Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study.
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ABSTRACT: Background
Respiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital.Methods
We conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing.Results
Survey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice.Conclusion
Prescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.
SUBMITTER: Burrowes SAB
PROVIDER: S-EPMC8629209 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectivesInappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes.MethodsThis was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.ResultsOf 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.ConclusionsAntibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.
| S-EPMC8564887 | biostudies-literature
Project description:BACKGROUND:Antibiotics are not recommended for treating uncomplicated respiratory tract infections (RTIs), despite this, antibiotic prescribing for this is widespread. General practitioners (GPs) report parental pressure and fear of losing patients if they do not prescribe antibiotics, however, parental views on antibiotics for RTIs are unclear. Therefore, this study examined GPs' and parents' perceptions regarding antibiotic prescribing for RTIs in young children. METHODS:We conducted semi-structured interviews with 20 GPs, and a survey and focus groups with 50 parents and carers of children under the age of five between June 2014 and July 2015 in Melbourne, Australia. Qualitative data were thematically analysed using NVivo and quantitative data were analysed using SPSS. RESULTS:GPs believed that parents expect antibiotics for RTIs and were more likely to prescribe them if parents were insistent. They believed parents would go elsewhere if they did not prescribe antibiotics. GPs suggested that there would be less conflict if parents were better educated on appropriate antibiotics use. In contrast, parents demonstrated good knowledge of RTIs and appropriate antibiotic use. Their main expectation from GPs was to obtain a diagnosis, discuss management, and receive reassurance that the illness was not serious. Parental satisfaction with GPs was not dependent on receiving antibiotics (r = 0.658, p < 0.001), and they would not seek another GP if antibiotics were not prescribed (r = 0.655, p < 0.001). CONCLUSION:GPs and parents have dissonant views on antibiotic prescribing for RTI in young children. GPs perceived parents wanting a diagnosis and reassurance that their child is not severely ill as pressure to prescribe antibiotic. To overcome these barriers, targeted training for both GPs and parents to improve communication and reassurance that satisfaction is not related to receiving antibiotics may reduce unnecessary antibiotic prescribing for RTI in young children.
| S-EPMC6437946 | biostudies-literature
Project description:OBJECTIVE:Happy Audit project is a European-funded survey aimed at reducing antibiotic prescribing for respiratory tract infections (RTI). The aim of this study is to investigate the antibiotic treatment administered for these RTIs in Spain and to find out which criteria are associated with its use. DESIGN:Cross-sectional study carried out in January and February 2008. SETTING:Primary health care. PARTICIPANTS:General practitioners registered all the RTI during a 3-week period using a template. PRINCIPAL MEASUREMENTS:Age and gender, days with symptoms, signs presented (fever, cough, purulent ear discharge, sore throat, tonsillar exudate, swollen neck glands, dyspnoea, increase in sputum, purulent sputum), diagnosis, antibiotic therapy and demand of antibiotics. A logistic regression with the prescription of antibiotic as the dependent variable was performed. RESULTS:Out of the 332 physicians invited to participate, 309 filled in and returned the templates (93.1%), registering 16,751 RTIs, with the common cold (39.7%), pharyngitis (14.4%) and acute bronchitis (12.6%) being the most common. Antibiotic therapy was given to 4,675 RTIs (27.9%), mainly for pneumonia (89.9%), tonsillitis (88.9%), and otitis media (87.3%). The criterion most associated with antibiotic therapy was the presence of tonsillar exudate (OR: 32.1; 95CI%: 24.5-42), followed by ear discharge (25.2; 95%CI: 18.2-35) and purulence of sputum (18.1; 95%CI: 15.5-21.2); conversely, cough (OR: 0.4; 95%CI: 0.3-0.5) was considered as protective factor. DISCUSSION:Antibiotic treatment for RTIs is very high in our country. This study provides information on the criteria that predict this antibiotic therapy and is important to take into account if a more rational use of antibiotics is required.
| S-EPMC7022111 | biostudies-literature
Project description:Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.
| S-EPMC4914667 | biostudies-literature
Project description:ObjectiveTo assess the overall effect of delayed antibiotic prescribing on average symptom severity for patients with respiratory tract infections in the community, and to identify any factors modifying this effect.DesignSystematic review and individual patient data meta-analysis.Data sourcesCochrane Central Register of Controlled Trials, Ovid Medline, Ovid Embase, EBSCO CINAHL Plus, and Web of Science.Eligibility criteria for study selectionRandomised controlled trials and observational cohort studies in a community setting that allowed comparison between delayed versus no antibiotic prescribing, and delayed versus immediate antibiotic prescribing.Main outcome measuresThe primary outcome was the average symptom severity two to four days after the initial consultation measured on a seven item scale (ranging from normal to as bad as could be). Secondary outcomes were duration of illness after the initial consultation, complications resulting in admission to hospital or death, reconsultation with the same or worsening illness, and patient satisfaction rated on a Likert scale.ResultsData were obtained from nine randomised controlled trials and four observational studies, totalling 55 682 patients. No difference was found in follow-up symptom severity (seven point scale) for delayed versus immediate antibiotics (adjusted mean difference -0.003, 95% confidence interval -0.12 to 0.11) or delayed versus no antibiotics (0.02, -0.11 to 0.15). Symptom duration was slightly longer in those given delayed versus immediate antibiotics (11.4 v 10.9 days), but was similar for delayed versus no antibiotics. Complications resulting in hospital admission or death were lower with delayed versus no antibiotics (odds ratio 0.62, 95% confidence interval 0.30 to 1.27) and delayed versus immediate antibiotics (0.78, 0.53 to 1.13). A significant reduction in reconsultation rates (odds ratio 0.72, 95% confidence interval 0.60 to 0.87) and an increase in patient satisfaction (adjusted mean difference 0.09, 0.06 to 0.11) were observed in delayed versus no antibiotics. The effect of delayed versus immediate antibiotics and delayed versus no antibiotics was not modified by previous duration of illness, fever, comorbidity, or severity of symptoms. Children younger than 5 years had a slightly higher follow-up symptom severity with delayed antibiotics than with immediate antibiotics (adjusted mean difference 0.10, 95% confidence interval 0.03 to 0.18), but no increased severity was found in the older age group.ConclusionsDelayed antibiotic prescribing is a safe and effective strategy for most patients, including those in higher risk subgroups. Delayed prescribing was associated with similar symptom duration as no antibiotic prescribing and is unlikely to lead to poorer symptom control than immediate antibiotic prescribing. Delayed prescribing could reduce reconsultation rates and is unlikely to be associated with an increase in symptoms or illness duration, except in young children.Study registrationPROSPERO CRD42018079400.
| S-EPMC8080136 | biostudies-literature
Project description:BACKGROUND:Acute respiratory tract infections (ARIs) are common in the outpatient setting. Although they are predominantly viral, antibiotics are often prescribed for the treatment of ARIs. METHODS:Using the U.S. Medical Expenditure Panel Survey (MEPS; 2010-2015), we estimated the national prevalence and predictors of outpatient antibiotic prescribing for ARIs by provider type. We categorized the trends of antibiotic prescriptions (overall or broad-spectrum) for ARIs by provider type (physician and advanced practice provider [APP] which includes nurse practitioner [NP], and physician assistant [PA]). The outcome variable was defined as receipt of an antibiotic prescription during a consultation with a provider for an ARI (including outpatient clinic visit or doctor's office visit). RESULTS:There were 64,081,892 ARI antibiotic prescriptions written, with a decrease from 10.9 (2010) to 9.7 million (2015) during the study interval (p?<?0.0001). Associations of patient- and provider-level variables with antibiotics prescription were examined using binary logistic regression. Blacks were more likely to receive antibiotics than whites (OR 1.51; 95% CI 1.25, 1.84; p?<?0.001), and antibiotic prescription was more likely if the patient-provider race was concordant (OR 5.41; 95% CI 4.65, 6.29, p?<?0.0001). Although the majority of patients with ARI were cared for by physicians, APPs were seeing an increasing number of ARI patients. CONCLUSIONS:Antibiotic prescribing for ARIs though declining, remains high. More research is needed to better understand the drivers of ARI antibiotic prescribing and to develop targeted interventions for both patients and providers.
| S-EPMC6607511 | biostudies-literature
Project description:BackgroundThis study aimed to evaluate the clinical safety of delayed antibiotic prescribing for upper respiratory tract infections (URTIs), which is recommended in treatment guidelines for less severe cases.MethodsTwo population-based cohort studies used the English Clinical Practice Research Databank and Welsh Secure Anonymized Information Linkage, containing electronic health records from primary care linked to hospital admission records. Patients with URTI and prescriptions of amoxicillin, clarithromycin, doxycycline, erythromycin, or phenoxymethylpenicillin were identified. Patients were stratified according to delayed and immediate prescribing relative to URTI diagnosis. Outcome of interest was infection-related hospital admission after 30 days.ResultsThe population included 1.82 million patients with an URTI and antibiotic prescription; 91.7% had an antibiotic at URTI diagnosis date (immediate) and 8.3% had URTI diagnosis in 1-30 days before (delayed). Delayed antibiotic prescribing was associated with a 52% increased risk of infection-related hospital admissions (adjusted hazard ratio, 1.52; 95% confidence interval, 1.43-1.62). The probability of delayed antibiotic prescribing was unrelated to predicted risks of hospital admission. Analyses of the number needed to harm showed considerable variability across different patient groups (median with delayed antibiotic prescribing, 1357; 2.5% percentile, 295; 97.5% percentile, 3366).ConclusionsThis is the first large population-based study examining the safety of delayed antibiotic prescribing. Waiting to treat URTI was associated with increased risk of hospital admission, although delayed antibiotic prescribing was used similarly between high- and low-risk patients. There is a need to better target delayed antibiotic prescribing to URTI patients with lower risks of complications.
| S-EPMC8282258 | biostudies-literature
Project description:BackgroundKnowledge of key drivers for antibiotic prescribing in pediatric lower respiratory tract infection (LRTI) could support rational antibiotic use. Thus, we aimed to determine the impact of clinical and laboratory factors on antibiotic prescribing in children and adolescents with febrile LRTI.MethodsPediatric patients from the standard care control group of a randomized controlled trial (ProPAED) investigating procalcitonin guided antibiotic treatment in febrile LRTI were included in a multivariate logistic regression analysis to evaluate the impact of laboratory and clinical factors on antibiotic prescribing.ResultsThe standard care control group of the ProPAED study comprised 165 LRTI patients (median age: 2.7 years, range: 0.1-16), out of which 88 (55%) received antibiotic treatment. Factors significantly associated with antibiotic prescribing in patients with complete clinical and laboratory documentation (n = 158) were C-reactive protein (OR 5.8 for a 10-fold increase, 95%CI 2.2-14.9), white blood count beyond age-dependent reference range (OR 3.9, 95%CI 1.4-11.4), body temperature (OR 1.7 for an increase by 1°C, 95%CI 1.02-2.68), and pleuritic pain (OR 2.8, 95%CI 1.1-7.6). Dyspnea (OR 0.3, 95%CI 0.1-0.7) and wheezing (OR 0.3, 95%CI 0.13-0.95) were inversely associated with antibiotic prescribing.ConclusionLaboratory markers were strong drivers of antibiotic prescribing in children with febrile lower respiratory tract infections, in spite of their known poor prediction of antibiotic need. Building on current guidelines for antibiotic treatment in children with febrile LRTI, a reliable decision algorithm for safe antibiotic withholding considering the laboratory and clinical factors evaluated in this study has the potential to further reduce antibiotic prescribing.
| S-EPMC5619731 | biostudies-literature
Project description:IntroductionDelayed prescribing can be a useful strategy to reduce antibiotic prescribing, but it is not clear for whom delayed prescribing might be effective. This protocol outlines an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) and observational cohort studies to explore the overall effect of delayed prescribing and identify key patient characteristics that are associated with efficacy of delayed prescribing.Methods and analysisA systematic search of the databases Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus and Web of Science was conducted to identify relevant studies from inception to October 2017. Outcomes of interest include duration of illness, severity of illness, complication, reconsultation and patient satisfaction. Study authors of eligible papers will be contacted and invited to contribute raw IPD data. IPD data will be checked against published data, harmonised and aggregated to create one large IPD database. Multilevel regression will be performed to explore interaction effects between treatment allocation and patient characteristics. The economic evaluation will be conducted based on IPD from the combined trial and observational studies to estimate the differences in costs and effectiveness for delayed prescribing compared with normal practice. A decision model will be developed to assess potential savings and cost-effectiveness in terms of reduced antibiotic usage of delayed prescribing and quality-adjusted life years.Ethics and disseminationEthical approval was obtained from the University of Southampton Faculty of Medicine Research Ethics Committee (Reference number: 30068). Findings of this study will be published in peer-reviewed academic journals as well as General Practice trade journals and will be presented at national and international conferences. The results will have important public health implications, shaping the way in which antibiotics are prescribed in the future and to whom delayed prescriptions are issued.Prospero registration numberCRD42018079400.
| S-EPMC6347865 | biostudies-literature
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