The use of CRP tests in patients with respiratory tract infections in primary care in Sweden can be questioned

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1 week in November in 2000 and 2002 respectively. As a part of the study, the use and results of C-reactive protein (CRP) tests in relation to duration of symptoms and antibiotic prescribing in 6778 patients assigned a diagnosis of respiratory tract infections were analysed. In almost half (42%) of the patients, a CRP test was performed. The majority of CRP tests (69%) were performed in patients assigned diagnosis upper respiratory tract infection, where the test is not recommended. Overall, there was a minor decrease in antibiotic prescribing when CRP was used (41%), in comparison to 44% of the patients where no CRP was performed (p < 0.01). Patients assigned diagnoses implying a bacterial aetiology were prescribed antibiotics irrespective of result of CRP or length of symptoms before consultation. For patients assigned viral diagnoses, antibiotic prescribing increased with increasing duration of symptoms and increasing value of CRP. The use of CRP decreased antibiotic prescribing in patients assigned to viral diagnoses and with longstanding symptoms (p < 0.001). However, 59% of the patients assigned viral diagnoses with CRP > or = 25 received antibiotics, which seems to indicate a misinterpretation of CRP and a non-optimal use of antibiotics.     

Management of urinary tract infections in primary care: a repeated 1-week diagnosis-prescribing study in five counties in Sweden in 2000 and 2002

A diagnosis-antibiotic prescribing study was performed in 5 counties in Sweden during 1 week in November in the y 2000 and 2002, respectively. As part of the study, the characteristics and clinical management of patients who received diagnoses of urinary tract infections (UTIs) (n = 1564) in primary care, were analysed. 85% of the visits were by women, and 74% of all consultations were diagnosed as lower UTIs. One or more diagnostic tests were performed in 98% of the women with suspected lower or recurrent UTIs and 95% were prescribed an antibiotic. The most commonly prescribed antibiotics for lower UTIs were trimethoprim followed by pivmecillinam and a quinolone. The study indicated a change in antibiotic prescribing with improved adherence to the national recommendations. There was an increase of prescribed nitrofurantoin and a decrease of prescribed quinolones to women with lower UTIs between the studied y. Furthermore, 3-d treatment with trimethoprim increased although the prescribed duration was mostly 7 d. In contrast to the guidelines, few urine cultures were performed. The study highlights the necessity of updating the guidelines for the management of lower UTIs in general practice.     

Upper respiratory tract infections in general practice: diagnosis,antibiotic prescribing,duration of symptoms and use of diagnostic tests

A diagnosis/antibiotic prescribing study was performed in 5 counties in Sweden for 1 week in November 2000. As part of this study, the characteristics and clinical management of patients with upper respiratory tract infections (n = 2899) in primary care were analyzed. Almost half of the patients were aged < 15 y and one-fifth of the patients consulted out of hours. Of all patients seeking primary care for upper respiratory tract infections, 56.0% were prescribed an antibiotic. Almost all patients who were given the diagnoses streptococcal tonsillitis, acute otitis media or acute sinusitis were prescribed antibiotics, compared to 10% of patients with common cold or acute pharyngitis. The most frequently prescribed antibiotic was penicillin V (79.2%) and this was even more pronounced out of hours, when the diagnoses otitis media and streptococcal tonsillitis were more frequently used. In patients with common cold and acute pharyngitis, the percentage who received antibiotics increased with increasing length of symptoms and increasing CRP levels. In patients with acute pharyngitis or streptococcal tonsillitis, antibiotics were prescribed less frequently provided streptococcal tests were performed. The management of patients with upper respiratory tract infections in general practice seems to be in good agreement with current Swedish guidelines. However, the study indicates some areas for improvement. The diagnosis of acute sinusitis seems to have been overestimated and used only to justify antibiotic treatment.     

Antibiotic prescribing and penicillin-resistant pneumococci in a Merseyside Health District

OBJECTIVES: To measure the effects of antibiotic prescribing changes in the community on the prevalence of penicillin-resistant pneumococci. METHODS: Penicillin-resistant pneumococci were isolated from clinical samples taken from 549 patients between January 1987 and December 2000. Changes in the percentage of penicillin-resistant pneumococci isolated over the 14-year period and changes in prescribing practices were determined. RESULTS: Between January 1987 and December 2000, the prevalence of penicillin resistant pneumococci increased from 1.4% to a peak of 12.9% in 1997, subsequently falling to 8.9% after changes in antibiotic prescribing practices in the community.Over 65% of isolates were community acquired with 53% of patients having received antibiotics in the 3 months prior to their first isolate. Thirteen patients had a history of recent travel abroad. CONCLUSION: Reduction in antibiotic prescribing in general practice was followed by a reduction in the prevalence of penicillin-resistant pneumococci.     

Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics

The use of antibiotics in both ambulatory and inpatient settings is heavily shaped by cultural and economic factors as well as by microbiological considerations. These nonpharmacologic factors are relevant to clinicians and policymakers because of the clinical and fiscal toll of inappropriate antibiotic prescribing, including excessive use, preventable adverse effects, and the increasing prevalence of resistant organisms. An understanding of the determinants of antibiotic consumption is critical to explain current patterns of use and to devise programs to reduce inappropriate use. Patient motivations include the desire for a tangible product of the clinical encounter coupled with incorrect perceptions of the effectiveness of antibiotics, particularly in viral infections. Physician behavior can be explained by such factors as lack of information, a desire to satisfy patient demand, and pressure from managed care organizations to speed throughput. Marketing campaigns directed at both physicians and patients further serve to increase demand, especially for newer, costlier products. Studies of antibiotic use patterns in inpatient and outpatient care consistently demonstrate considerable inappropriate prescribing, which is likely to exacerbate the emergence of resistant organisms. Several approaches have been shown to improve the rationality of antibiotic use. Computer-based algorithms or reminders can prompt physicians to improve antibiotic choices at the time of prescribing; paper-based order entry forms can achieve the same goal. Interactive educational outreach ("academic detailing") is a practical implementation of social marketing principles to improve antibiotic use. Public education programs directed at consumers can help to reduce the inappropriate patient demand that helps to drive much improper antibiotic prescribing.     

Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections

OBJECTIVE: Prior studies have shown that 60% to 75% of adults with upper respiratory tract infections want antibiotics. More recent research indicates declines in antibiotic prescribing for upper respiratory tract infections. To investigate whether there has been a comparable decrease in patients' desire for antibiotics, we measured the proportion of adults with upper respiratory tract infections who wanted antibiotics in the winter of 2001-2002. We also sought to identify factors independently associated with wanting antibiotics and antibiotic prescribing. DESIGN: Prospective survey of adults with upper respiratory tract infections prior to visiting an acute care clinic from November 2001 to February 2002. MEASUREMENTS AND MAIN RESULTS: Thirty-nine percent of 310 patients wanted antibiotics. Many patients wanted relief from symptoms (43%) or pain (24%) and many patients expected to receive a diagnosis (49%) or reassurance during the visit (13%). In multivariable modeling, independent predictors of wanting antibiotics were prior antibiotic use (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.7) and current smoking (OR, 3.1; 95% CI, 1.3 to 7.3). Physicians prescribed antibiotics to 46% of patients who wanted antibiotics and 29% of patients who did not want antibiotics (P=.01). In multivariable modeling, wanting antibiotics was an independent predictor of antibiotic prescribing (OR, 2.1; 95% CI, 1.1 to 4.4). CONCLUSIONS: Only 39% of adults seeking care for upper respiratory tract infections wanted antibiotics, less than in previous studies. In continuing efforts to break the cycle of inappropriate antibiotic use, physicians should not assume that most patients with upper respiratory tract infections want antibiotics.     

Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments

STUDY OBJECTIVE: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. METHODS: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. RESULTS: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43; 95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32; 95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. CONCLUSION: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of antibiotic resistance.     

Results of a Local Antibiotic Management Program on Antibiotic Use in a Tertiary Intensive Care Unit in Hungary

Background  Massive antibiotic use in intensive care units (ICU) is associated with increased microbial resistance. Therefore avoiding unneccesary antibiotic usage is essential. To achieve a more considered antibiotic prescribing practice, a new antibiotic policy was implemented at our ICU. In this paper, we evaluated the impact of this intervention, and described the aetiology and incidence of blood stream infections and selected antibiotic-resistant pathogens. Materials and Methods  In November 2002, a local antibiotic management program (LAMP) was implemented. This included a new infectious diseases specialist consultation service and restricted authorisation to prescribe antibiotics. The effect on ward-level antibiotic use was examined by segmented regression analysis. Patient, ICU and microbiology data were also recorded and compared before and after policy implementation. Results  The patient populations and the subsequent mortality rate were comparable before and after the implementation of the policy. Total antibiotic consumption was markedly reduced from 162.9 to 101.3 defined daily dose (DDD) per 100 patients, and per day (DDD per 100 patient-days). This was mainly accounted for a reduction in the use of quinolones, aminoglycosides, glycopeptides, metronidazol, carbepenems and third generation cephalosporins. Conclusion  This study has confirmed that establishing a targeted LAMP, based on close co-operation between intensive care physicians and infectious disease specialists together with a restricted prescribing authority, can reduce the use of antibiotics.     

Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study

BACKGROUND

Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).

OBJECTIVE

To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.

DESIGN

A two-phase, 27-month demonstration project.

SETTING

Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).

PARTICIPANTS

Thirty-nine providers were included in the project.

INTERVENTION

A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.

MAIN OUTCOME MEASURES

1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.

KEY RESULTS

The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57 % [95 % CI, ?5.35 %, 8.49 %] in adults and ?1.89 % [95 % CI, ?9.03 %, 5.26 %] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, ?16.30 %, [95 % CI, ?24.81 %, ?7.79 %] in adults and ?16.30 [95%CI, ?23.29 %, ?9.31 %] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.

CONCLUSIONS

This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.     

Antibiotics and paediatric acute respiratory infections in rural Vietnam: health-care providers' knowledge, practical competence and reported practice

Objective  To assess knowledge, practical competence and reported practices among health-care providers about antibiotics to treat acute respiratory infections in children under five in rural Vietnam.
Method  Health-care providers prescribing or dispensing western drugs for children self-completed a structured questionnaire. Recommendations concerning antibiotic use from WHO and national guidelines were used to assess the appropriateness of reported treatment of acute respiratory infections.
Results  Ninety-six per cent of 409 eligible health care providers participated. Only 27% demonstrated correct knowledge regarding the consequences of resistance. Seventy-nine per cent would use antibiotics for common colds with fever, and 21% in cases with no fever. Nineteen per cent had overall knowledge compliant with recommended guidelines. Stated antibiotic use in written scenarios for common colds (81%) was not significantly different from that for non-referral cases of pneumonia (87%). The proportion of antibiotic use in the common cold scenario was significantly lower among health-care providers who had the correct overall knowledge. According to reported symptoms from the most recent encounter with a sick child, the diseases seen were 62% mild acute respiratory infections, 19% severe, and 19% non-respiratory infections. Among those, antibiotics, most commonly beta-lactams, were used in 90%, 87% and 78% of cases, respectively.
Conclusions  Antibiotics are often prescribed or dispensed to treat common colds. Interventions to change prescribing and dispensing practices should be developed and implemented in collaboration with local and national paediatricians. Continuous training of health-care providers, particularly drug sellers, is important.     

Community-acquired pneumonia mortality: a potential link to antibiotic prescribing trends in general practice

BACKGROUND: Community prescribing of antibiotics has decreased substantially in the UK in recent years. We examine the association between pneumonia mortality and recent changes in community-based antibiotic prescribing for lower respiratory tract infections (LRTI). METHODS: Retrospective analysis of aggregated data for pneumonia mortality, influenza incidence, and antibiotic prescribing for LRTI in England and Wales during 12-week winter periods between 1993/94 and 1999/2000. RESULTS: Winter antibiotic prescribing for LRTI showed a 30.0% decline since 1995/96. Over the same period, there was a 50.6% increase in winter excess pneumonia mortality adjusted for influenza incidence. Negative binomial regression analysis showed that the incidence of influenza alone had a significant association with winter pneumonia mortality (P<0.001). The analysis also showed the reduction in antibiotic prescribing had a small but significant association with mortality (P<0.001), when simultaneously modelling for influenza incidence. CONCLUSIONS: Our findings suggest an association between recent reductions in antibiotic prescribing for LRTI in general practice and an increase in pneumonia mortality in England and Wales. This retrospective study of aggregate data represents the first attempt to assess the effect of limiting antibiotic prescribing on patient outcomes, and highlights the need to identify which patients benefit from antibiotic treatment for LRTI.     

Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital

A point-prevalence study at a tertiary Australian hospital found 199 of 462 inpatients (43%) to be receiving antibiotic therapy. Forty-seven per cent of antibiotic use was discordant with guidelines or microbiological results and hence considered inappropriate. Risk factors for inappropriate antibiotic prescribing included bone/joint infections, the absence of infection, creatinine level >120 μmol/L, carbapenem or macrolide use and being under the care of the aged care/rehabilitation team. In the setting of finite antimicrobial stewardship resources, identification of local determinants for inappropriate antibiotic use may enable more targeted interventions.