Unnecessary Prescribing Research Articles

Antibiotic use in pediatric dental infections: knowledge and awareness levels of dentists

Antibiotics are crucial in treating infections; however, their unnecessary and incorrect use can lead to numerous health issues, notably antibiotic resistance. Evaluating the accuracy and awareness of antibiotic prescription practices among dentists, who play a significant role in antibiotic use, is critical in developing effective health policies and professional training programs. This study assesses dentists’ knowledge levels and practice habits regarding antibiotic use. Using a structured questionnaire, the research employed a cross-sectional design and was conducted with 202 general dentists, 98 pediatric dentists, and 43 oral and maxillofacial surgeons. Data were analyzed using demographic characteristics, antibiotic prescription practices, and scenario-based questions measuring knowledge levels. The results revealed that while most participants were generally knowledgeable about antibiotic use, inconsistencies in prescription practices were evident. Notably, unnecessary antibiotic prescriptions were identified in some cases, contributing to significant health issues such as antibiotic resistance. This study emphasizes the necessity of promoting conscious antibiotic use by evaluating dentists’ practices. Therefore, the urgent need for developing professional training programs and strengthening strategies to combat antibiotic resistance is paramount.

Bacterial profiles and their antibiotic susceptibility patterns in neonatal sepsis at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.

Neonatal sepsis is a major cause of morbidity and mortality worldwide. Understanding the bacterial profiles and antibiotic susceptibility patterns causing neonatal sepsis is crucial for guiding appropriate treatment, improving patient outcomes, and combating the emergence of antibiotic resistance. Despite its importance, data regarding neonatal sepsis in the study area is limited. Therefore, this study aimed to characterize the bacterial pathogens and identify associated factors among neonates with suspected sepsis at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. A cross-sectional study was conducted by reviewing laboratory records of neonates admitted for suspected sepsis from January 2019 to December 2021. Data were checked for completeness and encoded in a spreadsheet program. Then, data were exported to STATA version 17 for analysis. Descriptive statistics such as frequency and percentage were computed. The association between neonatal sepsis and potential risk factors was assessed using Pearson's chi-square test. A p-value of < 0.05, was considered statistically significant. A total of 1,236 neonates were included. Of these, 96.2% (1,190/1,236) had a fever before admission. The prevalence of culture-confirmed sepsis was 25.4% (314/1,236). Bacterial pathogens accounted for 23% (284/1,236) of these isolates, with Gram-negative bacteria being more prevalent at 75.3% (214/284) than Gram-positive bacteria at 24.7% (70/284). The most frequently isolated bacterial pathogens were K. pneumoniae 38.7% (110/284) and S. aureus 13% (37/284). The isolates demonstrated a high resistance level to commonly used antibiotics, with 61.6% exhibiting multidrug resistance. K. pneumoniae showed the highest rate of multidrug resistance (90.9%). Neonatal sepsis was associated with several factors, including fever before and after admission, hypothermia, increased respiration, suspected pneumonia, and suspected meningitis. This study identified a high prevalence of culture-confirmed sepsis in neonates at UoGCSH, with Gram-negative bacteria, especially K. pneumoniae, dominating the isolated pathogens. The isolated bacteria exhibited alarming resistance to commonly used antibiotics, with a high proportion demonstrating multidrug resistance. Implementing effective antibiotic stewardship programs is crucial to optimize antibiotic use, reduce unnecessary prescriptions, and curb the spread of resistant strains.

Epidemiological and clinical features of a large blastomycosis outbreak at a paper mill in Michigan.

Blastomycosis is an environmentally acquired fungal infection that can result in severe pulmonary illness and high hospitalization rates. In 2023, a blastomycosis outbreak was detected among workers at a paper mill in Delta County, Michigan. We included patients with clinical and laboratory evidence of blastomycosis who had spent ≥40 hours in Delta County since September 1, 2022 and had illness onset December 1, 2022-July 1, 2023. We assessed epidemiological and clinical features of patients and evaluated factors associated with hospitalization. We performed whole-genome sequencing to characterize genetic relatedness of clinical isolates from eight patients. In total, 131 patients were identified; all had worked at or visited the mill. Sixteen patients (12%) were hospitalized; one died. Compared with non-hospitalized patients, more hospitalized patients had diabetes (p=0.03) and urine antigen titers above the lower limit of quantification (p<0.001). Hospitalized patients were also more likely to have had ≥1 healthcare visits before receiving a blastomycosis diagnostic test (p=0.02) and to have been treated with antibiotics prior to antifungal prescription (p=0.001). All sequenced isolates were identified as Blastomyces gilchristii and clustered into a distinct outbreak cluster. This was the largest documented blastomycosis outbreak in the United States. Epidemiologic evidence indicated exposures occurred at or near the mill, and genomic findings suggested a common exposure source. Patients with diabetes may have increased risk for hospitalization, and elevated urine antigen titers could indicate greater disease severity. Early suspicion of blastomycosis may prompt earlier diagnosis and treatment, potentially reducing unnecessary antibiotic prescriptions and improving patient outcomes.

Unnecessary antibiotic use in men who have sex with men (MSM) with anogenital symptoms attending a sexual health clinic: a retrospective analysis

ObjectivesTo quantify the amount of unnecessary antibiotics, in particular ceftriaxone, given to men who have sex with men (MSM) with anogenital symptoms as part of presumptive management in an urban...

Functional neurological disorder in pregnancy, labour and the postpartum period: systematic review.

Functional neurological disorder (FND) most often presents in women of childbearing age, but little is known about its course and outcomes during pregnancy, labour and postpartum (the perinatal period). We searched MEDLINE, PsycInfo and Embase combining search terms for FND and the perinatal period. We extracted data on patient demographics, subtype of FND, timing of symptom onset, comorbidities, medications, type of delivery, investigations, treatment, pregnancy outcomes and FND symptoms at follow-up. We included 36 studies (34 case reports and 2 case series) describing 43 patients. Six subtypes of FND were identified: functional (dissociative) seizures, motor weakness, movement disorder, dissociative amnesia, speech disorders and visual symptoms. New onset of perinatal FND was more common in the third trimester and onwards. Some women with functional seizures were exposed to unnecessary anti-seizure prescriptions and intensive care admissions. Prospective studies are urgently needed to explore how FND interacts with women's health in the perinatal period.

Antibiotic Appropriateness for Urinary Tract Infections in Children.

We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives. We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests. Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity. Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship.

Carrier rates of group A streptococci in Australian wet tropics and their impact on the clinical usefulness of throat swabs.

Rapid point-of-care tests (POCT) are likely to assist with the detection of group A streptococci (GAS), but their usefulness is determined by the presence of carriers of GAS. This is insufficiently explored in the wet tropics. This study included 77 patients attendingprimary care in the wet tropics complaining of a sore throat, and 49healthy controls. Carrier rates of GAS and the positive and negative etiological predictive values (P-EPV and N-EPV, respectively) of a POCT were calculated. The carrier rates were 8.3% among healthy children and 2.7% for adults. TheP-EPV for children was 71% (95%confidence interval [CI]: 0.0-100%) and for adults it was 85% (95% CI: 0.0-100%). The corresponding N-EPV was99% (95% CI: 95-100%) for children and99% (95% CI: 98-100%) for adults. N-EPV, ruling out GAS, was sufficiently high with narrow CIs to allow for defining a stopping rule to avoid unnecessary antibiotic prescribing.

Carrier rates of group A streptococci in Australian wet tropics and their impact on the clinical usefulness of throat swabs.

Rapid point-of-care tests (POCT) are likely to assist with the detection of group A streptococci (GAS), but their usefulness is determined by the presence of carriers of GAS. This is insufficiently explored in the wet tropics. This study included 77 patients attendingprimary care in the wet tropics complaining of a sore throat, and 49healthy controls. Carrier rates of GAS and the positive and negative etiological predictive values (P-EPV and N-EPV, respectively) of a POCT were calculated. The carrier rates were 8.3% among healthy children and 2.7% for adults. TheP-EPV for children was 71% (95%confidence interval [CI]: 0.0-100%) and for adults it was 85% (95% CI: 0.0-100%). The corresponding N-EPV was99% (95% CI: 95-100%) for children and99% (95% CI: 98-100%) for adults. N-EPV, ruling out GAS, was sufficiently high with narrow CIs to allow for defining a stopping rule to avoid unnecessary antibiotic prescribing.

Appropriateness of antibiotic prescribing among patients treated for dental diseases in Mekelle city, Northern Ethiopia: a cross sectional study

BackgroundLocal operative treatments are generally preferred for most dental diseases, with antibiotics only recommended as an adjunct in specific cases. Misuse and overuse of antibiotics has been shown to significantly contribute to the development of resistant bacteria. However, the antibiotic prescribing practices of dentists in Ethiopia have not been thoroughly studied. This study aimed to assess the appropriateness of antibiotic prescribing for patients with dental diseases at dental clinics in Mekelle City, Northern Ethiopia.MethodsA cross sectional study was conducted in April and May 2020 among patients visiting dental clinics in Mekelle City. Data were collected through patient medical record reviews and dentist interviews. The appropriateness of antibiotic prescription was evaluated based on guidelines from the American Dental Association and the European Society of Endodontology. Data were analyzed using SPSS Statistics, version 29. Binary logistic regression analysis was performed, and the results were presented as odds ratios with 95% confidence intervals. A p value less than 0.05 was considered statistically significant.ResultsTwo hundred and thirty-one patients with dental diseases participated in the study. The mean age was 30.6 years with a standard deviation of 16.1. Most participants had dental pulp related disease. 89% of patients were prescribed antibiotics, with amoxicillin being the most common. Inappropriate antibiotic prescribing was identified in 175 (75.8%) of the study participants. The most common inappropriate prescribing was unnecessary antibiotic prescribing for dental conditions without systemic signs, assessed in 141 (80.1%) participants. Patients diagnosed with pulp related disease without systemic signs and those who had tooth extractions were significantly associated with inappropriate antibiotic prescription (p value < 0.001).ConclusionsThe study findings show that antibiotics are over-prescribed for dental conditions in this resource constrained setting, especially in patients who have had tooth extractions. Dentists need training on appropriate antibiotic use and antimicrobial stewardship interventions should be implemented in dental setting to reduce unnecessary antibiotic prescriptions and prevent antibiotic resistance development.

Can patient education initiatives in primary care increase patient knowledge of appropriate antibiotic use and decrease expectations for unnecessary antibiotic prescriptions?

Healthcare globally is increasingly threatened by antibiotic resistance. Misunderstanding of the appropriate use of antibiotics is common within the general population, therefore patient education could be a useful tool to employ against antibiotic resistance. Patient satisfaction with healthcare is important, and antibiotic awareness is crucial to avoid disappointment when antibiotic stewardship is practiced. This review aims to identify whether patient education is an effective tool to improve knowledge and awareness of the appropriate use of antibiotics and whether it has an effect on expectations of or prescription rates of antibiotics. Embase, Medline, Web of Science, PubMed, and Cochrane Library were searched to identify studies examining the impact of various forms of patient education on awareness of appropriate antibiotic use and antibiotic prescription rates. Reference lists of eligible studies were also screened. Three hundred and fourteen unique studies were identified, of which 18 were eligible for inclusion. All studies were of good quality. Three studies examined public health campaigns, five examined leaflets, two examined posters, three examined videos, four used mixed interventions and one study examined a presentation. The results were too heterogenous to perform a meta-analysis. Patient education is an effective tool to increase public knowledge and awareness of the appropriate use of antibiotics, and can reduce the expectation of or prescription rates of antibiotics. The form of patient education matters, as interventions involving active learning and engagement demonstrate significant positive outcomes, whereas passive forms of learning do not appear to have any effect on understanding or prescriptions.

Antimicrobial prescription pattern and appropriateness for respiratory tract infection in outpatients: a systematic review and meta-analysis

BackgroundMillions of people die every year as a result of antimicrobial resistance worldwide. An inappropriate prescription of antimicrobials (e.g., overuse, inadequate use, or a choice that diverges from established guidelines) can lead to a heightened risk of antimicrobial resistance. This study aimed to determine the rate and appropriateness of antimicrobial prescriptions for respiratory tract infections.MethodsThis review was conducted in accordance with the PRISMA guidelines. Web of Science, PubMed, ProQuest Health and Medicine, and Scopus were searched between October 1, 2023, and December 15, 2023, with no time constraints. Studies were independently screened by the first author and the co-authors. We included original studies reporting antimicrobial prescription patterns and appropriateness for respiratory tract infections. The quality of included studies’ was assessed via the Joanna Briggs Institute’s Critical Appraisal Checklists for Cross-Sectional Studies. The assessment of publication bias was conducted using a funnel plot and Egger’s regression test. A random effect model was employed to estimate the pooled antibiotic prescribing and inappropriate rates. Subgroup analysis was conducted by country, study period, data source, and age group.ResultsOf the total 1220 identified studies, 36 studies were included in the review. The antimicrobial prescribing rate ranged from 25% (95% CI 0.24–0.26) to 90% (95% CI 0.89–0.91). The pooled antimicrobial prescription rate was 66% (95% CI 0.57 to 0.73). Subgroup analysis by region revealed that the antimicrobial prescription rate was highest in Africa (79%, 95% CI 0.48–0.94) and lowest in Europe (47%, 95% CI 0.32–0.62). Amoxicillin and amoxicillin-clavulanate antimicrobials from the Access group, along with azithromycin and erythromycin from the Watch group, were the most frequently used antimicrobial agents. This study revealed that the major reasons for antimicrobial prescription were acute bronchitis, pharyngitis, sinusitis, and the common cold. The pooled inappropriate antimicrobial prescription rate was 45% (95% CI 0.38–0.52). Twenty-eight of the included studies reported that prescribing antimicrobials without proper indications was the main cause of inappropriate antimicrobial prescriptions. Additionally, subgroup analysis by region showed a higher inappropriate antimicrobial prescription rate in Asia at 49% (95% CI 0.38–0.60). The result of the funnel plot and Egger’s tests revealed no substantial publication bias (Egger’s test: p = 0.268).ConclusionThe prescribing rate and inappropriate use of antimicrobials remain high and vary among countries. Further studies should be conducted to generate information about factors contributing to unnecessary antimicrobial prescriptions in outpatients.Systematic review registrationSystematic review registration: CRD42023468353.

Clinical diagnosis of group A streptococcal pharyngitis and progress in the application of scoring systems

Pharyngitis can be caused by various pathogens, including viruses and bacteria. Group A streptococcus (GAS) is the most common bacterial cause of pharyngitis. However, distinguishing GAS pharyngitis from other types of upper respiratory tract infections is challenging in clinical settings. This often leads to empirical treatments and, consequently, the overuse of antimicrobial drugs. With the advancement of antimicrobial drug management and healthcare payment reform initiatives in China, reducing unnecessary testing and prescriptions of antimicrobial drugs is imperative. To promote standardized diagnosis and treatment of GAS pharyngitis, this article reviews various international guidelines on the clinical diagnosis and differential diagnosis of GAS pharyngitis, particularly focusing on clinical scoring systems guiding laboratory testing and antimicrobial treatment decisions for GAS pharyngitis and their application recommendations, providing a reference for domestic researchers and clinical practitioners.

Specifying behavioural and strategy components of de-implementation efforts targeting low-value prescribing practices in secondary health care

Background/AimsDe-implementation, including the removal or reduction of unnecessary or inappropriate prescribing, is crucial to ensure patients receive appropriate evidence-based health care. The utilization of de-implementation efforts is contingent on the quality of strategy reporting. To further understand effective ways to de-implement medical practices, specification of behavioural targets and components of de-implementation strategies are required. This paper aims to critically analyse how well the behavioural targets and strategy components, in studies that focused on de-implementing unnecessary or inappropriate prescribing in secondary healthcare settings, were reported.MethodsA supplementary analysis of studies included in a recently published review of de-implementation studies was conducted. Article text was coded verbatim to two established specification frameworks. Behavioural components were coded deductively to the five elements of the Action, Actor, Context, Target, Time (AACTT) framework. Strategy components were mapped to the nine elements of the Proctor’s ‘measuring implementation strategies’ framework.ResultsThe behavioural components of low-value prescribing, as coded to the AACTT framework, were generally specified well. However, the Actor and Time components were often vague or not well reported. Specification of strategy components, as coded to the Proctor framework, were less well reported. Proctor’s Actor, Action target: specifying targets, Dose and Justification elements were not well reported or varied in the amount of detail offered. We also offer suggestions of additional specifications to make, such as the ‘interactions’ participants have with a strategy.ConclusionSpecification of behavioural targets and components of de-implementation strategies for prescribing practices can be accommodated by the AACTT and Proctor frameworks when used in conjunction. These essential details are required to understand, replicate and successfully de-implement unnecessary or inappropriate prescribing. In general, standardisation in the reporting quality of these components is required to replicate any de-implementation efforts.Trial registrationNot registered.

Comprehensive Analysis of Anticoagulant Therapy in Patients with Isolated Atrial Flutter

Limited comparative data exist regarding the risk of cardiogenic emboli in patients with isolated atrial flutter (AFL). Some studies suggest a lower complication risk in AFL compared to atrial fibrillation (AFib), but methodological limitations and conflicting reports necessitate a comprehensive investigation. Our analysis proposes that isolated AFL carries a lower risk of ischemic events and left atrial thrombus formation than AFib. Importantly, we caution against applying stroke risk assessment approaches designed for AFib to AFL patients, as it may lead to harmful overestimations and unnecessary anticoagulant prescriptions. Furthermore, we highlight the current lack of sufficient data to determine the overall clinical benefit of prolonged anticoagulant therapy in patients with isolated AFL, especially when CHA2DS2-VASc index values are below 4. This review challenges existing perceptions, offering insights into the nuanced risk profiles of the transitional nature of isolated AFL due to the high incidence of AFib development within a year of AFL diagnosis. In conclusion, tailored risk assessments and further research are essential for precise clinical decision-making in this dynamic landscape.

A step forward in the diagnosis of urinary tract infections: from machine learning to clinical practice

ObjectivesUrinary tract infections (UTIs) are common infections within the Emergency Department (ED), causing increased laboratory workloads and unnecessary antibiotics prescriptions. The aim of this study was to improve UTI diagnostics in clinical practice by application of machine learning (ML) models for real-time UTI prediction. MethodsIn a retrospective study, patient information and outcomes from Emergency Department patients, with positive and negative culture results, were used to design models – ‘Random Forest’ and ‘Neural Network’ – for the prediction of UTIs. The performance of these predictive models was validated in a cross-sectional study. In a quasi-experimental study, the impact of UTI risk assessment was investigated by evaluating changes in the behaviour of clinicians, measuring changes in antibiotic prescriptions and urine culture requests. ResultsFirst, we trained and tested two different predictive models with 8692 cases. Second, we investigated the performance of the predictive models in clinical practice with 962 cases (Area under the curve was between 0.81 to 0.88). The best performance was the combination of both models. Finally, the assessment of the risk for UTIs was implemented into clinical practice and allowed for the reduction of unnecessary urine cultures and antibiotic prescriptions for patients with a low risk of UTI, as well as targeted diagnostics and treatment for patients with a high risk of UTI. ConclusionThe combination of modern urinalysis diagnostic technologies with digital health solutions can help to further improve UTI diagnostics with positive impact on laboratory workloads and antimicrobial stewardship.

Use of fluoroquinolones and the risk of aortic and mitral regurgitation: A nationwide case-crossover study.

Recently, there have been conflicting results reporting an increased risk of AR or MR associated with oral fluoroquinolones (FQs).This study investigated whether the use of FQs increases the risk of mitral regurgitation (MR) or aortic regurgitation (AR). A retrospective cohort study was conducted by using the Taiwan National Health Insurance research database. A unidirectional case-crossover design without selecting controls from an external population was adopted in this study. A total of 26,650 adult patients with new onset of AR or MR between January 1, 2000, and December 31, 2012, were identified. The risk of outcomes was compared between the hazard period and one of the randomly selected referent periods of the same individuals. Before exclusion of pneumonia diagnosed within 2 months before the index date, patients who took FQs had a significantly greater risk of AR or MR (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI] 1.30-1.77), any AR (combined AR and MR) (aOR 1.50, 95% CI 1.10-2.04), and any MR (combined AR and MR) (aOR 1.37, 95% CI 1.16-1.62). After exclusion of pneumonia, FQs exposure remained significantly associated with a greater risk of MR (aOR 1.38, 95% CI 1.17-1.62) and any MR (aOR 1.25, 95% CI 1.05-1.48). The findings suggested that patients treated with FQs could be warned about the potential risk for MR even after considering the possibility of protopathic bias. Reducing unnecessary FQs prescriptions may be considered to reduce the risk of valvular heart disease.

Implementation of Choosing Wisely in gynecology and obstetrics internship

INTRODUCTION: Throughout undergraduate school, it is important to instill a continuous emphasis on cost-conscious thinking across all specialties, including obstetrics and gynecology (OB/GYN). One potential strategy is the implementation of the Choosing Wisely (CW) Campaign. OBJECTIVE: To describe and assess the implementation strategies of the Choosing Wisely (CW) campaign within a medical internship in Obstetrics and Gynecology (OB/GYN). METHODS: This intervention study involved medical teachers and undergraduate medical students at a Brazilian medical school. Initially, teachers identified three common unnecessary clinical scenarios, which were then grouped and adapted to fit the CW recommendation format. Based on the five most frequently occurring recommendations, educational activities were developed, including workshops, banners, and discussions on cost-consciousness in healthcare with undergraduate students and medical doctors. RESULTS: The top five recommendations were as follows: 1. Don’t routinely order hormone levels for menopause diagnosis; 2. Don’t recommend ovarian removal during hysterectomy for premenopausal women without ovarian câncer risk; 3. Don’t prescribe broad-spectrum antibiotics for uncomplicated acute cystitis treatment; 4. Don’t request preventive examinations for colpitis diagnosis; and 5. Don’t request unnecessary exams during low-risk prenatal care, such as kidney and liver function tests. The theoretical and practical components of these educational activities led to increased awareness and subsequent discussions among internship faculty and undergraduate students. CONCLUSION: Implementation of the CW campaign within the medical internship in OB/GYN resulted in a positive impact, fostering reflection among participants and aiding in the avoidance of unnecessary treatments or prescriptions.

A Longitudinal Multivariable Analysis: State Policies and Opioid Dispensing in Medicare Beneficiaries Undergoing Surgery.

States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients. To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies. A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common. State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management. Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED). The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively. While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.

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

Testing Different Message Styles about Unnecessary Antibiotics Using an Online Platform.

Patients' expectations are a major contributor to the unnecessary prescribing of antibiotics, yet limited research has examined how physicians can calibrate these expectations. The studies we conducted tested how varying messages could impact patients' expectations for antibiotics and their experience of medical appointments. All the participants read a short scenario about an appointment for mild sinusitis symptoms, with the patient's expectation of antibiotics. In Study 1, the participants (n = 1069) were randomly assigned to read a positively framed, neutral, or negatively framed message regarding unnecessary antibiotics. In Study 2, the participants (n = 1073) read a message emphasizing either the societal or personal harms of unnecessary antibiotics, or a message without additional rationale. None of our pre-registered hypotheses were supported, but our exploratory analyses indicated that the societal message increased concern about antibiotic resistance. The participants who were more concerned about resistance were less likely to ask for antibiotics, more satisfied when the physician did not prescribe them, and more likely to recommend the physician to a friend. Discussing the consequences of the different courses of action did not appear to negatively impact physician-patient rapport. These studies demonstrate an inexpensive method with which to pre-test various messages about antibiotic consumption, and suggest that such messages are not negatively received by patients.