Reduction In Antibiotic Prescribing Research Articles

Point-of-care C-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in Vietnamese primary health care: a randomised controlled trial.

SummaryBackgroundInappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam.MethodWe did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1–65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579.FindingsBetween March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics within 14 days was 581 (64%) of 902 patients in the C-reactive protein group versus 738 (78%) of 947 patients in the control group (odds ratio [OR] 0·49, 95% CI 0·40–0·61; p<0·0001). Highly significant differences were seen in both children and adults, with substantial heterogeneity of the intervention effect across the 10 sites (I2=84%, 95% CI 66–96). 140 patients in the C-reactive protein group and 137 patients in the routine care group missed the urine test on day 3, 4, or 5. Antibiotic activity in urine on day 3, 4, or 5 was found in 267 (30%) of 877 patients in the C-reactive protein group versus 314 (36%) of 882 patients in the routine treatment group (OR 0·78, 95% CI 0·63–0·95; p=0·015). Time to resolution of symptoms was similar in both groups. Adverse events were rare, with no deaths and a total of 14 hospital admissions (six in the C-reactive protein group and eight in the control group).InterpretationC-reactive protein point-of-care testing reduced antibiotic use for non-severe acute respiratory tract infection without compromising patients' recovery in primary health care in Vietnam. Health-care providers might have become familiar with the clinical picture of low C-reactive protein, leading to reduction in antibiotic prescribing in both groups, but this would have led to a reduction in observed effect, rather than overestimation. Qualitative analysis is needed to address differences in context in order to implement this strategy to improve rational antibiotic use for patients with acute respiratory infection in low-income and middle-income countries.FundingWellcome Trust, UK, and Global Antibiotic Resistance Partnership, USA.

Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records—REDUCE Trial study original protocol

IntroductionRespiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered,...

Safety of reduced antibiotic prescribing for self limiting respiratory tract infections in primary care: cohort study using electronic health records

Objective To determine whether the incidence of pneumonia, peritonsillar abscess, mastoiditis, empyema, meningitis, intracranial abscess, and Lemierre’s syndrome is higher in general practices that prescribe fewer antibiotics for self limiting...

Reducing general practice trainees’ antibiotic prescribing for respiratory tract infections: an evaluation of a combined face-to-face workshop and online educational intervention

Over-prescription of antibiotics for non-pneumonia respiratory tract infections (RTIs) is a major concern in general practice. Australian general practice registrars (trainees) have inappropriately high rates of prescription of antibiotics for RTIs. The ‘apprenticeship’ educational model and the trainee–trainer relationship are drivers of this inappropriate prescribing. We aimed to reduce registrars’ non-pneumonia RTI antibiotic prescribing via an educational intervention (a 90-min face-to-face workshop supported by online modules), complemented by delivery of the same intervention, separately, to their trainers. We conducted a pre- and post-intervention comparison of the registrars’ intention to prescribe antibiotics for common RTIs using McNemar’s test. We similarly tested changes in supervisors’ intended prescribing. Prescribing intentions were elicited by responses to six written clinical vignettes (upper respiratory tract infection, otitis media, sore throat and three acute bronchitis vignettes). We found that, for registrars, there were statistically significant reductions in antibiotic prescribing for the sore throat (24.0% absolute reduction), otitis media (17.5% absolute reduction) and two of the three acute bronchitis (12.0% and 18.0% absolute reduction) vignettes. There were significant reductions in supervisors’ antibiotic prescribing intentions for the same four vignettes. We conclude that our intervention produced a significant change in registrars’ intention to prescribe antibiotics for non-pneumonia RTIs.

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care.

Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

98 Are we seeing more cases of Infective Endocarditis after Nice CG64 Recommended Cessation of the use of Antibiotic Prophylaxis? The Welsh Experience

Background Infectious endocardits (IE) is a rare condition associated with high morbidity and mortality. IE develops as a result of a complex interaction between the vascular endothelium, haemostatic mechanisms, the immune system and exposure to the causative microorganism. Historically cardiologists have utilised prophylactic antibiotics to cover procedures known to cause bacteraemia such as dental surgery to prevent IE. However, this practice was without evidence base and its efficacy questioned. In 2008 NICE CG64 was published advocating a radical change in practice, recommending cessation of chemoprophylaxis for the prevention of IE. In this study we aim to assess the impact of NICE CG 64 in Wales. Methods Chemoprophylaxis was most commonly prescribed in the form of a single 3 g oral dose of Amoxicillin or a 600 mg oral dose of Clindamycin. We obtained data of all prescriptions for either Amoxicillin 3 g or Clindamycin 600 mg in Wales from 2001 to 2012. We obtained data on diagnosis of IE including the causative microorganism from PEDW database (Patient Episode Database for Wales) via SAIL databank (Secure Anonymised Information Linkage) to assess the impact of NICE CG64. Previous studies have suggested an upward trend in the incidence of IE prior to the introduction of NICE CG64. We therefore performed analysis of our data using a Poisson regression model with identity link function to correct for any trend in our data. Results Prescriptions of Amoxicillin 3 g and Clindamycin 600 mg reduced by 77% and 92% (p Conclusion The reduction in antibiotic prescriptions seen after 2008 provides evidence that NICE CG64 is being followed in Wales. NICE CG64 accepted that patients who had previously received chemoprophylaxis may continue this practice which may explain the number of prescriptions seen following 2008. Alternatively practitioners may be following international guidance from AHA 2007 and ESC 2009 that continue to recommend chemoprohylaxis in high risk patients. Despite the major change in prescribing of chemoprophylaxis observed we only identified a gradual, non-significant increasing trend in the incidence of IE. This trend may be explained by increasing population size and improved diagnostics. There was no significant deviation in this linear trend with the introduction of NICE CG64 in 2008 providing support that the cessation of chemoprophylaxis has not resulted in a large increase in the incidence of IE over a four year period.

Impact of the lab-score on antibiotic prescription rate in children with fever without source: a randomized controlled trial.

BackgroundThe Lab-score, based on the combined determination of procalcitonin, C-reactive protein and urinary dipstick results, has been shown accurate in detecting serious bacterial infections (SBI) in children with fever without source (FWS) on retrospective cohorts. We aimed to prospectively assess the utility of the Lab-score in safely decreasing antibiotic prescriptions in children with FWS and to determine its diagnostic characteristics compared to common SBI biomarkers.MethodsRandomized controlled trial in children 7 days to 36 months old with FWS, allocated either to the Lab-score group (Lab-score reported, blinded WBC count) or to the control group (WBC, bands and C-reactive protein determined, blinded procalcitonin and Lab-score), followed up until recovery. Demographic data, antibiotic prescription rate, admission rate and diagnostic properties of the Lab-score were analyzed.Results271 children were analyzed. No statistically significant difference concerning antibiotic prescription rate was observed: 41.2% (54 of 131) in the Lab-score group and 42.1% (59 of 140) in the control group (p = 1.000). If recommendations based on the Lab-score had been strictly applied, a hypothetical 30.6% treatment rate would have been encountered, compared to the overall 41.7% observed rate (p = 0.0095). A Lab-score ≥3 showed the following characteristics: sensitivity 85.1% (95% CI: 76.5–93.6%), specificity 87.3% (95% CI: 82.7–91.8%), positive predictive value 68.7% (95% CI: 58.7–78.7%), negative predictive value 94.1% (95% CI: 91.5–97.9%), positive and negative likelihood ratios: 6.68 and 0.17 respectively. Area under the receiver operating characteristic curve was best for the Lab-score (0.911, 95% CI: 0.871–0.950).DiscussionNo difference regarding antibiotic treatment rate was observed when using the Lab-score, due to lack of adherence to the related recommendations. However, if strictly followed, a significant 26.5% reduction of antibiotic prescriptions would have been encountered. Medical education needs to be reinforced in order to observe rather than treat low-risk well-appearing children with FWS.Trial RegistrationClinicalTrials.gov NCT02179398

Exploring patients' views of primary care consultations with contrasting interventions for acute cough: a six-country European qualitative study.

Background:In a pan-European randomised controlled trial (GRACE INTRO) of two interventions, (i) a point-of-care C-reactive protein test and/or (ii) training in communication skills and use of an interactive patient booklet, both interventions resulted in large reductions in antibiotic prescribing for acute cough.Aims:This process evaluation explored patients’ views of primary care consultations using the two interventions in six European countries.Methods:Sixty-two interviews were conducted with patients who had participated in the GRACE INTRO trial. Interviews were transcribed verbatim and translated into English where necessary. Analysis used techniques from thematic and framework analysis.Results:Most patients were satisfied with their consultation despite many not receiving an antibiotic. Patients appeared to accept the use of both intervention approaches. A minority, but particularly in the trial arm with both interventions, reported that they would wait longer before consulting for cough in future.Conclusions:Patients perceived that both interventions supported the general practitioner’s (GP’s) prescribing decisions by helping them understand when an antibiotic was, and was not, needed. Patients consulting with acute cough had largely positive views about the GP’s enhanced communication skills, which included understanding their concerns, and the use of a near-patient test as an additional investigation.

Effectiveness of two types of intervention on antibiotic prescribing in respiratory tract infections in Primary Care in Spain. Happy Audit Study

ObjectiveTo evaluate the effectiveness of two types of intervention in reducing antibiotic prescribing in respiratory tract infections (RTI). DesignBefore–after audit-based study. SettingPrimary Care centres in Spain. ParticipantsGeneral practitioners (GPs) registered all patients with RTIs for 15 days in winter 2008 (pre-intervention), and again in winter 2009 (post-intervention). InterventionsIntervention activities included meetings, with the presentation and discussion of the results, and several training meetings on RTI guidelines, information brochures for patients, workshops on point-of-care tests – rapid antigen detection tests and C-reactive protein rapid test – and provision of these tests in the clinic. All GPs, with the exception of those in Catalonia, made up the full intervention group (FIG); conversely, Catalan doctors underwent the same intervention, except for the workshop on rapid tests (partial intervention group, PIG). Multilevel logistic regression was performed taking the prescription of antibiotics as the dependent variable. ResultsOut of a total of 309 GPs involved in the first register, 281 completed the intervention and the second register (90.9%), of which 210 were assigned to the FIG, and 71 to the PIG. The odds ratio of antibiotic prescribing after the intervention was 0.99 (95% CI: 0.89–1.10) among GPs assigned to PIG, and 0.50 (95% CI: 0.44–0.57, p<0.001) among those who were allocated to FIG. The reduction in antibiotic prescribing in FIG was more marked in flu infection, common cold, acute pharyngitis, acute tonsillitis, and acute bronchitis. ConclusionsActive participation of GPs with the performance of point-of-care tests in the clinic is accompanied by a drastic reduction of antibiotic use in RTIs, primarily in infections considered as mainly viral.

Antibiotic prescription patterns among Swedish dentists working with dental implant surgery: adherence to recommendations.

To investigate antibiotic prophylaxis prescription behaviors among Swedish dentists working with dental implant surgery and the influence of scientific reviews. An observational questionnaire study was conducted in 2008 and 2012. Dental clinic addresses were found through online search services of Swedish telephone directories. The questionnaires were posted to eligible dentists (120 in 2008, 161 in 2012) in the Stockholm region, Sweden. Absolute frequencies were used to describe the data. Chi-square tests were applied to assess statistically significant differences. The response rate was 75% in 2008 and 88% in 2012. In 2008, 88% of the dentists routinely prescribed antibiotic prophylaxis when performing implant surgery and 74% in 2012 (P=0.01). There was a significant reduction in the dentists prescription patterns as 65% prescribed a single dose in 2012, compared to 49% in 2008 (P=0.04). Amoxicillin was the drug of choice for 47% of the respondents in 2012, and 21% in 2008 (P=0.01). Dentists without postgraduate clinical training were significantly more prone to extend antibiotic administration after surgery (P<0.009). There is a wide variation in the choice of compound and prescription patterns of prophylactic antibiotic prior to implant insertion. A reduction in antibiotic prescription to a single dose was observed comparing 2008 and 2012, probably influenced by scientific reviews. Dentists with postgraduate education are more likely to limit antibiotic usage.

Antibiotic Judo

Antibiotic Judo

Parents’ and clinicians’ views of an interactive booklet about respiratory tract infections in children: a qualitative process evaluation of the EQUIP randomised controlled trial

Background‘When should I worry?’ is an interactive booklet for parents of children presenting with respiratory tract infections (RTIs) in primary care and associated training for clinicians. A randomised controlled trial (the EQUIP study) demonstrated that this intervention reduced antibiotic prescribing and future consulting intentions. The aims of this qualitative process evaluation were to understand how acceptable the intervention was to clinicians and parents, how it was implemented, the mechanisms for any observed effects, and contextual factors that could have influenced its effects.MethodsSemi-structured interviews were conducted with 20 parents and 13 clinicians who participated in the trial. Interviews were audio-recorded and transcribed verbatim. Data were analysed using a framework approach, which involved five stages; familiarisation, development of a thematic framework, indexing, charting, and interpretation.ResultsMost parents and clinicians reported that the ‘When should I worry’ interactive booklet (and online training for clinicians) was easy to use and valuable. Information on recognising signs of serious illness and the usual duration of illness were most valued. The interactive use of the booklet during consultations was considered to be important, but this did not always happen. Clinicians reported lack of time, lack of familiarity with using the booklet, and difficulty in modifying their treatment plan/style of consultation as barriers to use. Increased knowledge and confidence amongst clinicians and patients were seen as key components that contributed to the reductions in antibiotic prescribing and intention to consult seen in the trial. This was particularly pertinent in a context where decisions about the safe and appropriate management of childhood RTIs were viewed as complex and parents reported frequently receiving inconsistent messages.ConclusionsThe ‘When should I worry’ booklet, which is effective in reducing antibiotic prescribing, has high acceptability for clinicians and parents, helps address gaps in knowledge, increases confidence, and provides a consistent message. However, it is not always implemented as intended. Plans for wider implementation of the intervention in health care settings would need to address clinician-related barriers to implementation.Trial registrationISRCTN46104365

Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial

SummaryBackgroundHigh-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems.MethodsAfter a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214.ResultsThe baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001).InterpretationInternet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries.FundingEuropean Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.

Long-term effects of an educational seminar on antibiotic prescribing by GPs: a randomised controlled trial

High levels of outpatient antibiotic use remain observed in many European countries. Several studies have shown a strong relationship between antibiotic use and bacterial resistance. To assess the long-term effect of a standardised educational seminar on antibiotic prescriptions by GPs. Randomised controlled trial of 171 GPs (of 203 initially randomised) in France. GPs in the control group (n = 99) received no antibiotic prescription recommendation. Intervention group GPs (n = 72) attended an interactive seminar presenting evidence-based guidelines on antibiotic prescription for respiratory infections. The proportion of prescriptions containing an antibiotic in each group and related costs were compared to the baseline up to 30 months following the intervention. Data were obtained from the National Health Insurance System database. In the intervention group, 4-6 months after the intervention, there was a significant decrease in the proportion of prescriptions containing an antibiotic from 15.2 ± 5.4% to 12.3 ± 5.8% (-2.8% [95% CI = -3.8 to -1.9], P<0.001). By contrast, an increase was observed in controls from 15.3 ± 6.0 to 16.4 ± 6.7% (+1.1% [95% CI = +0.4 to +1.8], P<0.01), resulting in a between-group difference of 3.93% ([95% CI = 2.75 to 5.11], P<0.001). The between-group difference was maintained 30 months after intervention (1.99% [95% CI = 0.56 to 3.42], P<0.01). Persistence of the intervention effect over the entire study period was confirmed in a hierarchical multivariate analysis. This randomised trial shows that a standardised and interactive educational seminar results in a long-term reduction in antibiotic prescribing and could justify a large-scale implementation of this intervention.

Antibiotic prescribing and C-reactive protein testing for pulmonary infections in patients with intellectual disabilities

Excessive prescribing of antibiotics in patients with lower respiratory tract infections (LRTIs) is common in the general population. Due to communication difficulties, it is hypothesised that prescriptions are even more commonplace in the primary care of individuals with intellectual disabilities. Point-of-care C-reactive protein (POC-CRP) testing might lead to more efficient prescribing of antibiotics. To evaluate the effect of POC-CRP testing on antibiotic prescriptions for LRTIs by physicians specialising in the care of individuals with intellectual disabilities. A prospective case-control study in four care centres for individuals with intellectual disabilities in The Netherlands. Between 27 October 2010 and 27 October 2011, a prospective efficiency study was performed with a base population of 1472 individuals. This population consisted of 882 individuals in whom POC-CRP tests were used and a control group (n = 590) in whom no POC-CRP test was performed. Of the 48 patients in the control group who were diagnosed as having an LRTI, 43 (90%) received antibiotics, compared with 59 out of the 144 patients (41%) in the case group (OR = 12.0; 95% CI = 4.1-35.3). No significant differences in outcome were found between both groups during a follow-up period of 1 month. This study shows that the use of POC-CRP testing in patients with intellectual disabilities and LRTIs can lead to a significant reduction in antibiotic prescriptions, with no significant differences in outcome during follow-up.

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

BackgroundExcessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.MethodsGPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.ResultsA total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.ConclusionA multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

Reduction in antibiotic use through procalcitonin testing in patients in the medical admission unit or intensive care unit with suspicion of infection

We report an evaluation of the utility of serum procalcitonin (PCT) measurement as an additional diagnostic tool to support initiating or withholding antibiotics in clinical situations where there is a clinical suspicion of infection but the diagnosis is uncertain. During a six-month period, 99patients on the medical admission unit (MAU) with suspected infection, and 42patients on the intensive care unit (ICU) with clinical signs or physiological parameters suggesting possible new infection, had serum PCT concentration measured with the result available within 90min of the request. The test was initiated by the microbiology/infection team during clinical consultations to support the antibiotic decision. On the basis of low PCT values, antibiotics were withheld in MAU on 52occasions and in ICU on 42occasions. Patients were followed up prospectively for a week. There was neither progression of bacterial infection requiring antibiotics, nor complications or infection-related mortality in any patients who were denied antibiotics on either MAU or ICU. Without the PCT value it is likely that all of these patients would have received empirical antibiotics. Reduction in unnecessary antibiotic usage was made without any adverse effects on these patients and there was a clear reduction in antibiotic prescribing with cost reduction implications. PCT has the potential to become a valuable tool in antibiotic management.

Decline in Clostridium difficile-associated disease rates in Singapore public hospitals, 2006 to 2008

BackgroundClostridium difficile is the major cause of pseudomembranous colitis associated with antibiotic use, and the spread of the hypervirulent epidemic ribotype 027/NAP-1 strain across hospitals worldwide has re-focused attention on this nosocomial pathogen. The overall incidence and trend of C. difficile-associated disease (CDAD) in Singapore is unknown, and a surveillance program to determine these via formal laboratory-based reporting was established.FindingsLaboratory and pharmacy data were collated from one tertiary and two secondary hospitals on a quarterly basis between 2006 and 2008. All hospitals tested for C. difficile using Immunocard Toxins A&B (Meridian Bioscience Inc., Cincinnati, OH) during this period. Duplicate positive C. difficile results within a 14-day period were removed. The CDAD results were compared with trends in hospital-based prescription of major classes of antibiotics.Overall CDAD incidence-density decreased from 5.16 (95%CI: 4.73 - 5.62) cases per 10,000 inpatient-days in 2006 to 2.99 (95%CI: 2.67 to 3.33) cases per 10,000 inpatient-days in 2008 (p < 0.001), while overall rates for C. difficile testing increased significantly (p < 0.001) within the same period. These trends were mirrored at the individual hospital level. Evaluation of antibiotic prescription data at all hospitals showed increasing use of carbapenems and fluoroquinolones, while cephalosporin and clindamycin prescription remained stable.ConclusionsOur results demonstrate a real decline of CDAD rates in three large local hospitals. The cause is unclear and is not associated with improved infection control measures or reduction in antibiotic prescription. Lack of C. difficile stool cultures as part of routine testing precluded determination of the decline of a major clone as a potential explanation. For more accurate epidemiological trending of CDAD and early detection of epidemic clones, data collection will have to be expanded and resources set in place for reference laboratory culture and typing.

Are antibiotics still “automatic” in France?

The first part of a series of three features on antimicrobial resistance looks the French campaign that has been held up as an example of how to change the way antibiotics are prescribed. But, as Gary Humphreys reports, 10 years after the campaign's launch France is still one of Europe's biggest consumers of antibiotics and trends are moving in the wrong direction. Dr Pierre Fayn recalls the effect a 2002 French National Health Insurance campaign promoting better-targeted antibiotic use had on the children of Cleon d'Andran, a sleepy village in the Drome in south-eastern France. I would start by explaining to the parent why there was no need to treat the little one's cold with an antibiotic, and the child would chant: Because 'antibiotics are not automatic They knew the catchphrase; he says with a grin. The catchphrase--Les antibiotiques, c'est pas automatique--was in fact the title of the campaign first launched in 2002 with the aim of decreasing antibiotic prescription in France by 25% over a period of five years. In particular, the campaign targeted the treatment of viral respiratory infections in children, for whom 40% of the prescriptions were being written. Since 2002 the campaign has been repeated every winter for the duration of the viral respiratory infections epidemic season. The campaign was part of a broader government initiative rolled out in 2001 and called Keep Antibiotics Working--a multi-pronged plan that included the promotion of streptococcal rapid antigen testing and treatment guidelines among health-care professionals and the targeting of primary care physicians in one-on-one tutorials. At the time of the 2002 launch, France was consuming more antibiotics than any other country in Europe and facing a burgeoning antimicrobial resistance problem, notably with multidrug-resistant Streptococcus pneumoniae, a bacterium that colonizes the nose and throat and can cause problems that range from mild ear infections to life-threatening pneumonia and is especially dangerous for young children and elderly people. It has been known ever since antibiotics were developed that using them improperly leads to bacterial resistance, and overuse of antibiotics only increases that risk. The threat of widespread antimicrobial resistance raises the spectre of a world without effective antibiotics, where a patient can die from an infection once regarded as banal and easily treatable. The World Health Organization is devoting the next World Health Day on 7 April 2011 to raising awareness around the issue. France is one of 22 high-income whose measures to reduce antibiotic usage between 1990 and 2007 are assessed in a study by Dr Benedikt Hutmer and colleagues that was published in The Lancet in January 2010. They found that campaigns that were formally assessed, like the French one, seemed to reduce the use of antibiotics in outpatients at least in high-prescribing countries According to a study published in PLoS Medicine in June 2009, the French campaign exceeded expectations with a 26.5% reduction in the number of antibiotic prescriptions over the first five years. Though by no means the first to achieve significant results--yearly mass media campaigns in Belgium have been credited with a 36% reduction in antibiotic prescriptions between 1999 and 2000 and 2006 and 2007, for example--the French campaign is often held up as a model. For Professor Benoit Schlemmer, president of the government-appointed Keep Antibiotics Working committee, while the achievements of the French campaign are undeniable, nine years after its launch there are still major concerns about the way the French prescribe and consume antibiotics. For one thing France remains close to the top of Europe's antibiotic consumer league table, trailing super-prescribers Greece and Cyprus, although Schlemmer says league tables are of little interest to him. …

An interactive booklet reduces antibiotic use for children with respiratory tract infections

An interactive booklet reduces antibiotic use for children with respiratory tract infections