ANTIBIOTIC STEWARDSHIP IN PALLIATIVE CARE — DEVELOPMENT OF ANTIBIOTIC PRESCRIBING GUIDELINES FOR A HOSPICE INPATIENT UNIT

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

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

Journal of Applied Gerontology ◽

10.1177/07334648211018299 ◽

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.

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Palliative Care Development: The Nepal Model

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2007.02.009 ◽

2007 ◽

Vol 33 (5) ◽

pp. 573-577 ◽

Cited By ~ 6

Author(s):

Stuart Brown ◽

Fraser Black ◽

Pradeep Vaidya ◽

Sudip Shrestha ◽

Doug Ennals ◽

...

Keyword(s):

Palliative Care ◽

Care Development

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

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab178 ◽

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 < 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.

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Palliative care development in Asia Pacific region: A review of assessment indicators

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2021.04.017 ◽

2021 ◽

Author(s):

Associate Professor and Director Megan F. Liu ◽

Mu-Hsing Ho ◽

Senior Lecturer Jed Montayre ◽

Director-General Ying-Wei Wang ◽

Head and Professor Chia-Chin Lin

Keyword(s):

Palliative Care ◽

Asia Pacific ◽

Pacific Region ◽

Asia Pacific Region ◽

Care Development

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Palliative Care Development in Kyrgyzstan

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2017.05.010 ◽

2018 ◽

Vol 55 (2) ◽

pp. S41-S45

Author(s):

Aibek Mukambetov ◽

Taalaigul Sabyrbekova ◽

Lola Asanalieva ◽

Ilim Sadykov ◽

Stephen R. Connor

Keyword(s):

Palliative Care ◽

Care Development

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

10.1101/2020.01.02.20016329 ◽

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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An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial

10.21203/rs.3.rs-18556/v1 ◽

2020 ◽

Author(s):

Chao Zhuo ◽

Xiaolin Wei ◽

Zhitong Zhang ◽

Joseph Paul Hicks ◽

Jinkun Zheng ◽

...

Keyword(s):

Primary Care ◽

Antibiotic Stewardship ◽

Respiratory Infections ◽

Inappropriate Prescribing ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Care Facilities ◽

Randomised Controlled ◽

Antibiotic Stewardship Programme

Abstract Background: Inappropriate prescribing of antibiotics for acute respiratory infections at primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China’s primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages.Methods: We will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: 1) training using new operational guidelines, 2) improved management and peer-review of antibiotic prescribing, 3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months post-trial long-term follow-up.Discussion: Our study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All intervention activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs.Trial registration: ISRCTN, ISRCTN96892547. Registered 18 August 2019, http://www.isrctn.com/ISRCTN96892547

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Recalibrating the ‘world map’ of palliative care development

Wellcome Open Research ◽

10.12688/wellcomeopenres.15109.1 ◽

2019 ◽

Vol 4 ◽

pp. 77

Author(s):

Nicole Baur ◽

Carlos Centeno ◽

Eduardo Garralda ◽

Stephen Connor ◽

David Clark

Keyword(s):

Palliative Care ◽

End Of Life ◽

Grey Literature ◽

Primary Data ◽

Online Questionnaire ◽

Documentary Sources ◽

European Languages ◽

Data Limitations ◽

The University ◽

Care Development

Background: Despite growing interest from policy makers, researchers and activists in the global development of palliative care, there is still little science to underpin it. This study presents the methods deployed in the creation of a ‘world map’ of palliative care development. Building on two previous iterations, with improved rigour and taking into account reviewers’ feedback, the aim of this recalibrated version of the study is to determine the level of palliative care development in 198 United Nations recognised countries in 2017, whilst ensuring comparability with previous versions. We present methods of data collection and analysis. Methods and analysis: Primary data on the level of palliative care development in 2017 was collected from in-country experts through an online questionnaire and, where required, supplemented by published documentary sources and grey literature. Data relating to the total population of each country as well as per capita opioid consumption were derived from independent sources. Data analysis was conducted according to a new scoring system and algorithm developed by the research team. Ethics and dissemination: The study was approved by the University of Glasgow College of Social Sciences Research Ethics Committee. Findings of the study will be disseminated in peer-reviewed journals, as a contribution to the second edition of the Global Atlas of Palliative Care at the End-of-Life, and via social media, including the Glasgow End of Life Studies Group blog and the project website. Limitations of the study: There are potential biases associated with self-reporting by key in-country experts. In some countries, the identified key expert failed to complete the questionnaire in whole or part and data limitations were potentially compounded by language restrictions, as questionnaires were available only in three European languages. The study relied in part on data from independent sources, the accuracy of these data could not be verified.

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Differences in antibiotic prescriptions between direct-to-consumer telehealth and telehealth in the emergency department

Journal of Telemedicine and Telecare ◽

10.1177/1357633x211034994 ◽

2021 ◽

pp. 1357633X2110349

Author(s):

Peter Yao ◽

Kriti Gogia ◽

Sunday Clark ◽

Hanson Hsu ◽

Rahul Sharma ◽

...

Keyword(s):

Emergency Department ◽

Confidence Interval ◽

Respiratory Infection ◽

Antibiotic Stewardship ◽

Odds Ratio ◽

Acute Respiratory Infection ◽

Respiratory Infections ◽

Antibiotic Prescribing ◽

Acute Respiratory Infections ◽

Direct To Consumer

Background Telemedicine, which allows physicians to assess and treat patients via real-time audiovisual conferencing, is a rapidly growing modality for providing medical care. Antibiotic stewardship is one important measure of care quality, and research on antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine has yielded mixed results. We compared antibiotic prescription rates for acute respiratory infections in two groups treated by telemedicine: (1) patients treated via a direct-to-consumer telemedicine application and (2) patients treated via telemedicine while physically inside the emergency department. Methods We included direct-to-consumer telemedicine and emergency department telemedicine visits for patients 18 years and older with physician-coded International Classification of Diseases, Tenth Revision acute respiratory infection diagnoses between November 2016 and December 2018. Patients in both groups were seen by the same emergency department faculty working dedicated telemedicine shifts. We compared antibiotic prescribing rates for direct-to-consumer telemedicine and emergency department telemedicine visits before and after adjustment for age, sex, and diagnosis. Results We identified a total of 468 acute respiratory infection visits: 191 direct-to-consumer telemedicine visits and 277 emergency department telemedicine visits. Overall, antibiotics were prescribed for 47% of visits (59% of direct-to-consumer telemedicine visits vs 39% of emergency department telemedicine visits; odds ratio 2.23; 95% confidence interval 1.53–3.25; P < 0.001). The difference in antibiotic prescribing rates remained significant after adjustment for age, sex, and diagnosis (odds ratio 2.49; 95% confidence interval 1.65–3.77; P < 0.001). Conclusion Patients seen by the same group of physicians for acute respiratory infection were significantly more likely to be prescribed antibiotics by direct-to-consumer telemedicine care compared with telemedicine care in the emergency department. This work suggests that contextual factors rather than evaluation over video may contribute to differences in antibiotic stewardship for direct-to-consumer telemedicine encounters.

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