.3%) of patients. Finally, 24/600 (4%) patients were prescribed in an appropriate indication with an appropriate dose and frequency, whereas inappropriate prescription were found in 576/600 (96%) patients. PPIs were used as prophylaxis for NSAIDs in highest number 147(51.2%) of patients. Oral was the most common 348(58%) route of prescribing PPIs. Omeprazole was the highest 577(96.2%) prescribed PPIs. Conclusion: Based on this study result, it could be concluded that in most of the patients PPIs prescriptions were not following appropriate indications, dose and frequency recommended by reference guidelines. Like any other drugs, PPIs should be prescribed for a clear indication, the minimum dose needed for the expected effect and medication halted when no longer necessary upon re-evaluation.

UTI Symptomatology and Antibiotic Prescribing among US Veterans Seen in Outpatient Clinics

Background: Infectious Diseases Society of America guidelines recommend antibiotic prescribing for urinary tract infections (UTIs) when there is a positive culture and signs and symptoms of infection. Despite these guidelines, prescribing for asymptomatic bacteriuria remains prevalent. We conducted a chart review of UTI outpatient encounters to determine the prevalence of antibiotic prescribing as well as patient and provider factors associated with inappropriate prescribing for UTIs. Methods: Patients who were seen at any Department of Veterans Affairs (VA) outpatient clinic with a positive urine culture from 1/1/2019-12/31/2022 were evaluated for inclusion. Exclusion criteria were pregnancy, neutropenia, neurogenic bladder, spinal cord injury/disorder, chronic kidney disease stage III and above, and those undergoing urologic surgical procedures within 7 days. Inappropriate prescribing was defined as an antibiotic prescription given for UTI treatment when no signs or symptoms of infection were recorded during the patient encounter. Chi-square, Fisher’s exact and t-tests were used to evaluate the association between patient and provider characteristics and antibiotic prescribing. Results: Among 341 visits, most patients were male (70%), White (40%), older (mean age of 65.8 ± 15.9 years) and treated at an urban facility (57%). Antibiotics were prescribed for 67% (229/341) of visits. Of the 229 antibiotic courses prescribed, 119 (52%) were appropriate; issued to patients with &gt; = 1 sign or symptom consistent with a urinary tract infection. The most common symptom recorded was dysuria, followed by frequency, urgency, and hematuria (Figure 1). The remaining 110 (48%) antibiotic prescriptions were inappropriate; given to patients without documented UTI-related signs or symptoms. The proportion of inappropriate prescribing was higher among advanced practice practitioners (39/56; 69%) compared to physicians (68/113; 60%; P &lt; 0 .0001). Prescribing of an antibiotic did not differ by gender (p-value=0.3779), race (p-value=0.3972), age (p-value=0.7461) or urban versus rural geography (p-value=0.3647). Discussion: In outpatient clinics, nearly half of antibiotics prescribed to patients with a positive urine culture occurred in the absence of documented of signs or symptoms of a UTI. These results suggest that interventions to improve antibiotic use for UTI-related concerns in the outpatient setting should address UTI-related signs and symptoms as well as asymptomatic bacteriuria. Advanced practice practitioners were more likely to prescribe without documentation of relevant signs or symptoms than physicians. Improving meaningful documentation about the presence or absence of signs and symptoms of a UTI may help reduce inappropriate antibiotic prescriptions in the outpatient setting.Disclosure: Robin Jump: Research support to my institution from Merck and Pfizer; Advisory boards for Pfizer

Investigation Into Potentially Inappropriate Prescribing Patterns of Loop Diuretics in a Nationally Representative Outpatient Population.

Loop diuretic therapy effectively treats edema related to heart failure, chronic kidney disease, and liver impairment; however, evidence supporting other indications is lacking. For indications such as hypertension or dependent edema or treatment of adverse events associated with other medications, the benefits likely do not outweigh the risks, putting patients at an unacceptably high risk of poor outcomes. What is the proportion of loop diuretic prescribing that occurs in the absence of a diagnosis of heart failure, chronic kidney disease, liver impairment, or other evidence-based indications? This was a national, retrospective, cross-sectional investigation conducted using the National Ambulatory Care Survey from 2013 to 2016. Outpatient visits for patients aged 18 years or older prescribed with loop diuretics were included. The primary end point was the frequency of potentially inappropriate loop diuretic prescribing. The secondary end point was a multivariable regression model that identified predictors of potentially inappropriate loop diuretic utilization. This analysis identified 5261 outpatient visits conducted during the study period in which loop diuretics were prescribed. Of these, 3648 visits (65.8% of weighted visits) were of patients without a history of heart failure, chronic kidney disease, or liver impairment. Positive predictors included age older than 65 years (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.38-2.13), concomitant calcium channel blocker (OR 1.42; 95% CI, 1.09-1.84), sodium-containing medication use (OR 2.78; 95% CI, 1.23-6.25), and office visit with a cardiology specialist (OR 2.84; 95% CI, 2.31-3.50). This analysis identified that loop diuretics are prescribed in the absence of evidence-based indications more frequently than they are prescribed for them. This prescribing pattern creates a unique opportunity for clinicians to optimize patient care. Further study of the outcomes associated with this prescribing pattern is warranted.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial

ObjectivesPotentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate...

Patient and Community Perspectives on Antibiotics and Antimicrobial Resistance: Fertile Grounds for Antimicrobial Stewardship

Background: Antimicrobial resistance is a serious public health threat. Overuse of antibiotics leads to the development and spread of antibiotic resistant pathogens. Antibiotics are also responsible for a high percentage of emergency department visits for adverse drug events. Despite this, ambulatory and urgent care providers often cite patient expectations as a reason for inappropriate antibiotic prescribing practices. We investigated patient and community understanding of antibiotics and antimicrobial resistance to inform how they can be engaged as partners in combating antimicrobial resistance in our southwestern Virginia community. Methods: From July to September 2023, we conducted an online survey of patients and community members within the footprint of a large healthcare system in Southwest Virginia. Electronic medical records were used to randomly select and directly email the survey link to a representative sample of ambulatory patients who met criteria. Respondents were also recruited through the health system’s social media channels and through posters with quick response (QR) codes in outpatient offices. The survey used Likert scales and multiple-choice questions to understand experiences with and perceptions about antibiotics and antimicrobial resistance. We conducted a descriptive analysis of survey responses. Results: In total, 2,021 individuals completed the survey. Nearly 16% of respondents agreed with the statement “antibiotics can kill viruses” and almost 12% more were unsure. Thirty percent of respondents either agreed with or were unsure about the statement “antibiotics work on most coughs and colds”. When asked more directly about antimicrobial resistance, almost a quarter (25%) of respondents agreed with or were unsure about the statement “there is no connection between taking antibiotics and the development of resistant bacteria”. Responding to questions about possible negative effects of antibiotics, over 9% disagreed with the statement “antibiotics can kill the 'good' bacteria that normally live on the skin and in the gut” and another 19% were unsure. Similarly, over 20% disagreed with or were unsure about the statement “bacteria that do not respond to antibiotics could infect me or my family”. Reflecting on their own providers, nearly 83% of respondents trusted their doctor’s or nurse’s advice about antibiotic necessity. Conclusions: There are opportunities for patient and community engagement around antibiotic effectiveness for common viral illnesses and about the negative effects of overuse of antibiotics. Our data suggests most patients trust their providers as it relates to antibiotic prescribing and may be receptive to discussions and strategies that promote antimicrobial stewardship.

Evidence‐based prescribing in general practice: the practice‐based pharmacist's role

Pharmacists are increasingly working in UK general practices, presenting an opportunity for practice teams to benefit from their additional professional skills and comprehensive knowledge of medicines. This article examines how pharmacists are helping to reduce inappropriate and inequitable prescribing in general practice and suggests ways in which their contribution can be optimised.

Antibiotic Stewardship for Patients With Pharyngitis: Implementing the Centor Tool

Pharyngitis is a common complaint seen in outpatient clinics, and patients are often sent home with antibiotics when not deemed necessary. The Centor clinical tool is an established, but seldom employed, resource to aid providers in decision-making and determining the likelihood of bacterial strep pharyngitis. The purpose of this paper is to describe a project conducted at 3 urgent care centers with a goal to decrease unnecessary testing and inappropriate antibiotic prescribing. The intervention included implementing the Centor scoring tool when evaluating patients with complaints of pharyngitis. Results indicated that as Centor documentation improved, antibiotic rates decreased.

Use of Azithromycin Attributable to Acute SARS-CoV-2 Infection.

In the early stages of the COVID-19 pandemic, preliminary results that later proved to be incorrect suggested the possible efficacy of anti-infective drugs such as azithromycin for the treatment of SARS-CoV-2 infection. These preliminary data may have influenced the prescription of azithromycin. However, no individual-level data linking the use of this antibiotic to acute SARS-CoV-2 infection are available. The present analysis aims to fill this gap. A retrospective population-based cohort design was used including patients diagnosed with SARS-CoV-2 infection in the period ranging from February 2020 to February 2022. The data source for antibiotic consumption was the drug database of outpatient prescriptions of Emilia-Romagna Region (Italy). Antibiotics were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. Consumption rates and percentages of azithromycin DDDs (defined daily doses) during the acute phase of the infection were compared with a previous control period and with the post-acute phase. Analyses were stratified by four groups according to the prevalent virus variant at time of diagnosis. Comparing the previous control period with the acute phase of infections, the rates of azithromycin consumption (DDD per 1000 individuals per day) increased from 1.17 to 23.11, from 0.80 to 33.03, from 0.81 to 21.01, and from 1.02 to 9.76, in the pre-Alpha, Alpha, Delta, and Omicron periods, respectively. Similarly, the percentages of individuals receiving azithromycin, and the azithromycin DDDs percentages over total systemic antibiotics DDDs increased in acute phases of infection compared with control periods. The consumption rates and percentages returned to preinfection levels in the post-acute phase. In the study period, 12.9% of the use of azithromycin in the entire adult population of Emilia-Romagna was attributable to acute SARS-CoV-2 infection. Considering the low likelihood of bacterial coinfections, the increased azithromycin consumption in the acute phase of SARS-CoV-2 infection suggests inappropriate prescribing of this antibiotic.

Antibacterial Properties of Mint Nanoemulsion Against Uropathogenic Escherichia coli Carrying Beta-Lactamase Resistance Genes

Background: Uropathogenic Escherichia coli (UPEC) is a significant contributor to urinary tract infections (UTIs). The inappropriate prescription and utilization of antibiotics in treating UTIs have resulted in a rise in antibiotic resistance. The aim of this study was to investigate the antibacterial properties of mint nanoemulsion against beta-lactam-resistant strains of UPEC. Methods: Three hundred fifty urine samples were collected in sterile containers and cultured on eosin-methylene blue agar and blood agar media under sterile conditions. Microbial sensitivity testing was conducted using the standard disk diffusion method. Molecular analysis was performed to identify the blaTEM, blaSHV, and blaCTX genes in the samples. The mint nanoemulsion was produced using the low-energy method of spontaneous emulsion formation and characterized using scanning electron microscopy (SEM), dynamic light scattering (DLS), and Fourier-transform infrared spectroscopy (FTIR). The antibacterial activity of the mint nanoemulsion against multidrug-resistant (MDR) isolates underwent assessment. Results: One hundred UPEC strains were isolated and identified, showing differing levels of resistance and sensitivity to various antibiotics. Nitrofurantoin exhibited the highest resistance (22%), while amikacin had the lowest resistance (4%). The prevalence of the blaTEM, blaSHV, and blaCTX genes among the UPEC isolates was 93.33%, 100%, and 73.33%, respectively. The mint nanoemulsion demonstrated effective antibacterial activity against resistant isolates, with a minimum inhibitory concentration of 0.2 mg/µL and a minimum bactericidal concentration of 0.3 mg/µL. Conclusion: The resistance of UPEC against conventional antibiotics commonly used to treat UTIs was consistently high and demonstrated an increasing trend over time. This escalating situation could potentially become more severe in the future if the rational consumption of antibiotics is not carefully managed. Nanoemulsions synthesized using mint revealed promising stability and robust antimicrobial properties against UPEC isolates. Consequently, it is evident that these synthesized nanoemulsions represent a viable candidate as effective antimicrobial agents in combating antibiotic resistance in UTI treatment.