scholarly journals Adaptation of the WHO Essential Medicines List for national antibiotic stewardship policy in England: being AWaRe

2019 ◽  
Vol 74 (11) ◽  
pp. 3384-3389 ◽  
Author(s):  
Emma Budd ◽  
Emma Cramp ◽  
Mike Sharland ◽  
Kieran Hand ◽  
Philip Howard ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Antibiotic Stewardship ◽  
Expert Elicitation ◽  
Essential Medicines ◽  
Antibiotic Prescribing ◽  
Appropriate Use ◽  
Specific Index ◽  
High Level ◽  
Global Strategies ◽  
Improve Access

Abstract Objectives Appropriate use of and access to antimicrobials are key priorities of global strategies to combat antimicrobial resistance (AMR). The WHO recently classified key antibiotics into three categories (AWaRe) to improve access (Access), monitor important antibiotics (Watch) and preserve effectiveness of ‘last resort’ antibiotics (Reserve). This classification was assessed for antibiotic stewardship and quality improvement in English hospitals. Methods Using an expert elicitation exercise, antibiotics used in England but not included in the WHO AWaRe index were added to an appropriate category following a workshop consensus exercise with national experts. The methodology was tested using national antibiotic prescribing data and presented by primary and secondary care. Results In 2016, 46/108 antibiotics included within the WHO AWaRe index were routinely used in England and an additional 25 antibiotics also commonly used in England were not included in the WHO AWaRe index. WHO AWaRe-excluded and -included antibiotics were reviewed and reclassified according to the England-adapted AWaRE index with the justification by experts for each addition or alteration. Applying the England-adapted AWaRe index, Access antibiotics accounted for the majority (60.9%) of prescribing, followed by Watch (37.9%) and Reserve (0.8%); 0.4% of antibiotics remained unclassified. There was unexplained 2-fold variation in prescribing between hospitals within each AWaRe category, highlighting the potential for quality improvement. Conclusions We have adapted the WHO AWaRe index to create a specific index for England. The AWaRe index provides high-level understanding of antibiotic prescribing. Subsequent to this process the England AWaRe index is now embedded into national antibiotic stewardship policy and incentivized quality improvement schemes.

scholarly journals 91. Knowledge, Attitudes, and Practice of Antibiotic Prescribing among Nurse Practitioners

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S160-S161
Author(s):  
Siobhán Brennan ◽  
Elizabeth Walters ◽  
Sydney E Browder ◽  
Ravi Jhaveri ◽  
Zach Willis
Keyword(s):  
Quality Improvement ◽  
Nurse Practitioners ◽  
Antibiotic Stewardship ◽  
Public Health Problem ◽  
Family Satisfaction ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Important Public Health Problem ◽  
Material Support ◽  
Antibiotic Overuse

Abstract Background Antibiotic overuse (AO) in ambulatory care is an important public health problem. Nurse practitioners (NPs) account for a growing proportion of outpatient antibiotic prescriptions: 14.6% in 2016. Our objective was to assess NPs’ attitudes about antibiotic prescribing practices and knowledge and use of antibiotic prescribing guidelines (APG) in their practice. Methods We distributed a survey via email to NPs listed as licensed by the North Carolina Board of Nursing. Surveys were distributed three times; duplicate responses were not permitted. Respondents who reported not prescribing antibiotics in the outpatient setting were ineligible. Three randomly selected respondents received gift cards. Questions assessed degree type, practice type, years in practice, and attitudes about antibiotic prescribing practices antibiotic stewardship. Respondents answered four questions assessing knowledge of APG. Analyses were descriptive; scores on knowledge questions were compared using T-tests. Results Survey requests were sent to 10,094 listed NPs; there were 846 completed responses (8.4%), of which 672 respondents (79.4%) reported prescribing antibiotics in outpatient care. Of those, 595 (88.5%) treat adult patients. Most respondents agreed that AO is a problem in their state (84.5%); 41.3% agreed that it was a problem in their practice. Patient/family satisfaction was the most frequently reported driver of AO (90.1%). Most respondents agreed that national APG are appropriate (95.4%) and that quality improvement (QI) is warranted (93.4%). Respondents reported following APG always (18.5%) or more than half the time (61.0%). Respondents answered a mean of 1.89 out of 4 knowledge questions correctly, with higher scores among those reporting following APG more than half the time (1.97 vs 1.58, p< 0.0001). Overall attitudes about antibiotic prescribing, antibiotic prescribing guidelines, and acceptance of Quality Improvement. N=595. Respondents’ reported drivers of antibiotic overuse. Respondents were permitted to select more than one driver. Content question performance by self-reported guideline compliance; scores represent the number correct out of four questions. Conclusion Respondents agree that AO is a problem but place responsibility externally. Confidence in APG was high; most respondents endorsed following APG most of the time. Performance on knowledge questions suggests a need for education. Most respondents would welcome QI focused on AO, including education and personalized feedback. Similar work is needed in other regions and among other prescriber groups. The results will inform outpatient antibiotic stewardship. Disclosures Elizabeth Walters, DNP, CPNP-PC, RN, Merck (Consultant, Other Financial or Material Support, I am a trainer for the Nexplanon product.) Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial Stipend as Co-editor in Chief, Clinical Therapeutics)Seqirus (Consultant)

scholarly journals Mapping actions to improve access to medicines for mental disorders in low and middle income countries

2017 ◽  
Vol 26 (5) ◽  
pp. 481-490 ◽  
Author(s):  
C. Barbui ◽  
T. Dua ◽  
K. Kolappa ◽  
B. Saraceno ◽  
S. Saxena
Keyword(s):  
Mental Health ◽  
Mental Disorders ◽  
Essential Medicines ◽  
World Health ◽  
Evidence Based ◽  
Appropriate Use ◽  
Psychotropic Medicines ◽  
Access To Essential Medicines ◽  
Evidence Based Guidelines ◽  
Improve Access

Aims.In recent years a number of intergovernmental initiatives have been activated in order to enhance the capacity of countries to improve access to essential medicines, particularly for mental disorders. In May 2013 the 66th World Health Assembly adopted the World Health Organization (WHO) Comprehensive Mental Health Action Plan 2013–2020, which builds upon the work of WHO's Mental Health Gap Action Programme. Within this programme, evidence-based guidelines for mental disorders were developed, including recommendations on appropriate use of medicines. Subsequently, the 67th World Health Assembly adopted a resolution on access to essential medicines, which urged Member States to improve national policies for the selection of essential medicines and to promote their availability, affordability and appropriate use.Methods.Following the precedent set by these important initiatives, this article presents eleven actions for improving access and appropriate use of psychotropic medicines.Results.A 4 × 4 framework mapping actions as a function of the four components of access – selection, availability, affordability and appropriate use – and across four different health care levels, three of which belong to the supply side and one to the demand side, was developed. The actions are: developing a medicine selection process; promoting information and education activities for staff and end-users; developing a medicine regulation process; implementing a reliable supply system; implementing a reliable quality-control system; developing a community-based system of mental health care and promoting help-seeking behaviours; developing international agreements on medicine affordability; developing pricing policies and a sustainable financing system; developing or adopting evidence-based guidelines; monitoring the use of psychotropic medicines; promoting training initiatives for staff and end-users on critical appraisal of scientific evidence and appropriate use of psychotropic medicines.Conclusions.Activating these actions offers an unique opportunity to address the broader issue of increasing access to treatments and care for mental disorders, as current lack of attention to mental disorders is a central barrier across all domains of the 4 × 4 access framework.

scholarly journals Interrupted Time-Series Analysis to Evaluate the Impact of a Behavioral Change Outpatient Antibiotic Stewardship Intervention

2021 ◽  
Vol 1 (S1) ◽  
pp. s15-s16
Author(s):  
Brittany Morgan ◽  
Larissa May ◽  
Haylee Bettencourt
Keyword(s):  
Quality Improvement ◽  
Antibiotic Stewardship ◽  
Respiratory Infections ◽  
Inappropriate Prescribing ◽  
The United States ◽  
Quality Improvement Intervention ◽  
Antibiotic Prescribing ◽  
The Impact ◽  
Improvement Intervention ◽  
Inappropriate Prescriptions

Background: The Centers for Disease Control and Prevention (CDC) estimates that outpatient settings account for 85%–90% of antibiotic prescriptions in the United States, and ~30% of those prescriptions are unnecessary. One of the most common examples of inappropriate prescribing is for viral upper respiratory infections (URIs). Up to 50% of prescriptions written for URIs are deemed inappropriate, making it an important focus for Antibiotic Stewardship programs. In this study, we evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing inappropriate antibiotic prescribing for viral URIs. Methods: A quasi-experimental study assessed the effects of an Antibiotic Stewardship intervention on antibiotic prescribing for viral URIs. The outcome of interest was a change in the number of antibiotics prescribed at each participating clinic over a 1-year preimplementation period and a 2-year postimplementation period. Time trends were analyzed using segmented regression analysis, and a stepped wedge design was used to account for intervention roll-out across clinics. Results: From 2017 to 2020, there were 63,028 patient visits in 21 clinic locations. Antibiotics were prescribed an average of 11.5% and 5.8% of visits during the pre- and postimplementation periods, respectively. The most frequently prescribed antibiotic over the study period was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with a 46% reduction in antibiotic prescriptions or 0.54 times (P = .001) as many inappropriate antibiotics prescribed as before the intervention. There was no significant change in the month-to-month trend in inappropriate prescriptions after the intervention was implemented (P = .87). Conclusions: Our study demonstrates that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for URI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed viral respiratory infections.Funding: NoDisclosures: None

scholarly journals Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

2020 ◽  
Vol 41 (S1) ◽  
pp. s188-s189
Author(s):  
Jeffrey Gerber ◽  
Robert Grundmeier ◽  
Keith Hamilton ◽  
Lauri Hicks ◽  
Melinda Neuhauser ◽  
...  
Keyword(s):  
Predictive Value ◽  
Gold Standard ◽  
Antibiotic Stewardship ◽  
Chart Review ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Tract Infections ◽  
The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis

2021 ◽  
pp. 073346482110182
Author(s):  
Sainfer Aliyu ◽  
Jasmine L. Travers ◽  
S. Layla Heimlich ◽  
Joanne Ifill ◽  
Arlene Smaldone
Keyword(s):  
Systematic Review ◽  
Nursing Home ◽  
Antibiotic Stewardship ◽  
Meta Analysis ◽  
Nursing Home Residents ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Prescribing Practices ◽  
Stewardship Program ◽  
Meta Analyses

Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988–2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran’s Q = 166,837.8, p < .001, I2 = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.

scholarly journals Measuring Antibiotic Appropriateness for Urinary Tract Infections in Nursing Home Residents

2017 ◽  
Vol 38 (8) ◽  
pp. 998-1001 ◽  
Author(s):  
Taniece Eure ◽  
Lisa L. LaPlace ◽  
Richard Melchreit ◽  
Meghan Maloney ◽  
Ruth Lynfield ◽  
...  
Keyword(s):  
Urinary Tract Infection ◽  
Nursing Home ◽  
Urinary Tract ◽  
Tract Infection ◽  
Urinary Tract Infections ◽  
Nursing Home Residents ◽  
Infect Control Hosp ◽  
Antibiotic Prescribing ◽  
Appropriate Use ◽  
Tract Infections

We assessed the appropriateness of initiating antibiotics in 49 nursing home (NH) residents receiving antibiotics for urinary tract infection (UTI) using 3 published algorithms. Overall, 16 residents (32%) received prophylaxis, and among the 33 receiving treatment, the percentage of appropriate use ranged from 15% to 45%. Opportunities exist for improving UTI antibiotic prescribing in NH.Infect Control Hosp Epidemiol 2017;38:998–1001

scholarly journals Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review

2021 ◽  
Author(s):  
James St. Louis ◽  
Arinze Nkemdirim Okere
Keyword(s):  
United States ◽  
Usual Care ◽  
Antibiotic Stewardship ◽  
The United States ◽  
Controlled Trials ◽  
Antibiotic Prescribing ◽  
Successful Implementation ◽  
Pharmacist Interventions ◽  
Outpatient Settings ◽  
The Impact

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. Methods Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. Results Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P &lt; 0.05). However, the results of these studies are not easily generalizable. Conclusion Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.

Physician Satisfaction With Clinical Laboratory Services: A College of American Pathologists Q-Probes Study of 138 Institutions

2009 ◽  
Vol 133 (1) ◽  
pp. 38-43
Author(s):  
Bruce A. Jones ◽  
Leonas G. Bekeris ◽  
Raouf E. Nakhleh ◽  
Molly K. Walsh ◽  
Paul N. Valenstein
Keyword(s):  
Quality Improvement ◽  
Clinical Laboratory ◽  
Turnaround Time ◽  
Physician Satisfaction ◽  
Reliability Of Results ◽  
Improvement Program ◽  
Valuable Component ◽  
Laboratory Services ◽  
Survey Results ◽  
High Level

Abstract Context.—Monitoring customer satisfaction is a valuable component of a laboratory quality improvement program. Objective.—To survey the level of physician satisfaction with hospital clinical laboratory services. Design.—Participating institutions provided demographic and practice information and survey results of physician satisfaction with defined aspects of clinical laboratory services, rated on a scale of 1 (poor) to 5 (excellent). Results.—One hundred thirty-eight institutions participated in this study and submitted a total of 4329 physician surveys. The overall satisfaction score for all institutions ranged from 2.9 to 5.0. The median overall score for all participants was 4.1 (10th percentile, 3.6; 90th percentile, 4.5). Physicians were most satisfied with the quality/reliability of results and staff courtesy, with median values of excellent or good ratings of 89.9%. Of the 5 service categories that received the lowest percentage values of excellent/good ratings (combined scores of 4 and 5), 4 were related to turnaround time for inpatient stat, outpatient stat, routine, and esoteric tests. Surveys from half of the participating laboratories reported that 96% to 100% of physicians would recommend the laboratory to other physicians. The category most frequently selected as the most important category of laboratory services was quality/reliability of results (31.7%). Conclusions.—There continues to be a high level of physician satisfaction and loyalty with clinical laboratory services. Test turnaround times are persistent categories of dissatisfaction and present opportunities for improvement.

scholarly journals Dissecting the mechanisms of a 5-year decline in antibiotic prescribing

2020 ◽  
Author(s):  
Stephen M. Kissler ◽  
R. Monina Klevens ◽  
Michael L. Barnett ◽  
Yonatan H. Grad
Keyword(s):  
Infectious Disease ◽  
Antibiotic Stewardship ◽  
Respiratory Infections ◽  
Medical Condition ◽  
Outpatient Visit ◽  
Antibiotic Prescribing ◽  
Medical Conditions ◽  
Outpatient Visits ◽  
Prescribing Trends ◽  
Tract Infections

AbstractImportanceThe mechanisms driving the recent decline in outpatient antibiotic prescribing are unknown.ObjectiveTo estimate the extent to which reductions in the number of antibiotic prescriptions filled per outpatient visit (stewardship) and reductions in the monthly rate of outpatient visits (observed disease) for infectious disease conditions each contributed to the decline in annual outpatient antibiotic prescribing rate in Massachusetts between 2011 and 2015.DesignOutpatient medical and pharmacy claims from the Massachusetts All-Payer Claims Database were used to estimate rates of antibiotic prescribing and outpatient visits for 20 medical conditions and their contributions to the overall decline in antibiotic prescribing. Trends were compared to those in the National Ambulatory Medical Care Survey (NAMCS).SettingOutpatient visits in Massachusetts between January 2011 and September 2015.Participants5,075,908 individuals with commercial health insurance or Medicaid in Massachusetts under the age of 65 and 495,515 patients included in NAMCS.Main outcomes and measuresThe number of antibiotic prescriptions avoided through reductions in observed disease and reductions in per-visit prescribing rate per medical condition.ResultsBetween 2011 and 2015, the January antibiotic prescribing rate per 1,000 individuals in Massachusetts declined by 18.9% and the July antibiotic prescribing rate declined by 13.6%. The mean prescribing rate for children under 5 declined by 42.8% (95% CI 21.7%, 59.4%), principally reflecting reduced wintertime prescribing. The monthly rate of outpatient visits per 1,000 individuals in Massachusetts declined (p < 0.05) for respiratory infections and urinary tract infections. Nationally, visits for medical conditions that merit an antibiotic prescription also declined between 2010 and 2015. Of the estimated 358 antibiotic prescriptions per 1,000 individuals avoided over the study period in Massachusetts, 59% (95% CI 54%, 63%) were attributable to reductions in observed disease and 41% (95% CI 37%, 46%) to reductions in prescribing per outpatient visit.Conclusions and relevanceThe decline in antibiotic prescribing in Massachusetts was driven by a decline in observed disease and improved antibiotic stewardship, with a contemporaneous reduction in visits for conditions prompting antibiotics observed nationally. A focus on infectious disease prevention should be considered alongside antibiotic stewardship as a means to reduce antibiotic prescribing.Key pointsQuestionHow did the separate mechanisms of improved stewardship and reductions in observed disease contribute to a 5-year decline in outpatient antibiotic prescribing in Massachusetts from 2011-2015?FindingsIn an observational analysis of insurance claims, reduced monthly rates of outpatient visits for infectious conditions and reduced probability of prescribing an antibiotic per outpatient visit both contributed to the decline in antibiotic prescribing. An estimated 358 antibiotic prescriptions per 1,000 individuals were avoided over the study period through the two mechanisms, 211 of which were attributable to reductions in outpatient visits and 147 to reduced antibiotic prescribing per visit.MeaningPreventing the need for outpatient visits should be considered alongside antibiotic stewardship as a means of reducing antibiotic prescribing.

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