Broad-spectrum Antibiotic Prescribing Research Articles

Antimicrobial prescribing in post-graduate training practices: a cross-sectional study of prescribing data in general practices in England

IntroductionSeventy-five percent of all antimicrobials are prescribed in primary care. There is a growing concern about inappropriate oral antimicrobial prescribing. Interventions to enhance antimicrobial stewardship are actively promoted through educational and other means. GP training practice status has been shown to influence patient care. This study seeks to study the influence of GP training practice status on antimicrobial prescribing.MethodsA cross-sectional analysis of practice antimicrobial prescribing data was conducted for the year 2015–2016 comparing training and non-training practices across England. Data for all practices and prescribing was obtained from NHS Digital. Univariate analyses were conducted on the two measures of antibiotic prescribing included in the study. Multivariable regression models were constructed to identify the predictors of antibiotic prescribing volumes and of broad spectrum antibiotic prescribing.ResultsGP training practice status was a significant predictor of overall antibiotic prescribing volume, B = −0.009 (95% confidence intervals, −0.012, −0.005), p < 0.001. GP training practices prescribed fewer antibiotics, representing a reduction of 6.2 centiles from the median. GP training practice status was also a significant predictor of broad spectrum antibiotic prescribing, B = −0.3 (95% confidence intervals, −0.04, −0.01), p = 0.001. GP training practices prescribed fewer broad spectrum antibiotics, representing a reduction from the median of 6.0 centiles.DiscussionTraining practices prescribe fewer antimicrobials overall and specifically fewer broad spectrum oral antimicrobials (quinolones and cephalosporins). There is a need for further research to understand the interplay between postgraduate GP training and reductions in antimicrobial prescribing.

The aerobic-anaerobic bacteria pattern and its sensitivity pattern in chronic rhinosinusitis patients, in Medan, Indonesia

Background: Rhinosinusitis is one of the most concerning illness due to high medical cost and its negative effect on the respiratory tract. The etiology of chronic rhinosinusitis remains unknown. The main cause of chronic rhinosinusitis with or without nasal polyp is bacterial infections; thus antibiotics remain a main therapeutic intervention. Prescription of broad spectrum antibiotics and the inappropriate combination of antibiotics are the main factors of antibiotic resistance. This study aims to obtain the pattern of aerobic and anaerobic bacteria in chronic rhinosinusitis patient (with or without nasal polyp) and its sensitivity pattern, in Medan, Indonesia. Methods: This is a case series. Samples were patient with chronic rhinosinusitis who had undergone functional endoscopic sinus surgery (FESS). Results: The most common aerobic bacteria found is Klebsiella oxytoca (21.7%), and it is sensitive to ceftriaxone, cefotaxime, levofloxacin, and meropenem. While for the anaerobic bacteria, one patient was positive for Peptostreptococcus and it is sensitive to chloramphenicol. Conclusion: The most common bacteria in the maxilla in patients with chronic Rhinosinusitis with and without polyps in Medan are the aerobic bacteria Klebsiella oxytoca and anaerobic bacteria Peptostreptococcus. It is suggested that the antibiotic prescribed should be based on microbiology examination.

Factors Associated with Prescribing Broad-Spectrum Antibiotics for Children with Upper Respiratory Tract Infections in Ambulatory Care Settings.

Objectives:Broad-spectrum antibiotics are frequently prescribed for children with upper respiratory tract infections (URI). Excessive use of broad-spectrum antibiotics leads to the emergence of resistant bacteria. This study aimed to identify factors associated with prescribing broad-spectrum antibiotics among children younger than 18 years presenting with URI in outpatient settings.Methods:We conducted a cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey-Outpatient Departments (NHAMCS-OPD) between 2006 and 2010. Descriptive statistics of visits from children with URI were estimated. Simple and multiple logistic regression analyses were used to identify socio-demographic and clinical characteristics associated with broad-spectrum antibiotic prescribing. We also completed a stratified analysis by age (⩽2 vs >2).Results:A total of 4013 outpatient visits for children with URI from both NAMCS and NHAMCS-0PD data were examined. Broad-spectrum antibiotics were prescribed in 39% of the visits, accounting for an estimated 6.8 million visits annually. Multivariable analysis showed that visits in the South region (odds ratio [OR] = 2.38; 95% confidence interval [CI]: 1.38-4.10) compared with the West region and visits with diagnoses of acute sinusitis (OR = 2.77; 95% CI: 1.65-4.63) and acute otitis media (OR = 1.90; 95% CI: 1.32-2.74) compared with those with acute pharyngitis were associated with greater odds of broad-spectrum antibiotic prescribing.Conclusions:The prescribing of broad-spectrum antibiotics is common for children with URI in ambulatory care settings. Diagnosis and management of URI remain a critical area for awareness campaigns promoting judicious use of antibiotics.

Antibiotic Prescribing Patterns Across the Continuum of Care for Children Hospitalized With Community-Acquired Pneumonia.

The aim of this study was to describe the variation in antibiotic prescribing practices for uncomplicated community-acquired pneumonia across the continuum of care for hospitalized pediatric patients to better inform future efforts at standardizing antibiotic therapy throughout a single hospitalization. This is a retrospective cohort study involving 4 hospitals caring for children aged 3 months to 18 years, hospitalized between January 1, 2011, and December 31, 2012, with diagnosis of uncomplicated pneumonia and without complex chronic medical conditions.Data collected include antibiotics prescribed before hospitalization, at the emergency department (ED) encounter, during hospitalization, and at hospital discharge. Six hundred nine children met inclusion criteria, with a mean age of 5.3 years and median length of stay of 2 days. Emergency department providers prescribed narrow-spectrum therapy 27% of the time, whereas discharging providers prescribed narrow-spectrum therapy 56% of the time. Third- and fourth-generation cephalosporins were less often prescribed in the preadmission setting and at discharge but were more often prescribed in the ED and inpatient setting. There was an association between inpatient prescription of broad-spectrum antibiotics when a blood culture was obtained, when broad-spectrum antibiotics were prescribed in the ED, and with increasing length of stay. Broad-spectrum antibiotic therapy for community-acquired pneumonia, especially third- and fourth-generation cephalosporins, often originates in the ED. When initiated in this setting, it is likely to be continued in the inpatient setting.

Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections

Acute respiratory tract infections account for the majority of antibiotic exposure in children, and broad-spectrum antibiotic prescribing for acute respiratory tract infections is increasing. It is not clear whether broad-spectrum treatment is associated with improved outcomes compared with narrow-spectrum treatment. To compare the effectiveness of broad-spectrum and narrow-spectrum antibiotic treatment for acute respiratory tract infections in children. A retrospective cohort study assessing clinical outcomes and a prospective cohort study assessing patient-centered outcomes of children between the ages of 6 months and 12 years diagnosed with an acute respiratory tract infection and prescribed an oral antibiotic between January 2015 and April 2016 in a network of 31 pediatric primary care practices in Pennsylvania and New Jersey. Stratified and propensity score-matched analyses to account for confounding by clinician and by patient-level characteristics, respectively, were implemented for both cohorts. Broad-spectrum antibiotics vs narrow-spectrum antibiotics. In the retrospective cohort, the primary outcomes were treatment failure and adverse events 14 days after diagnosis. In the prospective cohort, the primary outcomes were quality of life, other patient-centered outcomes, and patient-reported adverse events. Of 30 159 children in the retrospective cohort (19 179 with acute otitis media; 6746, group A streptococcal pharyngitis; and 4234, acute sinusitis), 4307 (14%) were prescribed broad-spectrum antibiotics including amoxicillin-clavulanate, cephalosporins, and macrolides. Broad-spectrum treatment was not associated with a lower rate of treatment failure (3.4% for broad-spectrum antibiotics vs 3.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 0.3% [95% CI, -0.4% to 0.9%]). Of 2472 children enrolled in the prospective cohort (1100 with acute otitis media; 705, group A streptococcal pharyngitis; and 667, acute sinusitis), 868 (35%) were prescribed broad-spectrum antibiotics. Broad-spectrum antibiotics were associated with a slightly worse child quality of life (score of 90.2 for broad-spectrum antibiotics vs 91.5 for narrow-spectrum antibiotics; score difference for full matched analysis, -1.4% [95% CI, -2.4% to -0.4%]) but not with other patient-centered outcomes. Broad-spectrum treatment was associated with a higher risk of adverse events documented by the clinician (3.7% for broad-spectrum antibiotics vs 2.7% for narrow-spectrum antibiotics; risk difference for full matched analysis, 1.1% [95% CI, 0.4% to 1.8%]) and reported by the patient (35.6% for broad-spectrum antibiotics vs 25.1% for narrow-spectrum antibiotics; risk difference for full matched analysis, 12.2% [95% CI, 7.3% to 17.2%]). Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.

Prescription pattern of antibiotics in paediatric inpatients at a tertiary care hospital in North East India

Background: Paediatric antibiotic prescription is a major concern in terms of public health since infections are the most frequent cause of childhood disease. The aim of this hospital-based cross sectional study was to assess the pattern of antibiotic use in the paediatric ward of RIMS hospital, Manipur, India.Methods: A retrospective study of six months duration was carried out for the month of October 2016 to March 2017. A total number of 200 patients case sheets were utilized for our study from paediatric in-patients department of RIMS hospital, Manipur. The data collected was then analysed for various prescribing indicators as laid down by world health organisation (WHO) for analysis of drug use parameters.Results: The mean age of paediatric patient was 2.1 years. The average number of drugs per encounter was 5.14. The average number of antibiotic per patient was 2.11. In present study antibiotic were 41% of total drugs prescribed. Most common prevalence of disease among study patients sample was acute gastroenteritis. The most commonly prescribed antibiotic was Ceftriaxone followed by Amikacin. In present study 8.2% of antibiotics were prescribed in generic name. Polypharmacy was evident from the study.Conclusions: Antibiotic prescribing in children is relatively high in RIMS, Imphal, Manipur. Prescription of broad-spectrum antibiotics though has increased demonstrably which h may result in development of bacterial resistance; however, development of guidelines for antibiotic prescription and use of appropriate drugs for the disease can result in minimizing the unfavourable use of antibiotics in children.

Trends and patterns in antibiotic prescribing among out-of-hours primary care providers in England, 2010-14.

Antimicrobial resistance is a global threat, increasing morbidity and mortality. In England, publicly funded clinical commissioning groups (CCGs) commission out-of-hours (OOH) primary care services outside daytime hours. OOH consultations represent 1% of in-hours general practice (GP) consultations. Antibiotic prescriptions increased 32% in non-GP community services between 2010 and 2013. We describe OOH antibiotic prescribing patterns and trends between 2010 and 2014. We: estimated the proportion of CCGs with OOH data available; described and compared antibiotic prescribing by volume of prescribed items, seasonality and trends in GP and OOH, using linear regression; and compared the proportion of broad-spectrum to total antibiotic prescriptions in OOHs with their respective CCGs in terms of seasonality and trends, using binomial regression. Data were available for 143 of 211 (68%) CCGs. OOH antibiotic prescription volume represented 4.5%-5.4% of GP prescription volume and was stable over time (P = 0.37). The proportion of broad-spectrum antibiotic prescriptions increased in OOH when it increased in the CCG they operated in (regression coefficient 0.98; 95% CI 0.96-0.99). Compared with GP, the proportion of broad-spectrum antibiotic prescriptions in OOH was higher but decreased both in GP and OOH (-0.57%, 95% CI - 0.54% to - 0.6% and -0.76%, 95% CI - 0.59% to - 0.93% per year, respectively). OOH proportionally prescribed more antibiotics than GPs although we could not comment on prescribing appropriateness. OOH prescribing volume was stable over time, and followed GP seasonal patterns. OOH antibiotic prescribing reflected the CCGs they operated in but with relatively more broad-spectrum antibiotics than in-hours GP. Understanding factors influencing prescribing in OOH will enable the development of tailored interventions promoting optimal prescribing in this setting.

Impact of Implementing National Guidelines on Antibiotic Prescriptions for Acute Respiratory Tract Infections in Pediatric Emergency Departments: An Interrupted Time Series Analysis.

Many antibiotics are prescribed inappropriately in pediatric emergency departments (PEDs), but little data are available in these settings about effective interventions based on guidelines that follow the antimicrobial stewardship principle. Our aim was to assess the impact of implementing the 2011 national guidelines on antibiotic prescriptions for acute respiratory tract infection (ARTI) in PEDs. We conducted a multicentric, quasiexperimental, interrupted time series analysis of prospectively collected electronic data from 7 French PEDs. We included all pediatric patients who visited a participating PED during the study period from November 2009 to October 2014 and were diagnosed with an ARTI. The intervention consisted of local protocol implementation, education sessions, and feedback. The main outcome was the antibiotic prescription rate of discharge prescriptions for ARTI per 1000 PED visits before and after implementation, analyzed using the segmented regression model. We included 242534 patients with an ARTI. The intervention was associated with a significant change in slope for the antibiotic prescription rate per 1000 PED visits (-0.4% per 15-day period, P = .04), and the cumulative effect at the end of the study was estimated to be -30.9%, (95% CI [-45.2 to -20.1]), representing 13136 avoided antibiotic prescriptions. The broad-spectrum antibiotic prescription relative percentage decreased dramatically (-62.7%, 95% CI [-92.8; -32.7]) and was replaced by amoxicillin. Implementation of the 2011 national French guidelines led to a significant decrease in the antibiotic prescription rate for ARTI and a dramatic drop in broad-spectrum antibiotic prescriptions, in favor of amoxicillin.

The impact of penicillin allergy labels on antibiotic and health care use in primary care: a retrospective cohort study

BackgroundSuspected penicillin allergy (Pen-A) is often not verified by diagnostic testing. In third line penicillin allergy labels were associated with prescription of broad spectrum antibiotics, hospital stay duration and readmission.ObjectiveAssess the impact of Pen-A labels on antibiotic and health care use in primary care.MethodsA retrospective cohort study was conducted in primary care in the Utrecht area, the Netherlands. All patients registered with a penicillin allergy on 31 December 2013 were selected from the General Practitioner Network database. Each patient with a Pen-A label was matched for age, gender, follow-up period with three patients without Pen-A label. Risk (OR) of receiving a reserve and second choice antibiotic, number and type of antibiotics prescribed during follow-up and number of GP contacts were compared between the two cohorts.ResultsOf 196,440 patients, 1254 patients (0.6%) with a Pen-A label were identified and matched with 3756 patients without Pen-A label. Pen-A labels resulted in higher risk of receiving ≥1 antibiotic prescription per year (OR 2.56, 95% CI 2.05–3.20), ≥1 s choice antibiotic prescription per year (OR 2.21 95% CI 1.11–4.40), and ≥4 GP contacts per year (OR 1.71 95% CI 1.46–2.00). The chance of receiving tetracyclins (OR 2.24, 95% CI 1.29–3.89), macrolides/lincosamides/streptogamins (OR 8.69, 95% CI 4.26–17.73) and quinolones (OR 2.59, 95% CI 1.22–5.48) was higher in Pen-A patients.ConclusionsIn primary health care Pen-A labels are associated with increased antibiotic use, including second choice antibiotics, and more health care use.

ANTIBIOTIC UTILIZATION PATTERN AT THE SURGERY DEPARTMENT OF A TERTIARY CARE HOSPITAL

Objective: The present study aims to determine the pattern of antibiotic utilization at the surgery department of a tertiary care hospital.Method: A prospective observational study was conducted over a period of 6 months period in surgical ward at Bharti Hospital and Research Centre, Pune, a 1000 bedded teaching hospital. Patients above 18 years and receiving antibiotic therapy pre and post-surgery were included in the study.Results:160 patients with surgical operations were included in the study.The disease spectrum was classified into respective system-wise surgical procedures of which 49.37% cases are skin &amp; soft tissue infections, 25.62% cases of general surgical procedure, 12.5% cases of gastrointestinal surgical procedure, 11.25% cases of urinary system and 1.25% case of head neck system. 20.62% of the study patients had hernia, 18.12% patients had cellulitis, 16.87% patients had diabetic foot ulcer, 16.25% patients had abscess, and 10.62% patients had appendicitis and cholelithiasis. In this study, it was found that 471 antibiotics were used in total of 160 patients, among which highest group of antibiotics prescribed were third generation Cephalosporin (28.23%) followed by Penicillins (23.56%). The most frequently prescribed antibiotics were Metronidazole − 19.74% among the Nitroimidazoles followed by Ceftriaxone − 19.53% of the class Cephalosporins.Conclusion: The rate of prescribing of broad-spectrum antibiotics has increased demonstrably which may result in development of bacterial resistance; however development of guidelines for antibiotic prescription and use of appropriate drugs for the diseases can minimize the unfavourable use of antibiotics and cost of healthcare.

Antibiotic prescribing for acute respiratory tract infections in Norwegian primary care out-of-hours service

Purpose: To examine factors correlating with antibiotic prescribing for acute respiratory tract infections (ARTIs) in Norwegian primary care out-of-hours service.Materials and methods: Retrospective data analysis for the year 2014 in two out-of-hours primary care units located in the towns of Hamar and Tønsberg in Norway, analysing type and frequency of different antibiotics prescribed by 117 medical doctors for ARTIs, and factors correlating with these.Results: The 117 doctors in two out-of-hours units diagnosed 6757 cases of ARTIs. 2310 (34.2%) of these resulted in an antibiotic prescription, where of 1615 (69.9%) were penicillin V (PcV). Tonsillitis and sinusitis were the two ARTI diagnoses with the highest antibiotic prescription rate. The antibiotic prescription rate increased successively with increasing activity level, measured as shorter median duration of consultations per session, from 28.7% (reference) in the least busy quintile of sessions to 36.6% (OR: 1.38 (95% CI =1.06–1.80)) in the busiest quintile of sessions. Prescribing of broad-spectrum antibiotics was not correlated with median duration of consultations per session. Female doctors had an OR of 0.61 (0.40–0.92) of a broad-spectrum antibiotic prescription compared to their male colleagues.Conclusions: Antibiotic prescribing for ARTIs in the primary care out-of-hours services investigated is at the same level as in Norwegian general practice, but with a higher prescription rate of PcV. Antibiotic prescribing increases on busy sessions, measured as median duration of consultations per session. The work frame in primary care out-of-hours service might influence the quality of clinical decisions.

Antibiotic prescriptions for inpatients having non-bacterial diagnosis at medicine departments of two private sector hospitals in Madhya Pradesh, India: a cross-sectional study

ObjectivesTo present and compare antibiotic prescribing for inpatients among the most common non-bacterial diagnoses groups at medicine departments of a teaching (TH) and a non-teaching hospital (NTH) in central India.SettingAn...

Antibiotic prescribing for acute respiratory infections in children in Jordan.

Most acute respiratory infections (ARIs) in children are due to viral etiology; however, over-prescribing of antibiotics for ARIs is common. The aim of this investigation was to identify antibiotic prescribing prevalence for children with ARIs and to identify predictors of broad-spectrum antibiotic prescribing. This was a prospective cross sectional study in a sample of ambulatory care settings in Jordan. Children (<18 years) presenting with ARIs were assessed in terms of patient's demographics, antibiotic prescription and clinical diagnosis. Multivariable logistic regression analysis was used to identify predictors of broad-spectrum antibiotic prescription. Antibiotics were prescribed for 78.4% (4575/5829) of children with ARIs. Antibiotic prescription for ARIs for which antibiotics are not indicated was 69.2% (2688/3883). Broad-spectrum antibiotic prescription occurred in 51.1% (2337/4575) of all antibiotic-prescribed participants. Some of the predictors of broad-spectrum antibiotic prescription were: otitis media (OR 4.93 [95% CI 3.44-7.14]), tonsillitis (OR 6.03 [95% CI 4.39-8.33]), age 0-5 years (OR 1.17 [95% CI 1.02-1.38]) compared to age 6-12 years, fever (OR 2.14 [95% CI 1.78-2.59]), outpatient setting (OR 73 [95% CI 2.17-3.42]) and military sector (OR 2.29 [95% CI 1.82-2.90]). Antibiotic prescribing is high and often inappropriate. Predictors of broad-spectrum antibiotic prescribing were identified. Health policy initiatives should involve all stakeholders to minimize inappropriate antibiotic prescription and to prevent poor outcomes associated with such practice.

The Management of Outpatient Cellulitis at The Moncton Hospital before and after the Initiation of a Clinical Treatment Pathway

BackgroundAntimicrobial Stewardship is a coordinated effort to improve and measure the appropriate use of antimicrobials. Antibiotic resistance is an emerging world health problem and unnecessary prescribing of broad-spectrum antibiotics is a major contributor to this. Skin and soft-tissue infections are a common reason to receive a prescription for antibiotics. Currently there exists a trend for using broad-spectrum intravenous antibiotics for moderate to severe infections when more narrow-spectrum options would be adequate. This study aimed to characterize the choice of antibiotic being prescribed for the management of outpatient cellulitis requiring intravenous antibiotics and evaluate the success of a clinical order set outlining optimal therapy.MethodsThis study was a retrospective chart review looking at antibiotic prescribing through the Emergency Department at The Moncton Hospital, in Moncton, New Brunswick. Charts were reviewed before and after the introduction of a clinical order set outlining optimal antibiotic therapy. The goal was to review charts from the pre- and post-intervention group and compare antibiotic usage, treatment failure rates, and adverse events.ResultsOf the 54 patients receiving IV antibiotics in the pre-intervention group, 3 received cefazolin, 50 received ceftriaxone, while 1 received levofloxacin. The median duration of IV therapy was four days. After the introduction of the clinical order set there was an absolute increase of 53.8% (n = 35) in the use of cefazolin and absolute decrease of 53.7% (n = 23) in the use of ceftriaxone in the post-intervention group of 59 patients. Both results were statistically significant (P < 0.001). The median duration of IV therapy in this group was 3.5 days. In eligible patients, the clinical order set was utilized 61.1% of the time. There was no significant difference in rates of treatment failure or adverse events between cefazolin and ceftriaxone.ConclusionThe introduction of a clinical order set outlining the preferential use of once-daily cefazolin plus probenecid for the treatment of outpatient cellulitis lead to a statistically significant increase use of cefazolin, and decrease use of ceftriaxone, thus demonstrating a positive stewardship effect at a local level.Disclosures All authors: No reported disclosures.

Center-level variability in broad-spectrum antibiotic prescribing for children undergoing hematopoietic cell transplantion for acute leukemia.

BackgroundAntibiotic exposure after allogeneic hematopoietic cell transplant (HCT) is common. Exposure to specific classes of antibiotics after HCT has been associated with mortality, relapse and graft-vs.-host disease. Exploring differences in antibiotic utilization across hospitals could provide opportunities for comparative effectiveness studies and quality improvement interventions.MethodsWe conducted a retrospective cohort study of patients undergoing HCT for acute leukemia using a dataset merged from two sources: the Pediatric Health Information System and the Center for International Blood and Marrow Transplant Research. Medication use data were obtained from the day of transplant through engraftment. Hospital antibiotic utilization rates were reported as antibiotic days/1000 neutropenic days. Adjusted rates were calculated using a poisson regression controlling for age, sex, race, graft characteristics and days of ICU-level care.ResultsAfter adjustment, hospital rates of anti-pseudomonal antibiotic use varied from 410 to 1037 antibiotic days/1000 neutropenic days (Figure 1A) and for Gram-positive antibiotic use from 109 to 771 antibiotic days/1000 neutropenic days (Figure 1B). As shown in Figure 1, within anti-pseudomonal antibiotics, there was variation by hospital in the use of Fourth and 5th generation cephalosporins, anti-pseudomonal penicillins and carbapenems; variation in Gram-positive exposure was driven by vancomycin. Gram-positive antibiotic use was moderately associated with days of ICU-level of care (spearman correlation coefficient = .55) but anti-pseudomonal antibiotic use was not (Figure 2). There was no association between days of antibiotic exposure and 30-day mortality.ConclusionAmong a homogenous population of children undergoing transplantation for acute leukemia, both the volume and spectrum of antibiotic exposure in the immediate post-transplant period varied widely. These data present an opportunity for hospitals to benchmark their antibiotic utilization practices and can be further leveraged to assess the clinical impact of differential antibiotic exposure.Disclosures B. T. Fisher, Pfizer, Inc.: Grant Investigator, Research support. Merck, Inc.: Investigator, Research support. T2 Biosystems, Inc.: Investigator, Research support. Ansun Biopharma: Investigator, Research support

"If it's a broad spectrum, it can shoot better": inappropriate antibiotic prescribing in Cambodia.

BackgroundCambodia is affected by antibiotic resistance but interventions to reduce the level of resistance require knowledge of the phenomena that lead to inappropriate prescribing. We interviewed physicians working in public hospitals to explore the drivers of inappropriate antibiotic prescribing.MethodsHospitals participating in a knowledge, attitudes and practices survey prior to this study were purposively selected and physicians were randomly recruited to participate in focus group discussions. Nvivo version 10 was used to inductively code the qualitative transcripts and manage thematic data analysis.ResultsInappropriate antibiotic prescribing was a common practice and driven by seven factors: prescribing habit, limited diagnostic capacity, lack of microbiology evidence, non-evidence-based clinical guidelines, perceived patient demand, poor hygiene and infection control, and perceived bacterial resistance to narrow spectrum antibiotics. “Every day, doctors are not performing appropriately. We have made lots of mistakes with our antibiotic prescribing.” When a patient’s clinical condition was not responsive to empiric treatment, physicians changed to a broader spectrum antibiotic and microbiology services were sought only after failure of a treatment with a broad-spectrum antibiotic. This habitual empirical prescribing was a common practice regardless of microbiology service accessibility. Poor hygiene and infection control practices were commonly described as reasons for ‘preventive’ prescribing with full course of antibiotics while perception of bacterial resistance to narrow-spectrum antibiotics due to unrestricted access in the community resulted in unnecessary prescribing of broad spectrum antibiotics in private practices.ConclusionsThe practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improvement in prescribing practice is unlikely to occur unless an education program for physicians focuses on the diagnostic capacity and usefulness of microbiology services. In parallel, hygiene and infection control in hospital must be improved, evidence-based antibiotic prescribing guidelines must be developed, and access to antibiotics in community must be restricted.

Prevalence of beta-lactam allergy: a retrospective chart review of drug allergy assessment in a predominantly pediatric population.

BackgroundResearch suggests that 90% of patients labeled beta-lactam allergic are able to tolerate penicillins following further assessment. This study aims to define and describe the frequency of true beta-lactam allergy following allergy patient evaluation in a predominantly pediatric population.Methods306 primary care patients referred between January 2010 and June 2015 were assessed for a suspected beta-lactam allergy. Patient demographics, history and test results were extracted from electronic medical records. Testing performed was based on specialist recommendation following review of patient history.Results34% of the study participants had intradermal testing. Oral challenge was given to 96.7% of the sample. 96% of patients with a prior history of beta-lactam allergy were advised that they could re-introduce beta-lactam antibiotics following evaluation.ConclusionsAmong patients with a documented beta-lactam allergy or a recent history of a reaction there is a low rate of ‘true’ beta-lactam allergy. Consistent evaluation of beta-lactam antibiotic allergies can reduce rates of broad spectrum antibiotic prescribing, among other harmful consequences.

Microfluidic advances in phenotypic antibiotic susceptibility testing.

A strong natural selection for microbial antibiotic resistance has resulted from the extensive use and misuse of antibiotics. Though multiple factors are responsible for this crisis, the most significant factor - widespread prescription of broad-spectrum antibiotics - is largely driven by the fact that the standard process for determining antibiotic susceptibility includes a 1-2-day culture period, resulting in 48-72h from patient sample to final determination. Clearly, disruptive approaches, rather than small incremental gains, are needed to address this issue. The field of microfluidics promises several advantages over existing macro-scale methods, including: faster assays, increased multiplexing, smaller volumes, increased portability for potential point-of-care use, higher sensitivity, and rapid detection methods. This Perspective will cover the advances made in the field of microfluidic, phenotypic antibiotic susceptibility testing (AST) over the past two years. Sections are organized based on the functionality of the chip - from simple microscopy platforms, to gradient generators, to antibody-based capture devices. Microfluidic AST methods that monitor growth as well as those that are not based on growth are presented. Finally, we will give our perspective on the major hurdles still facing the field, including the need for rapid sample preparation and affordable detection technologies.

Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010

ObjectivesAlthough antibiotic prescriptions are decreasing in the United States, broad-spectrum prescribing is increasing. It is unknown if decreases observed in national antibiotic prescribing differ by provider group. Understanding prescribing trends over time by provider group can be helpful for customizing antimicrobial stewardship efforts. Therefore, the purposes of this study were to describe outpatient antibiotic prescribing by provider group overall and adjusted for population and number of providers. In addition, trends in prescribing by class and seasonal variation are described by provider group over 6 years. DesignCross-sectional observation of outpatient antibiotic prescriptions. Setting and participantsA population-level analysis of U.S. prescribing from 2005 to 2010 with the use of the IMS Health Xponent dataset. Main outcome measuresNumber and rates of prescriptions dispensed overall and by provider group. ResultsThe majority (81.0%) of antibiotics were prescribed by physicians, followed by dentists (10.4%), nurse practitioners (NPs; 4.5%), and physician assistants (PAs; 4.2%). The percentage of antibiotic prescriptions decreased for physicians, but increased significantly for NPs and PAs. Provider-based and population-based prescribing rates decreased for physicians and dentists and increased for NPs and PAs. Penicillins were prescribed most frequently by all provider groups, decreasing for physicians and dentists. Increased prescribing of broad-spectrum agents was observed for NPs and PAs. With the exception of dentists, antibiotic prescriptions were higher in winter than in summer, with the largest seasonal increase by NPs. ConclusionOver 6 years, antibiotic prescriptions overall and for broad-spectrum agents decreased for physicians and increased for NPs and PAs. Thus, increasing trends in the US of broad-spectrum antibiotic prescriptions can be attributed to midlevel providers. Interventions should be designed to reverse increasing prescribing trends, especially of broad-spectrum agents prescribed by NPs and PAs. Stewardship efforts should also be targeted towards dentists, since this group prescribes a higher proportion of antibiotics compared with midlevel providers.

A Comparative Evaluation of Microbial Pattern and Antibiotic Susceptibility in a Level III NICU Between Two Decades

Background: Sepsis is one of the most common causes of neonatal mortality and morbidity in NICUs. Prescription of broad-spectrum antibiotics is increasing; hence, increase in antibiotic resistance is a concern. Information about changing microbial patterns and antimicrobial sensitivity over time helps us to choose the most appropriate antibiotics. Objectives: The aim of this research was to assess the changing microbial patterns and antibiotic susceptibility during a 23-year interval from 1992 to 2015 in the NICU of the Mofid Children’s hospital in Tehran, Iran. Methods: We conducted a retrospective comparative descriptive study between 1992 and 2015. Neonates with positive blood cultures were enrolled, and the microbial characteristics and antibiograms of the blood cultures were compared. Results: One-hundred cases of positive blood cultures in 1992 and 103 cases in 2015 were analyzed and compared. Overall, 57% of neonates were male and 43% were female; 56% of the sepsis was late onset and 44% was early onset; 63% of neonates had term gestation and 37% were preterm. We found that the most common causes of positive blood culture isolated in 1992 were Staphylococcus aureus (59%) and Staphylococcus epidermidis (40.9%). In 2015, the most common causes were (coagulase negative staphylococci) CONS (33.98%) and Pseudomonas aeruginosa (20.3%). In the evaluation of antibiograms, the rate of resistance to cephalosporins, aminoglycosides (except tobramycin), and oxacillins increased from 1992 to 2015. In 2015, the sensitivity rate to imipenem, meropenem, ciprofloxacillin, vancomycin, and linezolid was greater than the resistance, whereas to piperacillin, colistin, and cefepim, and cefotaxim, the rate of resistance was higher. In the evaluation of antibiotic sensitivity based on microorganisms in 2015, piperacillin had the highest effectiveness against pseudomonas and Klebsiella, with no effectiveness against Acinetobacter. Ciprofloxacin had the highest effectiveness against E. coli and Klebsiella. One-hundred percent of Streptococci, 83.3% of Staphylococcus aureus, and 71.4% of coagulase negative Staphylococci were sensitive to vancomycin. Conclusions: In this research, we found that the pattern of microbial and antibiotic sensitivity has changed, and overall antibiotic resistance is increasing. This is an indication that healthcare providers should use broad-spectrum antibiotics with caution.