A critical assessment of published guidelines and other decision-support systems for the antibiotic treatment of community-acquired respiratory tract infections

Guidelines are an important means by which professional associations and governments have sought to improve the quality and cost-effectiveness of disease management for infectious diseases. Prescribing of initial antibiotic therapy for community-acquired respiratory tract infections (RTIs) is primarily empiric and physicians may often have a limited appreciation of bacterial resistance. Recent guidelines for managing RTIs have adopted a more evidence-based approach. This process has highlighted important gaps in the existing knowledge base, e.g. concerning the impact of resistance on the effectiveness of oral antibiotics for outpatient community-acquired pneumonia and the level of resistance that should prompt a change in empiric prescribing. In upper RTIs, the challenge is to identify patients in whom antibiotic therapy is warranted. Concentrated, sustained efforts are needed to secure physicians' use of guidelines. The information should be distilled into a simple format available at the point of prescribing and supported by other behavioral change techniques (e.g. educational outreach visits). Advances in information technology offer the promise of more dynamic, computer-assisted forms of guidance. Thus, RTI prescribing guidelines and other prescribing support systems should help control bacterial resistance in the community. However, their effect on resistance patterns is largely unknown and there is an urgent need for collaborative research in this area. Rapid, cost-effective diagnostic techniques are also required and new antibiotics will continue to have a role in disease management.     

Challenges of and strategies for changing prescribing practices of health care providers

Problems related to inappropriate prescribing practices of physicians in general are well recognized. Dietary fluoride supplements have been implicated as one of the contributing factors in an increase in dental fluorosis. Inappropriate prescribing practices of providers have been cited as a major factor in this implication. Numerous studies of physicians and dentists have documented a lack of knowledge and inappropriate prescribing practices regarding fluoride supplements. The purpose of this paper is to identify barriers to changing fluoride-prescribing practices of health care providers and to suggest strategies for implementing change. To increase optimal and appropriate use of fluoride supplements, educational interventions are necessary for all user groups--detail men and women, physicians, dentists, pharmacists, nurse practitioners, dental hygienists, and the public. In addition, environmental supports for the educational activities in the form of policy, regulation, standards of care, and guidelines are recommended for consideration.     

Developing rational protocols for paediatric psychopharmacological prescribing.

The number of child psychiatrists, paediatricians and general practitioners prescribing psychotropic medication for children in the UK is increasing. Medication is being used not just to treat children of normal intelligence with hyperkinetic disorder or depression, but also to modify behavioural problems in children with developmental disorders and severe learning difficulties. Literature reviews highlight the lack of robust randomized controlled drug trials on which to base clinical practice and the authors have found no appropriate existing protocols to help develop a systematized approach. Against such a background the authors have developed a comprehensive set of protocols covering prescribing details for individual drugs, and also addressing issues such as informed consent, long-term monitoring and school liaison. All children referred to the authors' clinics go through a standardized decision-making process. This article describes both the protocols themselves and the philosophies that guided their development. The authors describe how such a system benefits the children, their families, general practitioners and schools, whilst also facilitating audit and research.     

Development and Face Validity of Explicit indicators of Appropriateness of Long Term Prescribing

Objectives: To develop a set of explicit and operationalisable indicators of appropriate prescribing and assess their face validity using clinical pharmacists practising in secondary and primary care. Method: Appropriateness indicators were derived from the literature, applied to data in the hospital clinical records of all newly prescribed long-term drugs for 50 randomly selected patients, further refined and then applied to another 25 randomly selected patients. A pre-piloted postal questionnaire was sent to 200 hospitals and primary care pharmacists, asking them to assess the indicators as to their importance for the assessment of appropriateness of long-term prescribing initiated in hospitals. Results: Fourteen indicators were developed and piloted. Of the 16 original indicators, 5 were discarded, as they were unable to be operationalised, and 2 were subdivided to reflect the routinely available data. Eighty-six pharmacists with individual patient-focussed clinical duties took part in the assessment of the face validity (response rate 43%). Eleven indicators achieved a median importance rating of 1 (very important), and three indicators a median importance rating of 2 on a 5-point scale. The three most important indicators overall were ‘indication included in discharge summary’, ‘questionable high-risk therapeutic combination’ and ‘hazardous drug-drug combination’. Conclusion: It was possible to develop and operationalise 14 indicators of the appropriateness of long-term prescribing commenced in hospital practice, all of which were considered to have face validity by an expert panel of clinical pharmacists. The development of these explicit indicators highlighted the incompleteness of the patient’s record. Further work is needed to assess their validity and reliability, before their use in research or audit can be recommended.