Prescribing For Upper Respiratory Infections Research Articles

De-implementation strategy to reduce unnecessary antibiotic prescriptions for ambulatory HIV-infected patients with upper respiratory tract infections in Mozambique: a study protocol of a cluster randomized controlled trial

BackgroundAntibiotics are globally overprescribed for the treatment of upper respiratory tract infections (URTI), especially in persons living with HIV. However, most URTIs are caused by viruses, and antibiotics are not indicated. De-implementation is perceived as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excessive or inappropriate antibiotic use for URTI, through the employment of evidence-based interventions to reduce these practices. Research into strategies that lead to successful de-implementation of unnecessary antibiotic prescriptions within the primary health care setting is limited in Mozambique. In this study, we propose a protocol designed to evaluate the use of a clinical decision support algorithm (CDSA) for promoting the de-implementation of unnecessary antibiotic prescriptions for URTI among ambulatory HIV-infected adult patients in primary healthcare settings.MethodsThis study is a multicenter, two-arm, cluster randomized controlled trial, involving six primary health care facilities in Maputo and Matola municipalities in Mozambique, guided by an innovative implementation science framework, the Dynamic Adaption Process. In total, 380 HIV-infected patients with URTI symptoms will be enrolled, with 190 patients assigned to both the intervention and control arms. For intervention sites, the CDSAs will be posted on either the exam room wall or on the clinician´s exam room desk for ease of reference during clinical visits. Our sample size is powered to detect a reduction in antibiotic use by 15%. We will evaluate the effectiveness and implementation outcomes and examine the effect of multi-level (sites and patients) factors in promoting the de-implementation of unnecessary antibiotic prescriptions. The effectiveness and implementation of our antibiotic de-implementation strategy are the primary outcomes, whereas the clinical endpoints are the secondary outcomes.DiscussionThis research will provide evidence on the effectiveness of the use of the CDSA in promoting the de-implementation of unnecessary antibiotic prescribing in treating acute URTI, among ambulatory HIV-infected patients. Findings will bring evidence for the need to scale up strategies for the de-implementation of unnecessary antibiotic prescription practices in additional healthcare sites within the country.Trial registrationISRCTN, ISRCTN88272350. Registered 16 May 2024, https://www.isrctn.com/ISRCTN88272350

The Behavior of Primary Healthcare Doctors Toward Antibiotic Prescriptions for Upper Respiratory Tract Infections.

Unnecessary prescription of antibiotics for patients with upper respiratory tract infections (URTIs) carries the potential risk to the development of bacterial resistance. This study aimed to investigate the behavior of primary healthcare (PHC) physicians toward an antibiotic prescription for URTI, Al-Madinah City, Saudi Arabia in 2021. A cross-sectional study was conducted at PHC centers in Al-Madinah City, Saudi Arabia. The study invited all physicians in the randomly selected 28 PHC centers to participate in the study. A master sheet adopted from a researcher done in the Asir region of Saudi Arabia about the pattern of prescription for URTIwas used and included data about socio-demographic characteristics and data about presenting symptoms and signs of URTIs, the clinical diagnosis, type of medication prescribed, and duration of treatment also, included data about the factors that press physicians to prescribe antibiotics and their response. The questionnairewas filled out and returned back by 140 physicians. The collected data were analyzed and tabulated using appropriate statistical tests. The mean age of the studied physicians was 34.4 ± 7.6 years (25-59 years). General practitioners and specialists were 66.4% and 33.6%, respectively. The prevalence of antibiotic prescriptions was 44.3%. The most prescribed antibiotics were amoxicillin (58.6%)and Augmentin(28.6%). Congested tonsils (87.1%), ear discharge (84.2%), and cervical lymphadenopathy (89.3%) were the most clinical factors that affected physicians' decisions to prescribe antibiotics for URTI. The non-clinical factors affecting physicians' decisions include patient request (52.8%) and press (28.5%), with no statistically significant difference detected between general practitioners and specialists. The study findings indicate the need to develop intervention programs targeting physicians as well as the general population to decrease inappropriate antibiotic prescriptions in primary care centers.

Barriers to Implementing Registered Nurse-Driven Clinical Decision Support for Antibiotic Stewardship: Retrospective Case Study.

Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited. As a delegation protocol, we adapted a validated electronic health record-integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers. We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors. Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties. Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels. ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303.

Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing?

There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis. A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics. Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics. Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.

Association between seasonal influenza vaccination and antimicrobial use in Japan from the 2015-16 to 2020-21 seasons: from the VENUS study.

Seasonal influenza vaccination might be considered an antimicrobial resistance (AMR) countermeasure because it can reduce unnecessary antimicrobial use for acute respiratory infection by mitigating the burden of such diseases. To examine the association between seasonal influenza vaccination and antimicrobial use (AMU) in Japan at the community level and to examine the impact of influenza vaccination on the frequency of unnecessary antimicrobial prescription for upper respiratory infection. For patients who visited any healthcare facility in one of the 23 wards of Tokyo, Japan, due to upper respiratory infection and who were aged 65 years or older, we extracted data from the Vaccine Effectiveness, Networking, and Universal Safety (VENUS) study database, which includes all claims data and vaccination records from the 2015-16 to 2020-21 seasons. We used the average treatment effect (ATE) with 1:1 propensity score matching to examine the association of vaccination status with frequency of antibiotic prescription, frequency of healthcare facility consultation, risk of admission and risk of death in the follow-up period of the same season (from 1 January to 31 March). In total, 244 642 people were enrolled. Matched data included 101 734 people in each of the unvaccinated and vaccinated groups. The ATE of vaccination was -0.004 (95% CI -0.006 to -0.002) for the frequency of antibiotic prescription, -0.005 (-0.007 to -0.004) for the frequency of healthcare facility consultation, -0.001 (-0.002 to -0.001) for the risk of admission and 0.00 (0.00 to 0.00) for the risk of death. Our results suggest that seasonal influenza vaccination is associated with lower frequencies of unnecessary antibiotic prescription and of healthcare facility consultation.

Improvement of antibiotic use in sore throat, tonsillitis and acute otitis media in Palestine: a prospective full cycle audit

Antibiotics are commonly prescribed for upper respiratory tract infections (URTIs) which are generally caused by viral pathogens and do not require antibiotics under most circumstances. Adherence to the international guidelines regarding the necessity of prescribing antibiotics and the selection of antibiotics used for these illnesses have never been reviewed in West Bank. This study was a prospective full cycle audit and re-audit done in West Bank, Palestine. Audit and re-audit phases involved short interviews. The intervention phase included surveys, oral presentations, and development of mobile/web applications. p values of < 0.05 were considered significant. A total of 297 cases were reviewed during the audit and reaudit phases. These cases included tonsillitis (56.9%), sore throat (29.6%) and acute otitis media (13.5%). Improvements in the percentages of correct antibiotics prescriptions in the reaudit phase were noticed, including + 6.5% for correct direct antibiotics prescriptions, + 44.4% for correct backup antibiotics prescriptions, and + 63.4% for correct no antibiotics prescriptions. Improvements in the percentages of prescribing the correct choice of antibiotic (+ 41.4%) and frequency, dosage and duration (+ 13.3%) were also recorded. There was inadequate adherence to the international guidelines of antibiotic prescription for URTIs indicating a possible national problem. There is an evident trend toward using the second-line antibiotics for URTI. Improvements were observed in antibiotic prescribing patterns over a four months period. Therefore, our study's improvement strategies and approaches can be extended to other disease management systems and locations.

Antimicrobial Stewardship Strategies Including Point-of-Care Testing (POCT) for Pediatric Patients with Upper-Respiratory-Tract Infections in Primary Care: A Systematic Review of Economic Evaluations.

Upper-respiratory-tract infections (URTIs) are among the main causes of antibiotic prescriptions in pediatric patients. Over one-third of all antibiotic prescriptions for URTIs in children are estimated to be inappropriate, as the majority of URTIs are caused by viral agents. Several strategies, including clinical scoring algorithms and different point-of-care tests (POCTs) have been developed to help discriminate bacterial from viral URTIs in the outpatient clinical setting. A systematic review of the literature was conducted following PRISMA guidelines with the objective of summarizing evidence from health–economic evaluations on the use of POCT for URTIs in pediatric outpatients. A total of 3375 records identified from four databases and other sources were screened, of which 8 met the inclusion criteria. Four studies were classified as being of high reporting quality, and three were of medium quality. Five out of eight studies concluded in favor of strategies that included POCTs, with an additional study finding several POCTs to be cost-effective compared to usual care but over an acceptable WTP threshold. This review found POCT could be a valuable tool for antimicrobial stewardship strategies targeted towards childhood URTIs in primary care.

A multimodal intervention to decrease inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated healthcare system.

To evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years. Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016-October 2017 and May 2018-March 2020. The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region. Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate. Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing. Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, -20.4%), internal medicine (-19.5%), pediatric medicine (-17.2%), and urgent care (-16.6%). A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.

Reducing Inappropriate Antibiotic Prescribing for Upper Respiratory Infections

Acute upper respiratory infections account for most urgent care visits, and most do not require antibiotics. A quality improvement project was conducted at an urgent care clinic in Texas over a 1-month period with the intent of improving antibiotic prescribing practices for acute upper respiratory infections. The rates of antibiotic prescribing before and after the implementation were compared, and focus group discussions were conducted for insight. A significant decrease in the rates of antibiotics prescribed was noted when prescribing rates before and after implementation were compared. Insightful information was collected from the focus groups.

126. Outpatient Antimicrobial Stewardship Utilizing a Decentralized Model

BackgroundThe majority of human antimicrobial utilization occurs in the outpatient setting. Despite being mainly viral in etiology, upper respiratory tract infections (URIs) were the most common indication for outpatient antimicrobial prescriptions at our institution.MethodsThrough our electronic health record (EHR), we were able to determine our rate of antibiotic prescriptions for inappropriate URI diagnosis at our primary care practice sites. We selected staff volunteers from each our primary care practice sites to serve as stewardship champions. They were given training in stewardship best practices, and an URI stewardship toolkit which included viral URI prescription pad, EHR order panel, and patient education signage. They were tasked with providing education and feedback to their practice sites. We meet with them on a monthly basis to disseminate prescribing data and education. They also provided feedback from practice sites to the stewardship committee. ResultsOur decentralized model was put in place in November 2020. In the 6 months prior to the intervention, the average prescribing rate was 29.1%. In the 6 months after the intervention, the average prescribing rate decreased by 15% to 24.8%. During the intervention phase, there was an increase in number of non-COVID URIs diagnosed at our primary care sites. Temporal Trend in Inappropriate Antibiotics Prescribing Rates for Viral URIs Pre- and Post- Intervention Inappropriate antibiotic prescribing rate for viral upper respiratory tract infections from May 2020 until May 2021. Intervention started in December 2021 (arrow). Pre-intervention average was 29.1%. Post-intervention age was 24.8% which is a 15% decline in prescribing rate.Viral Upper Respiratory Infections Visits The total number of visits for presumed viral upper respiratory infections to primary care sites from May 2020 until May 2021. The majority of COVID-19 precautions in the area expired at the end of March 2021.ConclusionWe have been able to lower our inappropriate prescriptions for URIs utilizing a decentralized model of stewardship champions. This result was especially notable as the intervention phase corresponded with the end of COVID-19 precautions and an increase in non-COVID URIs diagnosed. The advantage of this approach includes an advocate embedded at each practice site who is familiar with the opportunities and challenges of the site, and a two-way flow of information from practice sites to the stewardship committee. This model provided additional benefit during the COVID-19 pandemic as the ability of centralized staff to travel to off campus clinic sites was curtailed. Disclosures All Authors: No reported disclosures

Caregivers’ Perspectives of Pharmacist Intervention in Children’s Antibiotic Prescriptions for Upper Respiratory Tract Infections

Background: Community pharmacists can help fight antimicrobial resistance by intervening in children’s antibiotic prescriptions for upper respiratory tract infections (URTIs). However, caregivers’ attitudes and perspectives on this are unknown. Objective: To evaluate children’s caregivers’ acceptability of pharmacists intervening in their antibiotic prescriptions for URTIs with respect to their knowledge of and attitude toward pharmacists and knowledge, beliefs, and behaviors related to antibiotics. Methods: A 69-item survey was created and sent to a panel of caregivers. ANCOVA and path analysis were used to evaluate the relationship between caregiver characteristics and their acceptability of pharmacists intervening in children’s antibiotic prescriptions for URTIs. Results: Responses from 246 caregivers who met the inclusion and exclusion criteria were analyzed. Mean caregivers’ acceptability of pharmacists intervening in children’s antibiotic prescriptions for URTIs was 3.25 out of 5 (±1.01). The ANCOVA model (adjusted R2 = .636) showed positive attitude toward pharmacists and being more accepting of health advice from pharmacists since the start of the COVID-19 pandemic were associated with higher caregiver acceptability of pharmacists intervening in children’s antibiotic prescriptions. Caregivers with better relationships with their pharmacist also tend to have better attitudes toward pharmacists. Not wanting antibiotics for symptom relief was associated with decreased acceptability scores. Conclusion: Overall caregiver acceptability of pharmacists intervening in antibiotic prescriptions was slightly above neutral. Building a relationship with caregivers could help change their attitude and increase the acceptability of pharmacists intervening in children’s antibiotic prescriptions. Caregivers seeking symptomatic relief may be more open to non-antibiotic alternatives.

Improving antimicrobial prescribing for upper respiratory infections in the emergency department: Implementation of peer comparison with behavioral feedback.

To reduce inappropriate antibiotic prescribing for acute respiratory infections (ARIs) by employing peer comparison with behavioral feedback in the emergency department (ED). A controlled before-and-after study. The study was conducted in 5 adult EDs at teaching and community hospitals in a health system. Adults presenting to the ED with a respiratory condition diagnosis code. Hospitalized patients and those with a diagnosis code for a non-respiratory condition for which antibiotics are or may be warranted were excluded. After a baseline period from January 2016 to March 2018, 3 EDs implemented a feedback intervention with peer comparison between April 2018 and December 2019 for attending physicians. Also, 2 EDs in the health system served as controls. Using interrupted time series analysis, the inappropriate ARI prescribing rate was calculated as the proportion of antibiotic-inappropriate ARI encounters with a prescription. Prescribing rates were also evaluated for all ARIs. Attending physicians at intervention sites received biannual e-mails with their inappropriate prescribing rate and had access to a dashboard that was updated daily showing their performance relative to their peers. Among 28,544 ARI encounters, the inappropriate prescribing rate remained stable at the control EDs between the 2 periods (23.0% and 23.8%). At the intervention sites, the inappropriate prescribing rate decreased significantly from 22.0% to 15.2%. Between periods, the overall ARI prescribing rate was 38.1% and 40.6% in the control group and 35.9% and 30.6% in the intervention group. Behavioral feedback with peer comparison can be implemented effectively in the ED to reduce inappropriate prescribing for ARIs.

Systematic review of patient-oriented interventions to reduce unnecessary use of antibiotics for upper respiratory tract infections

BackgroundAntibiotics are prescribed frequently for upper respiratory tract infections (URTIs) even though most URTIs do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem globally. As physicians’ prescribing behaviour is influenced by patients’ expectations, there may be some opportunities to reduce antibiotic prescribing using patient-oriented interventions. We aimed to identify these interventions and to understand which ones are more effective in reducing unnecessary use of antibiotics for URTIs.MethodsWe conducted a systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL, and the Web of Science. We included English language randomized controlled trials (RCTs), quasi-RCTs, controlled before and after studies, and interrupted time series (ITS) studies. Two authors screened the abstract/titles and full texts, extracted data, and assessed study risk of bias. Where pooling was appropriate, a meta-analysis was performed by using a random-effects model. Where pooling of the data was not possible, a narrative synthesis of results was conducted.ResultsWe included 13 studies (one ITS, one cluster RCTs, and eleven RCTs). All interventions could be classified into two major categories: delayed prescriptions (seven studies) and patient/public information and education interventions (six studies). Our meta-analysis of delayed prescription studies observed significant reductions in the use of antibiotics for URTIs (OR = 0.09, CI 0.03 to 0.23; six studies). A subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects. The studies in the patient/public information and education group varied according to their methods of delivery. Since only one or two studies were included for each method, we could not make a definite conclusion on their effectiveness. In general, booklets or pamphlets demonstrated promising effects on antibiotic prescription, if discussed by a practitioner.ConclusionsPatient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic prescription for URTIs. Further research is needed to investigate the costs and feasibility of implementing these interventions as part of routine clinical practice.Systematic review registrationPROSPERO CRD42016048007.

Use of antibiotics for patients presenting with symptoms suggestive of upper respiratory tract infections of less than 3 days to an outpatient department of a tertiary hospital in Sri Lanka

Background: Upper respiratory tract infections (URTIs) include common cold, pharyngitis, sinusitis, tracheobronchitis and influenza. URTIs are generally due to viral infections and do not require antibiotic treatment. But unnecessary use of antibiotics for URTIs is common all over the world. Objectives: Objective of this study was to identify use of antibiotics for patients presenting with symptoms suggestive of URTI for less than 3 days to an outpatient department (OPD) of the Teaching Hospital, Karapitiya (THK), Sri Lanka. Methods: Study was conducted as a cross sectional study using an interviewer administrated questionnaire. Results: Total of 612 patients with symptoms suggestive of URIs for less than three days were included in the study, of which, 440 were prescribed antibiotics (71.90%). The most commonly used antibiotic was amoxicillin and the least commonly used antibiotic was co-amoxiclav. Percentages of antibiotic prescription were 65.1%, 76.1% and 71.4% for below 12 years, between 12 – 60 years and above 60 years age categories respectively. Patients with sore throat, hoarseness and myalgia received the highest percentage of antibiotics. Similar percentage of patients with symptoms for less than 24hrs as well as more than 48hrs were prescribed antibiotics. Conclusions: Prescription of antibiotics in OPD of THK is considerable high for URIs. Rate of antibiotics prescription reported in this study is the highest rate compared to all other studies published on antibiotic prescription for URTI.

Statewide Antibiotic Stewardship: : An eBrightHealth Choosing Wisely Initiative.

ObjectiveTo implement a collaborative statewide antibiotic stewardship initiative in both the ambulatory and inpatient settings.MethodsFive participating Delaware health systems each convened internal team(s) to translate the vision set forth by the eBrightHealth LLC Choosing Wisely Work Group into clinical action through process improvement efforts at their institutions. The teams focused on implementing antibiotic time-outs, and on improving antibiotic prescribing for upper respiratory infections in ambulatory settings. The learning network utilized an “all teach, all learn” methodology via monthly conference calls and quarterly face-to-face meetings.ResultsAll inpatient teams implemented antibiotic time-outs for at least 1 unit. Other interventions included commitment posters; submitting antibiotic utilization data nationally; provider/patient surveys; local stewardship champions; and provider prescribing data feedback. Barriers to implementation included competing priorities, lack of reliable utilization data, and suboptimal provider engagement. Overall antibiotic utilization decreased by 9%, compared to the pre-intervention period.ConclusionsThis initiative has demonstrated the value of multidisciplinary teams, from varying healthcare systems, coming together to work on a single project. While each team’s interventions and specific goals differed slightly, all teams implemented new initiatives to promote appropriate use of antibiotics.Policy ImplicationsAntibiotic stewardship is a national priority. Acute care hospitals are required to have antibiotic stewardship programs; similar programs are proposed for ambulatory settings.

Antibiotic Prescriptions for Upper Respiratory Infections in a Pediatric Office Versus an Urgent Care Center.

It is estimated that as many as 10 million unnecessary antibiotic prescriptions are written each year for children. Children are more likely to receive antibiotics for an upper respiratory infection in an urgent care center compared with the primary care office. However, no study has examined the antibiotic prescribing practices of the same physicians in these settings. This retrospective chart review evaluated pediatricians’ antibiotic prescribing practices for patients with symptoms of an upper respiratory tract infection in the office setting and an urgent care setting. There was no difference in the total antibiotic prescribing rate by pediatricians in their primary care office versus an urgent care setting. Pediatricians who were high antibiotic prescribers in the office setting were also high prescribers in the urgent care. The highest prescribing physicians prescribed the appropriate recommended antibiotics for a particular diagnosis the lowest percentage of the time. Efforts to promote antimicrobial stewardship should be directed toward the individual physician and not toward the location where the patients are being evaluated.

Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting.

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

Does locally relevant, real-time infection epidemiological data improve clinician management and antimicrobial prescribing in primary care? A systematic review.

PurposeAntimicrobial resistance is a significant threat to public health. Diagnostic uncertainty is a key driver of antimicrobial prescribing. We sought to determine whether locally relevant, real-time syndromic or microbiological infection epidemiology can improve prescribing by reducing diagnostic uncertainty.MethodsEligible studies investigated effects on primary care prescribing for common infections in Organisation For Economic Co-Operation And Development countries. We searched Medline, Embase, Cumulative index to nursing and allied health literature, Web of Science, grey literature sources, thesis databases and trial registries.ResultsWe identified 9548 reports, of which 17 were eligible, reporting 12 studies, of which 3 reported relevant outcomes. The first (observational) showed antibacterial prescribing for upper respiratory infections reduced from 26.4% to 8.6% (P = 0.01). The second (observational) showed antibacterial prescribing reduced during influenza pandemic compared with seasonal influenza periods [odds ratio (OR) 0.72 (95% CI, 0.68 to 0.77), P < 0.001], while antiviral prescribing increased [OR 6.43 (95% CI, 5.02 to 8.25), P < 0.001]. The likelihood of prescribing also decreased as the number of infection cases a physician saw increased in the previous week [OR 0.57 (95% CI, 0.51 to 0.63), P < 0.001 for ≥12 versus ≤1 patient). The third (randomized-controlled trial) showed an absolute reduction in antibacterial prescribing of 5.1% during a period of moderate influenza activity (P < 0.05). We did not find measures of diagnostic certainty, harms or costs.ConclusionThere is promising evidence that epidemiological syndromic and microbiological data can reduce primary care antimicrobial prescribing. Future research should use randomized designs of behaviourally informed interventions, investigate costs and harms, and establish mechanisms of behaviour change.PROSPERO registrationCRD42016038871.

The effect of continuity of care on antibiotics prescription for Palestinian refugees in UNRWA health centres: a cross-sectional study

BackgroundAntimicrobial resistance is a growing public health threat worldwide, with over-prescription of antibiotics for upper respiratory tract infections (URTI) in children being very common although at least half of URTIs have a viral aetiology. A Family Health Team (FHT) model was gradually implemented at United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) health centres to provide continuity of care and patient-centred care. These types of care are associated with lower antibiotic prescription rates for URTI in several European countries, but their effect in a refugee setting is unknown. The aim of this study was to assess the differences in medical officers' knowledge and beliefs about antibiotics and to investigate the association between sociobehavioural factors and high antibiotic prescription for URTI in children in FHT and non-FHT health centres. MethodsThis cross-sectional study included medical officers working at UNRWA health centres in Jordan, Gaza Strip, West Bank, and Lebanon in 2014. We used a self-administered, standardised multiple-choice questionnaire that covered demographics, beliefs, knowledge, and antibiotic use and included five case-vignettes on URTI in children. Case-vignette 1 described a child aged 9 months that was previously healthy but presented with fever of 38·5°C and rhinorrhoea. The child had been pulling at his right ear since the beginning of the day; the tympanic membrane was slightly pink, retracted, and had decreased mobility; and no air-fluid level was seen. A self-reported antibiotic prescription rate of more than 25% for URTI was considered high prescription. This cut-off was chosen to match an internal UNRWA target to not prescribe antibiotics for more than 25% of URTI cases and on the basis that more than 50% of URTI cases are viral and do not need an antibiotic treatment. We did χ2 tests to compare knowledge and beliefs about antibiotics, and we did multiple logistic regression to analyse the association between sociobehavioural factors and high antibiotic prescription in FHT and non-FHT health centres. Ethical approval was not considered necessary since questionnaires were obtained anonymously. Verbal consent was obtained from participants. Findings362 medical officers were asked to complete the questionnaire, and 335 (93%) medical officers completed the questionnaire (227 officers in the FHT group, 108 in the non-FHT-group). Medical officers in the two groups had similar demographics, including their self-reported prescription rate. Antimicrobial resistance was described as a problem in the community by more participants in the FHT group than in the non-FHT group (p=0·048), and the correct answer to case-vignette 1 was given more often in the FHT group than in the non-FHT group (p=0·001). No demographic determinant was associated with high prescription. In the non-FHT group, high antibiotic prescription was associated with previous clinical experience (odds ratio 0·14, 95% CI 0·03–0·74) and the educational level of patients' parents (11·6, 2·33–58·10). In the FHT group, high antibiotic prescription was associated with wanting to be on the safe side (2·49, 1·07–5·79). InterpretationThe FHT group had a better knowledge of antibiotics use and antimicrobial resistance as a community problem. The factors associated with high prescription differed between the FHT and non-FHT groups. Further research is needed to assess whether the working environment determines actual antibiotic prescribing in a refugee setting. FundingNone.

ANTIBIOTIC USE AT PRIMARY HEALTHCARE CENTERS IN SURABAYA: A SURVEILLANCE STUDY

Objective: Antibiotics are considered to be overprescribed in primary health care centers. This study aimed to investigate the defined daily dose (DDD) of antibiotics per 1000 patients visit in a year in primary health care centers, the prevalence of upper respiratory infections (URI) and diarrhea, the percentage of antibiotic prescription for URI and diarrhea in Surabaya.Methods: A surveillance study of antibiotic use was done from the reports and use of drug demand sheet, which called laporan pemakaian dan lembar permintaan obat (LPLPO), outpatient medication card, and health care information and management system of primary health care center, which called sistem informasi manajemen manajemen puskesmas (SIMPUS) in Surabaya. DDD/1000 patients were calculated for describing the antibiotics usage level in each primary health care centers. Three primary health care centers selected based on its antibiotic use or its population density to recognize its antibiotic prescribing percentage for non-pneumonia respiratory tract infection and nonspecific diarrhea.Results: The DDD antibiotic systemic per 1000 patients visit primary health care centers in Surabaya is relatively low. The results found higher prevalence URI does not correlate to the frequent antibiotic prescribed. The prevalence of URI at one primary healthcare center (25% cases) was less than at the other (44%), but the percentage of antibiotic prescription and the total antibiotic usage were higher (73%; 1006 DDD/1000 patients vs. 21%; 675 DDD/1000 patients). The prevalence of diarrhea at primary health care center 2 (2,84%) was less than at primary health care center 1 (4,95%), but the percentage antibiotic prescription and the total antibiotic usage were higher (43%; 1006 DDD/1000 patients vs 18%; 675 DDD/1000 patients).Conclusion: The antibiotic usage at primary healthcare centers in Surabaya was shown to vary widely. Eighty-seven percent (55/63) primary health care centers antibiotic usage was less than 4 DDD/1000 patients day, only two primary health care centers antibiotic usage 6 DDD/1000 patients day. Further research to investigate antibiotic usage and the differences in usage between primary health care centers in treating URI is required.