Optimal Prescribing Research Articles

Investigation of antimicrobial use at a tertiary care hospital in Southern Punjab, Pakistan using WHO methodology

BackgroundGlobally, between 20 to 50% of antimicrobial consumption is inappropriate, causing significant impact on the quality of care, cost of therapy and incidence of adverse drug reactions. The purpose of this study was to investigate the prescribing patterns and utilization of antimicrobials in ten selected wards at Bahawal Victoria Hospital (BVH), Bahawalpur, Punjab, Pakistan.MethodsA descriptive cross-sectional study was designed using the World Health Organization (WHO) indicators for antimicrobial use. Standard data collection forms were used in ten wards and the Pharmacy Department at BVH. Antimicrobial utilization patterns in terms of frequency and percentage were also determined. Systematic random sampling techniques were used to collect data from 1,000 prescription records out of 21,115 prescriptions written for the six months January to June 2016.ResultsFor the hospital indicators, a formulary list or essential medicines list (FL/EML) was available, but standard treatment guidelines (STGs) for infectious diseases was not. The average number of days that key antimicrobials were out of stock was 3.3 days per month. The expenditure on antimicrobials as a percentage of the total medicines costs was 12.2%. For the prescribing indicators, the percentage of hospitalizations with antimicrobial(s) prescribed was 82.3%, and the average number of antimicrobials per hospitalization was 1.4 (SD = 0.6). The average duration of antimicrobial treatment per hospitalization was 5.4 days (SD = 3.2). The average cost of antimicrobials prescribed per hospitalization was USD 5.4 (SD = 6.7). None of the patients who were prescribed antimicrobials, received AM according to the STGs (pneumonia and cesarean section cases). Among the patient-care and supplemental indicators, the average duration of hospital stay of patients who received antimicrobials was 6.4 (SD = 4.3) days. The drug sensitivity testing was almost non-existent, with only 0.24% prescription records having drug sensitivity tests. Ceftriaxone (39.6%), metronidazole (23.4%) and cefotaxime (23.1%) were the top most frequently prescribed antimicrobials.ConclusionsThe results of the current study revealed less than optimal antimicrobial prescribing and utilization patterns of selected wards at BVH. Continuous education and training of physicians, and cost-effective policies could play an important role in promoting the rational use of antimicrobials in this setting.

Step Therapy—Clinical Algorithms, Legislation, and Optimal Prescribing

Increasing prescription drug costs impose economic burdens for patients and payers and are reflected in substantial increases in insurance premiums for individuals and employers and budget stress for public programs. One widely used approach to control prescription costs is “step therapy”: requiring patients to try a less expensive drug for a given condition before a more expensive option can be approved. Authorization of the second-line agent may require attestation by the prescriber that the patient took the initial medication and had adverse effects or inadequate clinical benefit. Such clinical algorithms are often sensible and evidence based and can improve the quality of care. But sometimes they are not, because of limited evidence, inadequate attention to the underlying evidence, or an emphasis on cost containment rather than patient outcomes. The economic stakes can be high, because manufacturers’ promotion to both prescribers and patients is usually aimed at encouraging use of more costly second-line agents.

Self-Monitoring of Blood Glucose: Impact of Quantity Limits in Public Drug Formularies on Provincial Costs Across Canada.

For most patients with diabetes, routine use of blood glucose test strips (BGTS) has not been shown to be beneficial, yet the economic implications of broad publicly funded reimbursement for BGTS are substantial. We assessed the potential impact of BGTS quantity limits on utilization and costs for 6 publicly funded drug plans across Canada. A cross-sectional analysis was conducted in 6 provinces (Alberta, Saskatchewan, Manitoba, Nova Scotia, Newfoundland and Labrador and Prince Edward Island) for patients who received at least 1 prescription for BGTS in 2014 through the public drug program. We determined the number of BGTS that would have exceeded the quantity limits and the associated costs to the provincial drug program. A total of $38,051,026 was spent on BGTS reimbursed through public drug programs among the 6 provinces. In provinces where BGTS use is largely restricted to patients using insulin, the potential annual savings were minimal, ranging from 0.4% to 2.3%, whereas in provinces with more liberal listings, potential savings ranged from 12.4% to 19.8%. Combining these results with data from a previous analysis in Ontario and British Columbia, the cost savings associated with BGTS quantity limits for 8 provinces across Canada (capturing approximately three-quarters of the Canadian population) is estimated to be $30.3 million annually. The national implementation of a quantity limit policy for BGTS that aligns with evidence of efficacy, optimal prescribing and patient safety can lead to considerable savings for most public drug plans across Canada.

General Practitioners' Prescribing Patterns at Primary Healthcare Centers in National Health Insurance, Gezira, Sudan.

BackgroundThe appropriate use of medicines is essential for the provision of quality health services, patient safety, and the rational use of health resources. In Sudan, general practitioners (GPs) provide 80 % of insured patients’ health services. Pharmaceutical service costs have been increasing since 2010.ObjectivesWe aimed to use the World Health Organization (WHO) and International Network for the Rational Use of Drugs prescribing indicators to assess prescription quality among GPs in different types of primary healthcare centers (PHCCs) within the National Health Insurance Fund (NHIF) in Gezira State, Sudan.MethodWe followed established WHO guidelines to conduct a cross-sectional retrospective study. The study was carried out over 6 months and involved 197 GPs with valid prescriptions, representing 90 % of the total study population of 220 GPs. We collected a systematic random sample of 100 prescriptions for each GP and used Stata 12 to analyze the 19,700 prescriptions.ResultsThe mean ± standard deviation number of medications was 2.55 ± 1.32 per patient; 46.32 % of drugs prescribed were generics; 54.71 % of prescriptions were for antibiotics and 12.84 % were for injectable formulations; and 81.19 % of prescribed medicines were from the NHIF medicines list. The overall Index of Rational Drug Prescribing (IRDP) indicator was 3.39, and the average cost per prescription was 40.57 Sudanese pounds (SDG). Disregarding prescriptions for antibiotics, the prescribing quality of GPs in NHIF facilities was farther from optimal prescribing practice than those in State Ministry of Health-owned facilities and facilities owned by private groups, universities, and non-governmental organizations.ConclusionThe present study provides strong evidence of irrational prescribing practice among GPs, with significant disparities, particularly in terms of antibiotic overuse, generic drug underuse, and adherence to the NHIF medicines list.

What do I need to know about penicillin antibiotics?

The penicillins remain the class of antibiotics most commonly prescribed to children worldwide. In an era when the risks posed by antimicrobial resistance are growing, an understanding of antibiotic pharmacology...

The hospitalist perspective on opioid prescribing: A qualitative analysis.

Pain is a frequent symptom among patients in the hospital. Pain management is a key quality indicator for hospitals, and hospitalists are encouraged to frequently assess and treat pain. Optimal opioid prescribing, described as safe, patient-centered, and informed opioid prescribing, may be at odds with the priorities of current hospital care, which focuses on patient-reported pain control rather than the potential long-term consequences of opioid use. We aimed to understand physicians' attitudes, beliefs, and practices toward opioid prescribing during hospitalization and discharge. In-depth, semistructured interviews. Two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital located in Denver, Colorado or Charleston, South Carolina. Hospitalists (N = 25). We systematically analyzed transcribed interviews and identified emerging themes using a team-based mixed inductive and deductive approach. Although hospitalists felt confident in their ability to control acute pain using opioid medications, they perceived limited success and satisfaction when managing acute exacerbations of chronic pain with opioids. Hospitalists recounted negative sentinel events that altered opioid prescribing practices in both the hospital setting and at the time of hospital discharge. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions. At times, this left them feeling conflicted about how this practice could impact the patient over the long term. Strategies to provide adequate pain relief to hospitalized patients, which allow hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed. Journal of Hospital Medicine 2016;11:536-542. © 2016 Society of Hospital Medicine.

Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.

Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy. This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy. The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments. Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.

Misuse of prescription drugs and overdose deaths

Aims. This study examined overdose deaths involving benzodiazepines and prescription opioids, and studied associated factors. Methods. In a retrospective registry study of drug-overdose deaths (n = 167) with post-mortem toxicological findings of benzodiazepines and/or opioids/carisoprodol (strong analgesics) in Oslo, Norway, from 2006 to 2008, prescribing and dispensing patterns were investigated, and factors associated with benzodiazepines and/or strong analgesics in post-mortem toxicology where these medications were not prescribed were identified. Results. Among deceased with toxicological findings of only benzodiazepines, 28.1% (20.7–36.9) had been dispensed benzodiazepines four weeks prior to death; only strong analgesics, 33.3% (13.0–61.3) had been dispensed strong analgesics; both benzodiazepines and strong analgesics, 58.3% (36.9–77.2) had been dispensed benzodiazepines and/or strong analgesics. Also, 33.0% of the deceased had five or more different prescribing physicians of either benzodiazepines or strong analgesics in the year prior to death. Doses of both dispensed benzodiazepines and strong analgesics were higher than recommended. Younger age and residing outside Oslo were associated with having benzodiazepines and/or strong analgesics in the toxicological findings when these medications had not been dispensed (p = 0.006 and p = 0.039, respectively). Conclusion. The majority of benzodiazepines and strong analgesics detected in overdose deaths were non-prescribed and/or associated with less than optimal prescribing practices by some treating physicians.

Useful Implications of Low-dose Long-term Use of PDE-5 Inhibitors.

Phosphodiesterase type 5 (PDE-5) hydrolyzes cyclic guanylate monophosphate (cGMP) specifically to 5' GMP, promoting successful corporeal vascular relaxation and penile erection during sexual stimulation. Oral PDE-5 inhibitors such as sildenafil, vardenafil, tadalafil, and avanafil have provided noninvasive, effective, well-tolerated treatment for erectile dysfunction (ED) patients and, at the same time, stimulated both academic and clinical interests. Lately, some oral PDE-5 inhibitors were released as low-dose preparations with the concept of potential daily administration and long-term use. To highlight the possible potential implications of low-dose long-term use of PDE-5 inhibitors. A systematic review was carried out until December 2015 based on a search of all concerned articles in MEDLINE, medical subjects heading (MeSH) databases, Scopus, The Cochrane Library, EMBASE, and CINAHL databases without language restriction. Key words used to assess the outcome and estimates for concerned associations were: PDE-5 inhibitors; erectile dysfunction; low-dose; long-term; sildenafil; tadalafil; vardenafil; avanafil. Demonstrating different implications for low-dose long-term use of PDE-5 inhibitors. Low-dose and/or long-term use of PDE-5 inhibitors was shown to put forth beneficial sound effects in different medical implications with potentials that could be extended for different utilities. These implications included sexual, urogenital, cardiovascular, pulmonary, cutaneous, gastrointestinal, and reproductive, as well as neurological disorders. However, it is evident that most potential appliances were carried out experimentally on preclinical studies with off-label indications. Making use of and exploring low-dose and/or long-term use of several PDE-5 inhibitors for their possible implications seem to be valuable in different medical disorders. Increased knowledge of the drug characteristics, comparative treatment regimens, optimal prescribing patterns, and well-designed clinical trials are needed before these agents can be recommended for use.

Medical decision support systems and therapeutics: The role of autopilots.

For decades, medical practice has increasingly relied on prescription medicines to treat, cure, or prevent illness but their net benefit is reduced by prescribing errors that result in adverse drug reactions (ADRs) and tens of thousands of deaths each year. Optimal prescribing requires effective management of massive amounts of data. Clinical decision support systems (CDSS) can help manage information and support optimal therapeutic decisions before errors are made by operating as the prescribers' "autopilot."

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines.

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Psychosocial determinants of physicians’ acceptance of recommendations by antibiotic computerised decision support systems: A mixed methods study

Antibiotic computerised decision support systems (CDSSs) were developed to facilitate optimal prescribing, but acceptance of their recommendations has remained low. We aimed to evaluate physicians’ perceptions and attitudes toward antibiotic CDSSs and determine psychosocial factors associated with acceptance of CDSS recommendations for empirical therapy. A mixed methods study was conducted in an adult tertiary-care hospital in Singapore, with its in-house antibiotic CDSS that integrates antimicrobial stewardship with electronic prescribing. Focus group discussions were conducted among purposively sampled physicians and data were analysed using the framework approach. Emerging themes were included in the questionnaire with newly developed scales for the subsequent cross-sectional survey involving all physicians. Principal components analysis was performed to derive the latent factor structure that was later applied in multivariate analyses. Physicians expressed confidence in the credibility of CDSS recommendations. Junior physicians accepted CDSS recommendations most of the time, whilst senior physicians acknowledged overriding recommendations in complex patients with multiple infections or allergies. Willingness to consult the CDSS for common and complex infections (OR=1.68, 95% CI 1.16–2.44) and preference for personal or team decision (OR=0.61, 95% CI 0.43–0.85) were associated with acceptance of CDSS recommendations. Cronbach's α for scales measuring physicians’ attitudes and perceptions towards acceptance of CDSS recommendations ranged from 0.64 to 0.88. Physicians’ willingness to consult an antibiotic CDSS determined acceptance of its recommendations. Physicians would choose to exercise their own or clinical team's decision over CDSS recommendations in complex patient situations when the antibiotic prescribing needs were not met.

Antibiotic prescribing practice in residential aged care facilities — health care providers' perspectives

To explore organisational workflow and workplace culture influencing antibiotic prescribing behaviour from the perspective of key health care providers working in residential aged care facilities (RACFs). Qualitative approach using semistructured interviews, focus groups and onsite observation between 8 January 2013 and 2 July 2013. Nursing staff, general practitioners and pharmacists servicing residents at 12 high-level care RACFs in Victoria were recruited. Emergent themes on antibiotic prescribing practices in RACFs. Sixty-one participants (40 nurses, 15 GPs and six pharmacists) participated. Factors influencing antibiotic prescribing practice have been divided into workflow-related and culture-related factors. Five major themes emerged among workflow-related factors: logistical challenges with provision of medical care, pharmacy support, nurse-driven infection management, institutional policies and guidelines, and external expertise and diagnostic facilities. Lack of onsite medical and pharmacy staff led to nursing staff adopting significant roles in infection management. However, numerous barriers hindered optimal antibiotic prescribing, especially inexperienced staff, lack of training of nurses in antibiotic use and lack of institutional infection management guidelines. With regard to culture-related factors, pressure from family to prescribe and institutional use of advance care directives were identified as important influences on antibiotic prescribing practices. Workflow- and culture-related barriers to optimal antibiotic prescribing were identified. This study has provided important insights to guide antimicrobial stewardship interventions in the RACF setting, particularly highlighting the role of nurses.

Patient-centered prescribing of medications for comorbid illness in older adults with advanced cancer: A qualitative study.

122 Background: Polypharmacy is common, burdensome, and potentially harmful in older adults with advanced cancer. According to the IOM, prescribing and coordination of chronic disease medication for these patients is suboptimal. We conducted a qualitative study with patients, caregivers, nurses, and physicians to better understand these issues. Methods: We used semi-structured interviews to explore participants’ views on medication management, care coordination, and communication for advanced cancer patients enrolled in 3 hospice agencies in New England. Eligible hospice patients were aged ≥ 65 yrs, had a diagnosis of cancer, and prescribed ≥5 medications. Family caregivers participated at the patient’s discretion. We also interviewed nurses and physicians to obtain an interdisciplinary perspective on medication coordination and communication. We used content analysis to identify emerging themes. Eighteen (18) patients (mean age 80 yrs [SD 10], 42% female) and 8 caregivers (mean age 63 yrs [SD 16.6], 88% female) were included, along with 10 nurses and 7 physicians from hospice, outpatient oncology and primary care settings. Results: Emerging themes revealed that patients and families were receptive to comprehensive medication reviews upon transition to hospice that assess the ongoing use of longstanding medications for comorbid illness. Effective framing for discussions included a focus on reducing harmful and non-essential medications; a less effective approach emphasized time to benefit (i.e. whether a medication is indicated for active symptom management vs prevention). Hospice nurses reported physician reluctance to discontinue medications, lack of physician confidence in their medication assessments, and lack of prescribing guidelines as barriers to optimizing prescribing. Conclusions: Patients enrolled in hospice for cancer and their families are willing to reassess the ongoing use of chronic medications for comorbid illness; information about medication harms and their impact on quality of life is considered particularly useful. Barriers to optimal prescribing include physician reluctance to discontinue medications and mistrust between providers.

Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008-13): working towards hospital prescribing quality measures.

There is global concern that antimicrobial resistance is a major threat to healthcare. Antimicrobial use is a primary driver of resistance but little information exists about the variation in antimicrobial use in individual hospitals in England over time or comparative use between hospitals. The objective of this study was to collate, analyse and report issue data from pharmacy records of 158 National Health Service (NHS) acute hospitals. This was a cohort study of inpatient antibacterial use in acute hospitals in England analysed over 5 years through a data warehouse from IMS Health, a leading provider of information, services and technology for the healthcare industry. Around 98% of NHS hospitals were included in a country with a population of 50 million residents. There was a dramatic change in the usage of different groups of antibacterials between 2009 and 2013 with a marked reduction in the use of first-generation cephalosporins by 24.7% and second-generation cephalosporins by 41%, but little change in the use of third-generation cephalosporins (+5.7%) and fluoroquinolones (+1.6%). In contrast, use of co-amoxiclav, carbapenems and piperacillin/tazobactam increased by 60.1%, 61.4% and 94.8%, respectively. There was wide variation in the total and relative amounts of antibacterials used between individual hospitals. Longitudinal analysis of antibacterial use demonstrated remarkable changes in NHS hospitals, probably reflecting governmental and professional guidance to mitigate the risk of Clostridium difficile infection. The wide variation in usage between individual hospitals suggests potential for quality improvement and benchmarking. Quality measures of optimal hospital antimicrobial prescribing need urgent development and validation to support antimicrobial stewardship initiatives.

Prévention du risque d’œdème aigu pulmonaire associé à la transfusion

Hydrostatic pulmonary edema is a frequent and severe complication of blood transfusion. Recent epidemiological studies open the way for a better prevention of Transfusion-Associated Circulatory Overload. Preventive measures rely solely on the medical and nursing staff. Mitigation strategies include a careful identification of patients and conditions at-risk, a single-unit transfusion policy in patients with chronic anemia, the use of slow infusion rates, the careful monitoring of patient vital signs (particularly systemic arterial blood pressure). Peritransfusion IV diuretics use is likely to be helpful, although optimal prescribing patterns have not been defined.

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals.

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals. We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors. Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines. The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices. A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Electronically implemented clinical indicators based on a data warehouse in a tertiary hospital: Its clinical benefit and effectiveness

ObjectiveAssessing and monitoring care and service using clinical indicators (CIs) can allow the measurement of and lead to improvements in the quality of care. However, the management and maintenance of CI data has been shown to be difficult because the data are usually collected and provided manually. In this study, for the purpose of efficient managing quality indicators, a data warehouse (DW)-based CI monitoring system was developed. The clinical effectiveness and efficiency of a DW-based CI monitoring was investigated through several case studies of the system's operation at a tertiary hospital. MethodsThis study analyzed the CIs that have been developed over the past 8 years at a 1340-bed tertiary general university hospital in South Korea to improve and monitor the quality of care and patient safety. The hospital was opened as a fully digital hospital in 2003, and the CIs were computerized in 2005 by implementing a DW-based CI monitoring system. We classified the computerized CIs and evaluated the monitoring results for several representative CIs, such as the optimal prescribing of preventive antibiotics, the average length of stay, the mortality rate, and the rehospitalization rate. ResultsDuring the development of the system in 2005, 12 of 19 CIs were computerized, and this number gradually increased until 299 of 335 CIs were computerized by 2012. In addition, among the CIs built computationally through the CI task force team, focal CIs subject to monitoring were selected annually, and the results of this monitoring were shared with all of the staff or the related department and its staff. By providing some examples of our CI monitoring results, we showed the feasibility of improving the quality of care, and maintaining the optimum level of patient care with less labor. ConclusionsThe results of this study provide evidence regarding the clinical effectiveness and efficiency as well as the systems operation experience of a DW-based CI monitoring system. These findings may aid medical institutions that plan on computerizing CIs with respect to decision and policy making regarding their systems development and operations.

Novel surveillance system demonstrates burden of enteric fever in India

ations in prescribing decisions, including the proportion of broadand narrow-spectrum antibiotics used; ethnographic approaches will describe prescribers perceptions on their experience; in-game analytics will report engagement with the game and elicit any dose-effect relations (i.e., increased game time greatly improving prescribing decisions). The influence of prompts by different professionals (doctors, nurses, pharmacists or hospital managers) on prescriber’s decisions will be explored. Conclusion: The sustainability of optimal prescribing behaviours remains a challenge for antimicrobial stewardship initiatives worldwide. Serious games may be an affordable and feasible solution to address behavioural and social influences on prescribing.

Using antibiotics responsibly in companion animals

Antibiotics are regularly prescribed in practice and it is not uncommon for veterinary surgeons to prescribe them without having first documented an infection. As such, antibiotics are not always prescribed...