Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness.
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ABSTRACT: Background
One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.Methods
In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability.Results
Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70).Conclusions
This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.
SUBMITTER: Kronman MP
PROVIDER: S-EPMC7461202 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation's primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4?months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8?weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4?weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4?months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.
| S-EPMC6267302 | biostudies-other
Project description:ObjectiveTo analyse individual-patient electronic health records to evaluate changes in antibiotic (AB) prescribing in England for different age groups, for male and female subjects, and by prescribing indications from 2014 to 2017.MethodsData were analysed for 102 general practices in England that contributed data to the UK Clinical Practice Research Datalink (CPRD) from 2014 to 2017. Prescriptions for all ABs and for broad-spectrum ?-lactam ABs were evaluated. Relative rate reductions (RRR) were estimated from a random-effects Poisson model, adjusting for age, gender, and general practice.ResultsTotal AB prescribing declined from 608 prescriptions per 1000 person-years in 2014 to 489 per 1000 person-years in 2017; RRR 6.9% (95% CI 6.6% to 7.1%) per year. Broad-spectrum ?-lactam AB prescribing decreased from 221 per 1000 person-years in 2014 to 163 per 1000 person-years in 2017; RRR 9.3% (9.0% to 9.6%) per year. Declines in AB prescribing were similar for men and women but the rate of decline was lower over the age of 55 years than for younger patients. All AB prescribing declined by 9.8% (9.6% to 10.1%) per year for respiratory infections, 5.7% (5.2% to 6.2%) for genitourinary infections, but by 3.8% (3.1% to 4.5%) for no recorded indication. Overall, 38.8% of AB prescriptions were associated with codes that did not suggest specific clinical conditions, and 15.3% of AB prescriptions had no medical codes recorded.ConclusionAntibiotic prescribing has reduced and become more selective but substantial unnecessary AB use may persist. Improving the quality of diagnostic coding for AB use will help to support antimicrobial stewardship efforts.
| S-EPMC6661619 | biostudies-literature
Project description:ObjectivesTo evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections.DesignOpen label, two arm, cluster randomised controlled trial.SettingUK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017.Participants79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care.InterventionsAMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial.Main outcome measuresPrimary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported.ResultsThe trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13).ConclusionsElectronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation.Trial registrationISRCTN95232781.
| S-EPMC6371944 | biostudies-literature
Project description:Anti-influenza antiviral medications reduce influenza-related morbidity, but may often be used inappropriately.To measure the rate of antiviral and antibiotic prescribing, the appropriateness of antiviral prescribing, and evaluate independent predictors of antiviral and antibiotic prescribing for influenza in primary care.Retrospective analysis of 958 visits of clinician-diagnosed influenza in 21 primary care clinics in eastern Massachusetts from 1999 to 2007. We considered antiviral prescribing appropriate if patients had symptoms for 2 or fewer days, had fever, and any 2 of headache, sore throat, cough, or myalgias.Clinicians prescribed antivirals in 557 (58%) visits and antibiotics in 104 visits (11%). Of antiviral prescriptions, 38% were not appropriate, most commonly because of symptoms for more than 2 days (24% of antiviral prescriptions). In multivariate modeling, selected independent predictors of antiviral prescribing were symptom duration of 2 or fewer days (odds ratio [OR], 12.4; 95% confidence interval [CI], 8.3 to 18.6), year (OR, 1.4 for each successive influenza season; 95% CI, 1.3 to 1.7), patient age (OR, 1.3 per decade; 95% CI, 1.2 to 1.5), and, compared to having no influenza testing, having a negative influenza test (OR, 5.5; 95% CI, 3.4 to 9.1) or a positive influenza test (OR, 11.4; 95% CI, 6.7 to 19.3). Independent predictors of antibiotic prescribing included otoscopic abnormalities (OR, 3.3; 95% CI, 1.8 to 6.0), abnormal lung examination (OR, 4.0; 95% CI, 2.1 to 6.2), and having a chest x-ray performed (OR, 2.2; 95% CI, 1.3 to 3.8).Primary care clinicians are much more likely to prescribe antivirals to patients with symptoms for 2 or fewer days, but also commonly prescribe antivirals inappropriately.
| S-EPMC2659164 | biostudies-other
Project description:ObjectiveTo estimate the effectiveness of different strategies involving delayed antibiotic prescription for acute respiratory tract infections.DesignOpen, pragmatic, parallel group, factorial, randomised controlled trial.SettingPrimary care in the United Kingdom.Patients889 patients aged 3 years and over with acute respiratory tract infection, recruited between 3 March 2010 and 28 March 2012 by 53 health professionals in 25 practices.InterventionsPatients judged not to need immediate antibiotics were randomised to undergo four strategies of delayed prescription: recontact for a prescription, post-dated prescription, collection of the prescription, and be given the prescription (patient led). During the trial, a strategy of no antibiotic prescription was added as another randomised comparison. Analysis was intention to treat.Main outcome measuresMean symptom severity (0-6 scale) at days 2-4 (primary outcome), antibiotic use, and patients' beliefs in the effectiveness of antibiotic use. Secondary analysis included comparison with immediate use of antibiotics.ResultsMean symptom severity had minimal differences between the strategies involving no prescription and delayed prescription (recontact, post-date, collection, patient led; 1.62, 1.60, 1.82, 1.68, 1.75, respectively; likelihood ratio test χ(2) 2.61, P=0.625). Duration of symptoms rated moderately bad or worse also did not differ between no prescription and delayed prescription strategies combined (median 3 days v 4 days; 4.29, P=0.368). There were modest and non-significant differences in patients very satisfied with the consultation between the randomised groups (79%, 74%, 80%, 88%, 89%, respectively; likelihood ratio test χ(2) 2.38, P=0.667), belief in antibiotics (71%, 74%, 73%, 72%, 66%; 1.62, P=0.805), or antibiotic use (26%, 37%, 37%, 33%, 39%; 4.96, P=0.292). By contrast, most patients given immediate antibiotics used antibiotics (97%) and strongly believed in them (93%), but with no benefit for symptom severity (score 1.76) or duration (median 4 days).ConclusionStrategies of no prescription or delayed antibiotic prescription result in fewer than 40% of patients using antibiotics, and are associated with less strong beliefs in antibiotics, and similar symptomatic outcomes to immediate prescription. If clear advice is given to patients, there is probably little to choose between the different strategies of delayed prescription.Trial registrationISRCTN38551726.
| S-EPMC3944682 | biostudies-literature
Project description:BackgroundInappropriate use of antibiotics promotes antibiotic resistance. Little is known about physician characteristics that may be associated with inappropriate antibiotic prescribing. Our objective was to assess whether physician knowledge, time in practice, place of training and practice volume explain the differences in antibiotic prescribing among physicians.MethodsA historical cohort of 852 primary care physicians in Quebec who became certified between 1990 and 1993 was followed for their first 6-9 years of practice (1990-1998). We evaluated whether inappropriate antibiotic prescribing had occurred during the study period (1990-1998) for viral (prescription of antibiotics) and bacterial (prescription of second-or third-line antibiotics given orally) infections. We used logistic regression to estimate the independent contributions of time in practice, practice volume, place of medical training and scores on licensure examinations. Physician sex and visit setting were controlled for, as were patient age, sex, education, income and geographic area of residence.ResultsA total of 104 230 patients who received a diagnosis of a viral infection and 65 304 who received a diagnosis of a bacterial infection were included in our study. International medical graduates were more likely than University of Montréal graduates to prescribe antibiotics for viral respiratory infections (risk ratio [RR] 1.78, 95% confidence interval [CI] 1.30-2.44). Inappropriate antibiotic prescribing increased with time in practice. Physicians with a high practice volume were more likely than those with low practice volume to prescribe antibiotics for viral respiratory infections (RR 1.27, 95% CI 1.09-1.48) and to prescribe second-and third-line antibiotics as first-line treatment (RR 1.20, 95% CI 1.06-1.37). Physician scores on licensure examinations were not predictive of inappropriate antibiotic prescribing.InterpretationInternational medical graduates, physicians with high-volume practices and those who were in practice longer were more likely to prescribe antibiotics inappropriately. Developing effective interventions will require increased knowledge of the mechanisms that underlie these predictors of inappropriate antibiotic prescribing.
| S-EPMC1995156 | biostudies-literature
Project description:This study aimed to determine the association between factors relevant to diagnostic uncertainty and physicians' antibiotic-prescribing behaviour in primary care. A questionnaire survey was conducted on 327 physicians that measured their diagnostic ability, perceived frequency of diagnostic uncertainty, tolerance, and perceived patient tolerance of uncertainty. Physician antibiotic-prescribing behaviours were assessed based on their prescriptions (n = 207,804) of three conditions: upper respiratory tract infections (URTIs, antibiotics not recommended), acute tonsillitis (cautious use of antibiotics), and pneumonia (antibiotics recommended). A two-level logistic regression model determined the association between diagnostic uncertainty factors and physician antibiotic prescribing. Physicians perceived a higher frequency of diagnostic uncertainty resulting in higher antibiotic use for URTIs and less antibiotic use for pneumonia. Higher antibiotic use for acute tonsillitis was related to a low tolerance of uncertainty of physicians and patients. This study suggests that reducing diagnostic uncertainty and improving physician and patient uncertainty management could reduce antibiotic use.
| S-EPMC7994848 | biostudies-literature
Project description:With the onset of the coronavirus disease 2019 (COVID-19) pandemic, pediatric ambulatory encounter volume and antibiotic prescribing both decreased; however, the durability of these reductions in pediatric primary care in the United States has not been assessed. We conducted a retrospective observational study to assess the impact of the COVID-19 pandemic and associated public health measures on antibiotic prescribing in 27 pediatric primary care practices. Encounters from January 1, 2018, through June 30, 2021, were included. The primary outcome was monthly antibiotic prescriptions per 1000 patients. Interrupted time series analysis was performed. There were 69 327 total antibiotic prescriptions from April through December in 2019 and 18 935 antibiotic prescriptions during the same months in 2020, a 72.7% reduction. The reduction in prescriptions at visits for respiratory tract infection (RTI) accounted for 87.3% of this decrease. Using interrupted time series analysis, overall antibiotic prescriptions decreased from 31.6 to 6.4 prescriptions per 1000 patients in April 2020 (difference of -25.2 prescriptions per 1000 patients; 95% CI: -32.9 to -17.5). This was followed by a nonsignificant monthly increase in antibiotic prescriptions, with prescribing beginning to rebound from April to June 2021. Encounter volume also immediately decreased, and while overall encounter volume quickly started to recover, RTI encounter volume returned more slowly. Reductions in antibiotic prescribing in pediatric primary care during the COVID-19 pandemic were sustained, only beginning to rise in 2021, primarily driven by reductions in RTI encounters. Reductions in viral RTI transmission likely played a substantial role in reduced RTI visits and antibiotic prescriptions.
| S-EPMC9825803 | biostudies-literature
Project description:BACKGROUND: Information about antibiotic prescribing practice in primary care is not available for Ireland, unlike other European countries. The study aimed to ascertain the types of antibiotics and the corresponding conditions seen in primary care and whether general practitioners (GPs) felt that an antibiotic was necessary at the time of consultation. This information will be vital to inform future initiatives in prudent antibiotic prescribing in primary care. METHODS: Participating GPs gathered data on all antibiotics prescribed by them in 100 consecutive patients' consultations as well as data on the conditions being treated and whether they felt the antibiotic was necessary. RESULTS: 171 GPs collected data on 16,899 consultations. An antibiotic was prescribed at 20.16% of these consultations. The majority were prescribed for symptoms or diagnoses associated with the respiratory system; the highest rate of prescribing in these consultations were for patients aged 15-64 years (62.23%). There is a high rate of 2nd and 3rd line agents being used for common ailments such as otitis media and tonsillitis. Amoxicillin, which is recommended as 1st line in most common infections, was twice as likely to be prescribed if the prescription was for deferred used or deemed unnecessary by the GP. CONCLUSION: The study demonstrates that potentially inappropriate prescribing is occurring in the adult population and the high rate of broad-spectrum antimicrobial agents is a major concern. This study also indicates that amoxicillin may be being used for its placebo effect rather than specifically for treatment of a definite bacterial infection.
| S-EPMC3430589 | biostudies-other
Project description:Antibiotics are frequently prescribed at many of the visits to primary care clinics, often for conditions for which they provide no benefit, including viral respiratory tract infections.The aim was to evaluate primary care visits due to infectious diseases, and to estimate antibiotic prescribing and antibiotic dispensing by pharmacies.Diagnosis of infectious disease, antibiotic prescribing and dispensing data at the individual patient level were extracted for 2015 from Clalit Health Services' electronic medical records and linked to determine the condition for which the antimicrobial was prescribed.There were 6.6 million visits due to infections, representing 22% of all primary care visits. The most common events were upper respiratory tract infections (38%) and pharyngitis (10%). Highest prescription rates were for urinary tract infections (80%), otitis media (64%), pharyngitis (71%), sinusitis (63%), and lower respiratory tract infections (76%). The highest rates of undispensed prescriptions were for acute gastroenteritis, urinary tract infections, and pharyngitis (24, 23, and 16%, respectively).Infectious diseases constitute a heavy burden on primary care, with overprescribing of antibiotics. Intervention to reduce unwarranted antibiotic use is needed. In pediatric care, interventions should focus on better controlling antibiotic consumption and encouraging adherence to guidelines for upper respiratory tract infections, pharyngitis, and otitis media. In adults interventions should aim to monitor antibiotic prescribing for upper respiratory tract infections and improve adherence to guidelines for urinary tract infections.
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