scholarly journals Does diagnostic uncertainty increase antibiotic prescribing in primary care?

2021 ◽  
Vol 31 (1) ◽  
Author(s):  
Dan Wang ◽  
Chaojie Liu ◽  
Xinping Zhang ◽  
Chenxi Liu
Keyword(s):  
Primary Care ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Acute Tonsillitis ◽  
Diagnostic Uncertainty ◽  
Patient Tolerance ◽  
Prescribing Behaviour ◽  
Tolerance Of Uncertainty ◽  
Tract Infections

AbstractThis 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.

scholarly journals Knowledge, Attitudes, and Reported Practices Among Obstetrician-Gynecologists in the USA Regarding Antibiotic Prescribing for Upper Respiratory Tract Infections

2005 ◽  
Vol 13 (1) ◽  
pp. 17-24 ◽  
Author(s):  
Shadi Chamany ◽  
Jay Schulkin ◽  
Charles E. Rose ◽  
Laura E. Riley ◽  
Richard E. Besser
Keyword(s):  
Primary Care ◽  
Respiratory Tract Infections ◽  
Antibiotic Use ◽  
Upper Respiratory Tract Infections ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Office Visits ◽  
The Common ◽  
Upper Respiratory ◽  
Tract Infections

Background:Knowledge, attitudes, and practices regarding antibiotic prescribing for upper respiratory tract infections (URIs) have not been well described among obstetrician-gynecologists (OB/GYNs). This information is useful for determining whether an OB/GYN-specific program promoting appropriate antibiotic use would significantly contribute to the efforts to decrease inappropriate antibiotic use among primary care providers.Methods:An anonymous questionnaire asking about the treatment of URIs was sent to 1031 obstetrician-gynecologists.Results:The overall response rate was 46%. The majority of respondents (92%) were aware of the relationship between antibiotic use and antibiotic resistance, and respondents estimated that 5% of their patients had URI symptoms at their office visits. Overall, 56% of respondents reported that they would prescribe an antibiotic for uncomplicated bronchitis and 43% for the common cold. OB/GYNs with the fewest years of experience were less likely than those with the most years of experience to report prescribing for uncomplicated bronchitis (Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.91) or the common cold (OR 0.44, CI 0.22 to 0.89). The majority of respondents (60%) believed that most patients wanted an antibiotic for URI symptoms, with male OB/GYNs being more likely than female OB/GYNs (OR 2.1, CI 1.2 to 3.8) to hold this belief. Both male OB/GYNs (OR 1.9, CI 1.1 to 3.4) and rural practitioners (OR 2.1, CI 1.1 to 4.0) were more likely to believe that it was hard to withhold antibiotics for URI symptoms because other physicians prescribe antibiotics for these symptoms. OB/GYNs who believed that postgraduate training prepared them well for primary care management were more likely than those who did not (OR 2.1, CI 1.1 to 4.2) to believe that they could reduce antibiotic prescribing without reducing patient satisfaction.Conclusion:Multiple demographic factors affect attitudes and reported practices regarding antibiotic prescribing. However, in view of the low proportion of office visits for URIs, an OB/GYN-specific program is not warranted.

scholarly journals Immediate and delayed antibiotic prescribing strategies used by Australian early-career general practitioners.

2021 ◽  
pp. BJGP.2021.0026
Author(s):  
Andrew Davey ◽  
Amanda Tapley ◽  
Katie June Mulquiney ◽  
Mieke van Driel ◽  
Alison Fielding ◽  
...  
Keyword(s):  
Respiratory Tract ◽  
Multinomial Logistic Regression ◽  
Acute Bronchitis ◽  
Early Career ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Cross Sectional ◽  
Diagnostic Uncertainty ◽  
Prescribing Behaviour ◽  
Tract Infections

Background: Antibiotics are overused for non-pneumonia acute respiratory tract infections (ARTIs). Aim: To establish prevalence and explore associations of antibiotic prescribing strategies used by Australian early-career GPs for non-pneumonia ARTIs. Design and Setting: Cross-sectional analysis of data, September 2016 to December 2017, from the Registrar Clinical Encounters in Training cohort study. Method: Multinomial logistic regression of antibiotic prescribing (“no prescribing”, “immediate prescribing”, or “delayed prescribing”) to manage an ARTI. Results: Of 7,156 new ARTI problems, no antibiotics were prescribed for 4,892 problems (68%), antibiotics were prescribed for immediate use for 1,614 problems (23%) and delayed antibiotics were used for 650 problems (9%). “Delayed prescribing” was used in 22% of otitis media, 16% of sinusitis, 13% of sore throat, 11% of acute bronchitis/bronchiolitis, and 5% of upper respiratory tract infection (URTI). “Delayed prescribing” was used for 29% of all prescriptions written. “Delayed prescribing” and “immediate prescribing” were associated with markers of clinical concern. “Delayed prescribing” was associated with longer duration of consultation and with fewer problems dealt with in the consultation. Conclusion: Australian early-career GPs use “no prescribing” for ARTIs substantially more than established GPs, but, except for URTIs, still prescribe antibiotics in excess of validated benchmarks. They may use “delayed prescribing” more often than European GPs. They may use “delayed prescribing” to manage diagnostic uncertainty and, possibly, conflicting influences on prescribing behaviour. Consequently, the use of “delayed prescribing” may enable a transition to an environment of more rational antibiotic prescribing for ARTIs.

scholarly journals Inappropriate Azithromycin Use in Nine Primary-Care Clinics Before and After Implementation of Provider Guidance in the EMR

2020 ◽  
Vol 41 (S1) ◽  
pp. s292-s293
Author(s):  
Alexandria May ◽  
Allison Hester ◽  
Kristi Quairoli ◽  
Sheetal Kandiah
Keyword(s):  
Primary Care ◽  
Retrospective Chart Review ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
National Guidelines ◽  
Targeted Interventions ◽  
Primary Care Clinics ◽  
Before And After ◽  
Upper Respiratory ◽  
Tract Infections

Background: According to the CDC Core Elements of Outpatient Stewardship, the first step in optimizing outpatient antibiotic use the identification of high-priority conditions in which antibiotics are commonly used inappropriately. Azithromycin is a broad-spectrum antimicrobial commonly used inappropriately in clinical practice for nonspecific upper respiratory infections (URIs). In 2017, a medication use evaluation at Grady Health System (GHS) revealed that 81.4% of outpatient azithromycin prescriptions were inappropriate. In an attempt to optimize outpatient azithromycin prescribing at GHS, a tool was designed to direct the prescriber toward evidence-based therapy; it was implemented in the electronic medical record (EMR) in January 2019. Objective: We evaluated the effect of this tool on the rate of inappropriate azithromycin prescribing, with the goal of identifying where interventions to improve prescribing are most needed and to measure progress. Methods: This retrospective chart review of adult patients prescribed oral azithromycin was conducted in 9 primary care clinics at GHS between February 1, 2019, and April 30, 2019, to compare data with that already collected over a 6-month period in 2017 before implementation of the antibiotic prescribing guidance tool. The primary outcome of this study was the change in the rate of inappropriate azithromycin prescribing before and after guidance tool implementation. Appropriateness was based on GHS internal guidelines and national guidelines. Inappropriate prescriptions were classified as inappropriate indication, unnecessary prescription, excessive or insufficient treatment duration, and/or incorrect drug. Results: Of the 560 azithromycin prescriptions identified during the study period, 263 prescriptions were included in the analysis. Overall, 181 (68.8%) of azithromycin prescriptions were considered inappropriate, representing a 12.4% reduction in the primary composite outcome of inappropriate azithromycin prescriptions. Bronchitis and unspecified upper respiratory tract infections (URI) were the most common indications where azithromycin was considered inappropriate. Attending physicians prescribed more inappropriate azithromycin prescriptions (78.1%) than resident physicians (37.0%) or midlevel providers (37.0%). Also, 76% of azithromycin prescriptions from nonacademic clinics were considered inappropriate, compared with 46% from academic clinics. Conclusions: Implementation of a provider guidance tool in the EMR lead to a reduction in the percentage of inappropriate outpatient azithromycin prescriptions. Future targeted interventions and stewardship initiatives are needed to achieve the stewardship program’s goal of reducing inappropriate outpatient azithromycin prescriptions by 20% by 1 year after implementation.Funding: NoneDisclosures: None

scholarly journals Retrospective review of the management of acute infections and the indications for antibiotic prescription in primary care in northern Thailand

BMJ Open ◽  
2018 ◽  
Vol 8 (7) ◽  
pp. e022250 ◽  
Author(s):  
Rachel C Greer ◽  
Daranee Intralawan ◽  
Mavuto Mukaka ◽  
Prapass Wannapinij ◽  
Nicholas P J Day ◽  
...  
Keyword(s):  
Primary Care ◽  
Low Income ◽  
Retrospective Review ◽  
Antibiotic Prescription ◽  
Multivariable Logistic Regression Analysis ◽  
Upper Respiratory Tract ◽  
Acute Tonsillitis ◽  
Northern Thailand ◽  
Acute Infections ◽  
Tract Infections

IntroductionAntibiotic use in low-income and middle-income countries continues to rise despite the knowledge that antibiotic overuse can lead to antimicrobial resistance. There is a paucity of detailed data on the use of antibiotics in primary care in low-resource settings.ObjectiveTo describe the presentation of acute infections and the indications for antibiotic prescription.DesignA 2-year retrospective review of routinely collected data.SettingAll 32 primary care units in one district in northern Thailand.ParticipantsPatients attending primary care with a history of fever, documented temperature, International Statistical Classification of Diseases 10 code for infection or prescribed a systemic antibiotic. Patients attending after the initiation of a study on C-reactive protein testing in four centres were excluded.Outcome measuresThe proportion of patients prescribed an antibiotic and the frequency of clinical presentations.Results762 868 patients attended the health centres, of whom 103 196 met the inclusion criteria, 5966 were excluded resulting in 97 230 attendances consisting of 83 661 illness episodes.46.9% (39 242) of the patients were prescribed an antibiotic during their illness. Indications for antibiotic prescription in the multivariable logistic regression analysis included male sex (adjusted OR (aOR) 1.21 (95% CI 1.16 to 1.28), p<0.001), adults (aOR 1.77 (95% CI 1.57 to 2), p<0.001) and a temperature >37.5°C (aOR 1.24 (95% CI 1.03 to 1.48), p=0.020). 77.9% of the presentations were for respiratory-related problems, of which 98.6% were upper respiratory tract infections. The leading infection diagnoses were common cold (50%), acute pharyngitis (18.9%) and acute tonsillitis (5%) which were prescribed antibiotics in 10.5%, 88.7% and 87.1% of cases, respectively. Amoxicillin was the most commonly prescribed antibiotic.ConclusionsNearly half of the patients received an antibiotic, the majority of whom had a respiratory infection. The results can be used to plan interventions to improve the rational use of antibiotics. Further studies in private facilities, pharmacies and dental clinics are required.

scholarly journals Antibiotic prescribing quality for children in primary care: an observational study

2018 ◽  
Vol 68 (667) ◽  
pp. e90-e96 ◽  
Author(s):  
Megan Rose Williams ◽  
Giles Greene ◽  
Gurudutt Naik ◽  
Kathryn Hughes ◽  
Christopher C Butler ◽  
...  
Keyword(s):  
Primary Care ◽  
Young Children ◽  
Otitis Media ◽  
Descriptive Analysis ◽  
Inappropriate Prescribing ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Tract Infections ◽  
Disease Specific

BackgroundOveruse and inappropriate prescribing of antibiotics is driving antibiotic resistance. GPs often prescribe antibiotics for upper respiratory tract infections (URTIs) in young children despite their marginal beneficial effects.AimTo assess the quality of antibiotic prescribing for common infections in young children attending primary care and to investigate influencing factors.Design and settingAn observational, descriptive analysis, including children attending primary care sites in England and Wales.MethodThe Diagnosis of Urinary Tract infection in Young children study collected data on 7163 children aged <5 years, presenting to UK primary care with an acute illness (<28 days). Data were compared with the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) disease-specific quality indicators to assess prescribing for URTIs, tonsillitis, and otitis media, against ESAC-Net proposed standards. Non-parametric trend tests and χ2tests assessed trends and differences in prescribing by level of deprivation, site type, and demographics.ResultsPrescribing rates fell within the recommendations for URTIs but exceeded the recommended limits for tonsillitis and otitis media. The proportion of children receiving the recommended antibiotic was below standards for URTIs and tonsillitis, but within the recommended limits for otitis media. Prescribing rates increased as the level of deprivation decreased for all infections (P<0.05), and increased as the age of the child increased for URTIs and tonsillitis (P<0.05). There were no other significant trends or differences.ConclusionThe quality of antibiotic prescribing in this study was mixed and highlights the scope for future improvements. There is a need to assess further the quality of disease-specific antibiotic prescribing in UK primary care settings using data representative of routine clinical practice.

scholarly journals Results from a Patient-Based Health Education Intervention in Reducing Antibiotic Use for Acute Upper Respiratory Tract Infections in the Private Sector Primary Care Setting in Singapore

2017 ◽  
Vol 61 (5) ◽  
Author(s):  
Magdalene Hui Min Lee ◽  
Darius Shaw Teng Pan ◽  
Joyce Huixin Huang ◽  
Mark I-Cheng Chen ◽  
Joash Wen Chen Chong ◽  
...  
Keyword(s):  
Primary Care ◽  
Respiratory Tract ◽  
Respiratory Tract Infections ◽  
Care Setting ◽  
Primary Care Setting ◽  
Antibiotic Use ◽  
Upper Respiratory Tract Infections ◽  
Upper Respiratory Tract ◽  
Upper Respiratory ◽  
Tract Infections

ABSTRACT We investigated the efficacy of patient-targeted education in reducing antibiotic prescriptions for upper respiratory tract infections (URTIs) among adults in the private primary care setting in Singapore. Our randomized controlled trial enrolled patients aged 21 years and above presenting at general practitioner (GP) clinics with URTI symptoms for 7 days or less. Intervention arm patients were verbally educated via pamphlets about the etiology of URTIs, the role of antibiotics in treating URTIs, and the consequences of inappropriate antibiotic use. Control arm patients were educated on influenza vaccinations. Both arms were compared regarding the proportions prescribed antibiotics and the patients' postconsultation views. A total of 914 patients consulting 35 doctors from 24 clinics completed the study (457 in each arm). The demographics of patients in both arms were similar, and 19.1% were prescribed an antibiotic, but this varied from 0% to 70% for individual GPs. The intervention did not significantly reduce antibiotic prescriptions (odds ratio [OR], 1.20; 95% confidence interval [CI], 0.83–1.73) except in patients of Indian ethnicity (OR, 0.28; 95% CI, 0.09–0.93). Positive associations between the intervention and the view that antibiotics were not needed most of the time for URTIs (P = 0.047) and on being worried about the side effects of antibiotics (P = 0.018) were restricted to the Indian subgroup. GPs in limited liability partnerships or clinic chains prescribed less (OR, 0.36; 95% CI, 0.14 to 0.92), while certain inappropriate patient responses were associated with the receipt of antibiotics. Follow-up studies to investigate differences in responses to educational programs between ethnicities and to explore GP-targeted interventions are recommended.

scholarly journals 1135. The Effect of Penicillin Allergy Labels on Antibiotic Prescribing for Children Diagnosed with Upper Respiratory Tract Infections in Two Primary Care Networks

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S658-S659
Author(s):  
Torsten Joerger ◽  
Margaret Taylor ◽  
Debra Palazzi ◽  
Jeffrey Gerber
Keyword(s):  
Broad Spectrum ◽  
Respiratory Tract Infections ◽  
Antibiotic Use ◽  
Upper Respiratory Tract Infections ◽  
Antibiotic Prescribing ◽  
Second Line ◽  
Upper Respiratory Tract ◽  
Broad Spectrum Antibiotic ◽  
Upper Respiratory ◽  
Tract Infections

Abstract Background In pediatric inpatient settings, unconfirmed penicillin allergy labels (PALs) are associated with increased broad-spectrum antibiotic use, costs, and adverse events. However, 90% of antibiotics are prescribed in the outpatient setting and 70% of these antibiotics are given for upper respiratory tract infections (URTI.) Little is known about the effect of PALs on antibiotic prescribing in the pediatric outpatient population. Methods A retrospective birth cohort was created of children born between January 1st 2010 and June 30th 2020 and seen at one of 91 Texas Children’s Pediatrics or Children’s Hospital of Philadelphia primary care clinics. Children with an ICD10 code for an URTI and an antibiotic prescription were stratified into those with or without a penicillin allergy label at the time of the infection. Rates of second-line and broad-spectrum antibiotic use were compared. Results The birth cohort included 334,465 children followed for 1.2 million person-years. An antibiotic was prescribed for 696,782 URTIs and the most common diagnosis was acute otitis media. Children with PALs were significantly more likely to receive second-line antibiotics (OR 35.0, 95% CI 33.9-36.1) and broad-spectrum antibiotics (OR 23.9, 95% CI 23.2-24.8.) Children with PALs received more third generation cephalosporins (60% vs. 15%) and more macrolide antibiotics (25% vs. 3%) than those without a PAL. Overall, 18,015 children (5.4%) acquired a PAL during the study period, which accounted for 23% of all second-line antibiotic prescriptions and 17% of all broad-spectrum antibiotic use for URTIs. Multivariable logistic regression for receipt of second-line antibiotics for upper respiratory tract infections Conclusion PALs are common and account for a substantial proportion of second-line and broad-spectrum antibiotic use in pediatric outpatients treated for URTIs. Efforts to de-label children with PALs are likely to increase first-line antibiotic use and decrease broad-spectrum antibiotic use for URTIs, the most common indication for antibiotic prescribing to children. Disclosures Debra Palazzi, MD, MEd, AAP (Other Financial or Material Support, PREP ID Editorial Board, PREP ID Course)AHRQ (Research Grant or Support)Elsevier (Other Financial or Material Support, Royalties for writing and editing chapters)JAMA Pediatrics (Board Member)

scholarly journals Patient Factors in Inappropriate Antibiotic Prescribing for Upper Respiratory Tract Infection in the Emergency Department

2021 ◽  
Vol 28 (2) ◽  
pp. 72-83
Author(s):  
Azmi Ahmad ◽  
Junainah Nor ◽  
Ariff Arithra Abdullah ◽  
Tuan Hairulnizam Tuan Kamauzaman ◽  
Mohd Boniami Yazid
Keyword(s):  
Respiratory Tract ◽  
High Rate ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Patient Factors ◽  
Acute Tonsillitis ◽  
Cross Sectional ◽  
Duration Of Symptoms ◽  
Upper Respiratory ◽  
Tract Infections

Background: Emergency departments (EDs) are frequently misused for non-emergency cases such as upper respiratory tract infections (URTIs). Flooding of these cases may contribute to inappropriate antibiotic prescribing. The aim of this study was to determine the patient factors associated with inappropriate antibiotic prescribing for URTIs in the EDs. Methods: This cross-sectional study involved patients over age 3 years old who presented with URTI to the green zone of the ED of a tertiary hospital on the east coast of Malaysia in 2018– 2019. Convenient sampling was done. The patients were categorised into two groups according to their McIsaac scores: positive (≥ 2) or negative (< 2). Antibiotics given to the negative McIsaac group were considered inappropriate. Results: A total of 261 cases were included — 127 with positive and 134 with negative McIsaac scores. The most common symptoms were fever and cough. About 29% had inappropriate antibiotic prescribing with a high rate for amoxycillin. Duration of symptoms of one day or less (OR 18.5; 95% CI: 1.65, 207.10; P = 0.018), presence of chills (OR 4.36; 95% CI: 1.13, 16.88; P = 0.033) and diagnosis of acute tonsillitis (OR 5.26; 95% CI: 1.76, 15.72; P = 0.003) were significantly associated with inappropriate antibiotic prescription. Conclusion: Factors influencing inappropriate antibiotic prescribing should be pointed out to emergency doctors to reduce its incidence.

scholarly journals 1118. Trends of Paediatric Prescribing for Common Infections in British Columbia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S397-S397
Author(s):  
Ariana Saatchi ◽  
David M Patrick ◽  
James McCormack ◽  
Andrew Morris ◽  
Fawziah Marra
Keyword(s):  
Urinary Tract ◽  
Respiratory Tract ◽  
Urinary Tract Infections ◽  
Respiratory Tract Infections ◽  
Antibiotic Use ◽  
Pediatric Care ◽  
Antibiotic Prescribing ◽  
Upper Respiratory Tract ◽  
Upper Respiratory ◽  
Tract Infections

Abstract Background Antibiotic prescribing in pediatric care is highly prevalent, and quite often children are prescribed for conditions which are commonly self-limiting and viral in etiology. The purpose of this study was to examine the scope of pediatric antibiotic prescribing by indication, from 2013 to 2016, and identify potential new targets for provincial antimicrobial stewardship efforts. Methods Antibiotic prescription data for children were extracted from a provincial prescription database, and linked to physician billing data in order to obtain diagnostic information. Prescription rates were then calculated, and trends were examined by indication. Major categories included: upper respiratory tract infection, acute otitis media, lower respiratory tract, skin and soft tissue, and urinary tract infections. Results Our database included an average of 244,763 children per year, and 5,896,173 total antibiotic prescriptions. Increased indication-specific rates of prescribing were observed in children aged 0–2 years, for every category. Children aged 3–18 years experienced decreased prescribing across all indications, with the exception of urinary tract infections for those aged between 10–18 years. Urinary tract infections increased by 134% for children aged 0–2 years, and 75% for those aged 10–18 years, from 2013 to 2016. Although antibiotic use for upper respiratory tract infections decreased by 11% for all ages, these diagnoses continue to be prescribed for at rates 2 – 5 times higher than other conditions. Conclusion Although this study found a decrease in prescribing over time across all indications, antibiotic use continues to be a concern for upper respiratory tract infections in pediatric care. These diagnoses generally do not require antibiotics, and inappropriate prescribing is a major factor in antimicrobial resistance. The increased prescribing rates in the youngest age group (0–2 years) offers a new target for provincial stewardship efforts. Disclosures All authors: No reported disclosures.

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