Deprescribing in advanced illness

Patients with advanced illness such as cancer, chronic obstructive pulmonary disease, and Parkinson's disease experience acute symptoms and are usually prescribed medications to manage these, alongside drugs to treat other co-morbid, long-term conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Previous studies have revealed the prevalence of potentially inappropriate prescribing within this group of patients, and identified the need for attention to ‘deprescribing’. Deprescribing can be defined as a process of optimization of medication regimens through cessation of potentially inappropriate or unnecessary medications. Patients usually have reservations about taking medications and may be willing to discontinue one or more medications considered ‘inappropriate’. Similarly, healthcare professionals experience some challenges discussing deprescribing approaches to patients with advanced illness. This article reviews research on prescribing medicines to patients with advanced illness, focusing on the identification of the prevalence of inappropriate or unnecessary medicines to the initiation of the deprescribing process. The review demonstrates the paramount importance of further research exploring the perspective of healthcare professionals and patients on the subject of deprescribing to facilitate its further acceptance in practice.     

Antibiotic Stewardship through the EU Project "ABS International"

The increasing problem of antimicrobial resistance requires implementation of antibiotic stewardship (ABS) programs. The project "ABS International--implementing antibiotic strategies for appropriate use of antibiotics in hospitals in member states of the European Union" was started in September 2006 in Austria, Belgium, the Czech Republic, Germany, Hungary, Italy, Poland, Slovenia and Slovakia. A training program for national ABS trainers was prepared and standard templates for ABS tools (antibiotic list, guides for antibiotic treatment and surgical prophylaxis, antibiotic-related organization) and valid process measures, as well as quality indicators for antibiotic use were developed. Specific ABS tools are being implemented in up to five healthcare facilities in each country. Although ABS International clearly focuses on healthcare institutions, future antimicrobial stewardship programs must also cover public education and antibiotic prescribing in primary care.     

Defining antimicrobial stewardship competencies for undergraduate health professional education in the United Kingdom: A study protocol

Multi-drug resistant infections have been identified as one of the greatest threats to human health. Healthcare professionals are involved in an array of patient care activities for which an understanding of antimicrobial stewardship is important. Although antimicrobial prescribing and stewardship competencies have been developed for healthcare professionals who adopt the role of a prescriber, competencies do not exist for other medicine-related stewardship activities. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities. This report presents a protocol for a study designed to provide national consensus on antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education. A modified Delphi process will be used in which a panel of Experts, comprising members from across the United Kingdom, with expertise in prescribing and medicines management with regard to the education and practice of healthcare professionals, and antimicrobial prescribing and stewardship, will be invited to take part in two survey rounds. The competencies developed will be applicable to all undergraduate healthcare professional education programmes. They will help to standardise curricula content and enhance the impact of antimicrobial stewardship education.     

The Impact of Antibiotic Stewardship Programs in Combating Quinolone Resistance: A Systematic Review and Recommendations for More Efficient Interventions

Quinolones are among the most commonly prescribed antibiotics worldwide. A clear relationship has been demonstrated between excessive quinolone use and the steady increase in the incidence of quinolone-resistant bacterial pathogens, both in hospital and community sites. In addition, exposure to quinolones has been associated with colonization and infection with healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus and Clostridium difficile in hospitalized patients. Therefore, the management of quinolone prescribing in hospitals through antibiotic stewardship programs is considered crucial. Although suggestions have been made by previous studies on the positive impact of stewardship programs concerning the emergence and spread of multidrug-resistant bacteria at hospital level, the association of quinolone-targeted interventions with reduction of quinolone resistance is vague. The purpose of this article was to evaluate the impact of stewardship interventions on quinolone resistance rates and healthcare-associated infections, through a literature review using systematic methods to identify and select the appropriate studies. Recommendations for improvements in quinolone-targeted stewardship programs are also proposed. Efforts in battling quinolone resistance should combine various interventions such as restriction formulary policies, prospective audits with feedback to prescribers, infection prevention and control measures, prompt detection of low-level resistance, educational programs, and guidelines for optimal quinolone usage. However, the effectiveness of such strategies should be assessed by properly designed and conducted clinical trials. Finally, novel approaches in diagnostic stewardship for rapidly detecting bacterial resistance, including PCR-based techniques, mass spectrometry, microarrays, and whole-genome sequencing as well as the prompt investigation on the clonality of quinolone-resistant strains, will strengthen our ability to personalize quinolone prescribing to individual patients.     

Use of computerized decision support systems to improve antibiotic prescribing

This decade will see the emergence of the electronic medical record, electronic prescribing and computerized decision support in the hospital setting. Current opinion from key infectious diseases bodies supports the use of computerized decision support systems as potentially useful tools in antibiotic stewardship programs. However, although antibiotic decision support systems appear beneficial for improving the quality of prescribing and reducing the costs of antibiotic prescribing, their overall cost-effectiveness, impact on patient outcome and antimicrobial resistance is much less certain. This review describes computerized decision support systems used to assist with antibiotic prescribing, the evidence for their effectiveness and the current and future roles.     

Use of computerized decision support systems to improve antibiotic prescribing

This decade will see the emergence of the electronic medical record, electronic prescribing and computerized decision support in the hospital setting. Current opinion from key infectious diseases bodies supports the use of computerized decision support systems as potentially useful tools in antibiotic stewardship programs. However, although antibiotic decision support systems appear beneficial for improving the quality of prescribing and reducing the costs of antibiotic prescribing, their overall cost–effectiveness, impact on patient outcome and antimicrobial resistance is much less certain. This review describes computerized decision support systems used to assist with antibiotic prescribing, the evidence for their effectiveness and the current and future roles.     

A Quality Improvement Initiative to Improve Antibiotic Stewardship at a Federally Qualified Health Center

The development of antibiotic resistance is a growing public health concern. Antibiotic stewardship programs (ASPs) employ strategies to improve antibiotic prescribing practices. The purpose of this quality improvement project was to pilot an ASP with a focus on the management of sinusitis and pharyngitis. Antibiotic prescribing practices were evaluated before and after the implementation of the pilot ASP. The primary aim of this project was to improve the concordance of antibiotic prescribing practices with clinical practice guidelines. Although not statistically significant, it was noted that there was an improvement in adherence to clinical practice guidelines after the pilot ASP was implemented.     

Predictors of physician prescribing change in an educational experiment to improve medication use

In analyzing a university-based program to educate physicians about proper medication use, we sought to measure whether physician background characteristics and the quality or number of educational exposures influenced the rate of relinquishment of inappropriate prescribing. A sample of 435 doctors was randomized to control and experimental groups; interventions consisted of printed educational materials and face-to-face visits by clinical pharmacists. The program sought to reduce inappropriate use of three drug categories: propoxyphene, peripheral/cerebral vasodilators, and cephalexin. Outcome data included the total volume (tablets/capsules) of these drugs prescribed through Medicaid by each study physician 9 months before and after the program. We estimated average changes in prescribing levels by experimental and control physicians within each physician subgroup (e.g., board-certified versus uncertified), adjusting for prescribing level in the same 9 months of the previous year. The results indicated that the rate of prescribing change was independent of most physician background characteristics studied, including age, board certification, specialty, rural versus urban practice, intensity of previous target drug use, and size of Medicaid practice. Experimental effects were highly significant (-9% to -20%, P less than 0.025) in 11 of 14 physician subgroups. The presence of a follow-up reinforcement visit was a strong independent predictor of prescribing change (P less than 0.05). An increase from one visit to two visits was associated with an approximate doubling of the size of the program effect. However, total exposure time was not related to changes in prescribing behavior. These findings document that face to face education can be effective in improving the prescribing practices of a wide variety of physicians, and that brevity, repetition, and reinforcement of recommended practices are important components in the design of such programs.     

Evidence of Antimicrobial Stewardship in the Treatment of Uncomplicated Urinary Tract Infection

Urinary tract infections (UTIs) are a common and costly cause of morbidity. International research shows practice does not align with Infectious Disease Society Association guidelines, with prescribing concordance rates near 40%. This multidisciplinary quality improvement project evaluated the effectiveness of an evidence-based UTI diagnostic and treatment algorithm and provider education to improve prescribing concordance. After implementation of diagnostic and treatment algorithms and provider education prescribing concordance and antimicrobial stewardship as well as provider confidence was significantly improved.     

The incidence and factors of inappropriate rapid antigen test usage for group A streptococcus

IntroductionAlthough rapid antigen tests (RADTs) for group A streptococcus (GAS) can help diagnose group A streptococcal pharyngitis, little is known about the inappropriate use of these RADTs.MethodsThis retrospective observational study compared the appropriate vs. inappropriate use of RADTs in patients who had a RADT between January 2019 and August 2022. RADTs for patients with a low Centor score of 0–1 point were deemed inappropriate.ResultsOf the 1015 patients, 380 (37.4%) had inappropriate RADTs. Patients with asthma were associated with an increased risk of inappropriate testing. In contrast, during the coronavirus 2019 pandemic, outpatients and residents were associated with a reduced risk of inappropriate testing. Consequent to the inappropriate use of RADTs, 162 (16.0%) patients received potentially inappropriate antibiotics.ConclusionsOur results suggest that diagnostic stewardship for pharyngitis, including education for healthcare workers, is needed to reduce inappropriate test ordering and prevent unnecessary care.     

The responsible use of the clinical laboratory

Concern about spiralling health care costs is leading to a reexamination of the use of the clinical laboratory and other diagnostic technologies in patient care. Laboratory resources are viewed as limited and their use must be measured to meet real needs. Several observers have noted significant overutilization and inappropriate utilization of laboratory services by patient care physicians, especially at teaching hospitals. Efforts to modify physician behavior by use of educational programs, positive incentives and similar means have been largely disappointing. Several laboratory-based initiatives aimed at bringing about more responsible use of the laboratory are discussed. Improved education in the judicious use of the laboratory, beginning in medical school and carrying on through the early stages of a physician's career, is considered the most promising long-term approach. This, along with improved communication between the laboratory and the clinic, is the avenue most likely to bring about more responsible use of the clinical laboratory in health care.     

Antimicrobial stewardship: concepts and strategies in the 21st century

Large worldwide surveillance studies report that resistance to nearly all classes of antimicrobial is increasing, as is the emergence of what have been termed pan-drug–resistant and extremely drug-resistant pathogens. Concomitantly, bacterial binding sites have been exploited by available antimicrobials, and there has been a decline in the development of antimicrobials using novel mechanisms of action. These trends have prompted healthcare facilities to adopt antimicrobial stewardship programs (ASPs) and infection control programs (ICPs) to monitor antimicrobial use while simultaneously optimizing treatment, outcome, and cost. This article outlines the development of an effective ASP and the key components and operating principles, and also provides insight into the production of materials that will facilitate the execution of these programs at healthcare facilities. In this discussion, education of healthcare providers is emphasized, and a rationale is provided with regard to the health, safety, and financial benefits that can be obtained from an ASP. A brief history of antimicrobial stewardship is included, providing the context for several studies of antimicrobial stewardship practice, which are also reviewed. Programs for optimal use are illustrated, including a prospective audit and feedback strategy and preauthorization procedure. The components of an effective ASP are described in depth, drawing examples from the literature, as well as from the author's personal experience at the Maine Medical Center, Portland, ME.     

Application of antimicrobial stewardship to optimise management of community acquired pneumonia

The aim of this study was to review the application of antimicrobial stewardship principles to the management of community-acquired pneumonia (CAP). Data from 14 published clinical studies, meta-analyses and practice guidelines regarding the application of antimicrobial stewardship strategies to the management of CAP were identified and analysed. In the context of CAP, application of stewardship strategies (alone or in combination) has been shown to increase physician awareness of guidelines, improve appropriate antimicrobial use and reduce unnecessary antimicrobial prescribing. In addition, application has had a profound favourable impact on patient outcomes, including decreased 30-day mortality and in-hospital mortality rates, reduced length of hospital stay, reduced treatment failure rates and reduced healthcare costs. Antimicrobial stewardship programmes have been demonstrated to successfully increase the level of appropriate antibiotic prescribing, reduce pathogen resistance and improve clinical outcomes in the management of CAP within hospitals. Studies have also shown that adherence to evidence-based guidelines, even at the level of the individual clinician, can have a profound and positive impact on patient outcomes and healthcare costs. Adherence to evidence-based guidelines can have a profound and positive impact on patient outcomes and healthcare costs.     

Inappropriate prescribing for the elderly: beers criteria-based review

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings. DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999. DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings. DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use. CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.