A case of iatrogenic psychosis in the context of inappropriate prescribing for COVID-19

Introduction: Irrational or inappropriate prescribing practice is common in developing countries that can lead to ineffective treatment, prolonged hospitalization, harm to the patient, increased treatment cost and development of drug-resistant organisms. The prescription of antibiotics and other drugs in endodontics is limited to patients with progressive and diffuse swelling and with systemic infection. However, antibiotics continue to be over-prescribed by more than 66% dentists without a rational justification.Therefore, the periodic assessment of drug utilization pattern is important to know the existing pattern of drug use, decrease adverse effects and provide feedback to the prescribers. Objective: To evaluate the drug utilization pattern in endodontics using the World Health Organization prescribing indicators. Methodology: A cross-sectional prospective study was conducted among the patients visiting the outpatient department of Conservative Dentistry and Endodontics. After obtaining the informed consent, the relevant data were collected on a self-designed proforma by reviewing the health cards of the patients. The WHO prescribing indicators were calculated. Descriptive statistics were calculated using SPSS version 11.0. Results: Out of 187 patients, 101 (54%) were female. Mean age was 38.9±16.6 years. Majority of the patients suffered from acute apical periodontitis (30.5%). A total of 281 drugs were prescribed to 187 patients. Paracetamol+Ibuprofen (44.1%) was the most frequently prescribed drugs. Most of the patients were prescribed one drug (78.6%). Average drug per prescription was 1.5. Majority of the drugs (89.0%) were prescribed from Essential drug list of Nepal. Conclusions: Analgesics were the most frequently prescribed drug. The prescription practice was rational. There is need to increase the number of medicine prescribed from National List of Essential medicines.Educational initiatives should be undertaken to further strengthen the rational prescription among dental practitioners.

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154. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Adults with Acute Pharyngitis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.199 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S87-S87

Author(s):

Ebbing Lautenbach ◽

Keith W Hamilton ◽

Robert Grundmeier ◽

Melinda M Neuhauser ◽

Lauri Hicks ◽

...

Keyword(s):

Chart Review ◽

Inappropriate Prescribing ◽

Antibiotic Use ◽

University Of Pennsylvania ◽

Antibiotic Prescribing ◽

Acute Pharyngitis ◽

Test Characteristics ◽

Appropriate Prescribing ◽

Concurrent Infections ◽

The Impact

Abstract Background Although most antibiotic use occurs in outpatients, antibiotic stewardship programs (ASPs) have primarily focused on inpatients. A major challenge for outpatient ASPs is lack of accurate and accessible electronic data to target interventions. We developed and validated an electronic algorithm to identify inappropriate antibiotic use for adult outpatients with acute pharyngitis. Methods In the University of Pennsylvania Health System, we used ICD-10 diagnostic codes to identify patient encounters for acute pharyngitis at outpatient practices between 3/15/17 – 3/14/18. Exclusion criteria included immunocompromising conditions, comorbidities, and concurrent infections that might require antibiotic use. We randomly selected 300 eligible subjects. Inappropriate antibiotic use based on chart review served as the basis for assessment of the electronic algorithm which was constructed using only data in the electronic health record (EHR). Criteria for appropriate prescribing, choice of antibiotic, and duration included positive streptococcal testing, use of penicillin/amoxicillin (absent b-lactam allergy), and 10 days maximum duration of therapy. Results Of 300 subjects, median age was 42, 75% were female, 64% were seen by internal medicine (vs. family medicine), and 69% were seen by a physician (vs. advanced practice provider). On chart review, 127 (42%) subjects received an antibiotic, of which 29 had a positive streptococcal test and 4 had another appropriate indication. Thus, 74% (94/127) of patients received antibiotics inappropriately. Of the 29 patients who received appropriate prescribing, 27 (93%) received an appropriate antibiotic. Finally, of the 29 patients who were appropriately treated, 29 (100%) received the correct duration. Test characteristics of the EHR algorithm (compared to chart review) are noted in the Table. Conclusion Inappropriate antibiotic prescribing for acute pharyngitis is common. An electronic algorithm for identifying inappropriate prescribing, antibiotic choice, and duration is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future work. Test Characteristics of Electronic Algorithm for Inappropriate Prescribing, Agent, and Duration Disclosures All Authors: No reported disclosures

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Perspectives of Healthcare Professionals Regarding Factors Associated with Antimicrobial Resistance (AMR) and Their Consequences: A Cross Sectional Study in Eastern Province of Saudi Arabia

Antibiotics ◽

10.3390/antibiotics10070878 ◽

2021 ◽

Vol 10 (7) ◽

pp. 878

Author(s):

Mohamed A. Baraka ◽

Amany Alboghdadly ◽

Samar Alshawwa ◽

Asim Ahmed Elnour ◽

Hassan Alsultan ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Inappropriate Prescribing ◽

Healthcare Providers ◽

Cross Sectional Study ◽

Sectional Study ◽

Key Factors ◽

Eastern Province ◽

Cross Sectional ◽

Factors Associated ◽

Factors Influencing

Factors reported in the literature associated with inappropriate prescribing of antimicrobials include physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians’ decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing antimicrobials would minimize the risk of resistance and, consequently, improve patients’ clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber’s choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. A cross-sectional study was conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed, validated, and piloted survey specific with closed-ended questions. A value of p < 0.05 was considered to be statistically significant. All data analysis was performed using the Statistical Package for Social Sciences (IBM SPSS version 23.0). 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All of the respondents acknowledged effectiveness, previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) as being key factors influencing physicians’ choice during antimicrobial prescribing. The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials were reported to be common practices. Furthermore, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials, and the use of antimicrobials without a physician’s prescription (i.e., self-medication) represent key factors which contribute to AMR from participants’ perspectives. Furthermore, internal policy and guidelines are needed to ensure that the antimicrobials are prescribed in accordance with standard protocols and clinical guidelines.

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Identifying adults with acute rhinosinusitis in primary care that benefit most from antibiotics: protocol of an individual patient data meta-analysis using multivariable risk prediction modelling

BMJ Open ◽

10.1136/bmjopen-2020-047186 ◽

2021 ◽

Vol 11 (7) ◽

pp. e047186

Author(s):

Roderick P Venekamp ◽

Jeroen Hoogland ◽

Maarten van Smeden ◽

Maroeska M Rovers ◽

An I De Sutter ◽

...

Keyword(s):

Risk Prediction ◽

Individual Patient Data ◽

Meta Analysis ◽

Cochrane Review ◽

Inappropriate Prescribing ◽

Model Performance ◽

Patient Data ◽

Reference List ◽

Acute Rhinosinusitis ◽

Absolute Benefit

IntroductionAcute rhinosinusitis (ARS) is a prime reason for doctor visits and among the conditions with highest antibiotic overprescribing rates in adults. To reduce inappropriate prescribing, we aim to predict the absolute benefit of antibiotic treatment for individual adult patients with ARS by applying multivariable risk prediction methods to individual patient data (IPD) of multiple randomised placebo-controlled trials.Methods and analysisThis is an update and re-analysis of a 2008 IPD meta-analysis on antibiotics for adults with clinically diagnosed ARS. First, the reference list of the 2018 Cochrane review on antibiotics for ARS will be reviewed for relevant studies published since 2008. Next, the systematic searches of CENTRAL, MEDLINE and Embase of the Cochrane review will be updated to 1 September 2020. Methodological quality of eligible studies will be assessed using the Cochrane Risk of Bias 2 tool. The primary outcome is cure at 8–15 days. Regression-based methods will be used to model the risk of being cured based on relevant predictors and treatment, while accounting for clustering. Such model allows for risk predictions as a function of treatment and individual patient characteristics and hence gives insight into individualised absolute benefit. Candidate predictors will be based on literature, clinical reasoning and availability. Calibration and discrimination will be evaluated to assess model performance. Resampling techniques will be used to assess internal validation. In addition, internal–external cross-validation procedures will be used to inform on between-study differences and estimate out-of-sample model performance. Secondarily, we will study possible heterogeneity of treatment effect as a function of outcome risk.Ethics and disseminationIn this study, no identifiable patient data will be used. As such, the Medical Research Involving Humans Subject Act (WMO) does not apply and official ethical approval is not required. Results will be submitted for publication in international peer-reviewed journals.PROSPERO registration numberCRD42020220108.

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Inappropriate outpatient antibiotic use in children insured by Kentucky Medicaid

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.177 ◽

2021 ◽

pp. 1-7

Author(s):

Bethany A. Wattles ◽

Kahir S. Jawad ◽

Yana Feygin ◽

Maiying Kong ◽

Navjyot K. Vidwan ◽

...

Keyword(s):

Claims Data ◽

Inappropriate Prescribing ◽

Patient Characteristics ◽

Antibiotic Use ◽

Population Based ◽

Antibiotic Prescribing ◽

Cross Sectional ◽

Inappropriate Use ◽

Pharmacy Claims ◽

Medicaid Children

Abstract Objective: To describe risk factors associated with inappropriate antibiotic prescribing to children. Design: Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017. Participants: Population-based sample of pediatric Medicaid patients and providers. Methods: Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions. Results: Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07–1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1–4.2), age 0–2 years (OR, 1.39; 95% CI, 1.37–1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28–1.33). Conclusions: Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.

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Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol

Implementation Science ◽

10.1186/s13012-020-01078-9 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Julie C. Lauffenburger ◽

Thomas Isaac ◽

Lorenzo Trippa ◽

Punam Keller ◽

Ted Robertson ◽

...

Keyword(s):

Older Adults ◽

Usual Care ◽

Behavioral Science ◽

Inappropriate Prescribing ◽

The Novel ◽

Care Providers ◽

Health Records ◽

Electronic Health ◽

Stage 1

Abstract Background The prescribing of high-risk medications to older adults remains extremely common and results in potentially avoidable health consequences. Efforts to reduce prescribing have had limited success, in part because they have been sub-optimally timed, poorly designed, or not provided actionable information. Electronic health record (EHR)-based tools are commonly used but have had limited application in facilitating deprescribing in older adults. The objective is to determine whether designing EHR tools using behavioral science principles reduces inappropriate prescribing and clinical outcomes in older adults. Methods The Novel Uses of Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) project uses a two-stage, 16-arm adaptive randomized pragmatic trial with a “pick-the-winner” design to identify the most effective of many potential EHR tools among primary care providers and their patients ≥ 65 years chronically using benzodiazepines, sedative hypnotic (“Z-drugs”), or anticholinergics in a large integrated delivery system. In stage 1, we randomized providers and their patients to usual care (n = 81 providers) or one of 15 EHR tools (n = 8 providers per arm) designed using behavioral principles including salience, choice architecture, or defaulting. After 6 months of follow-up, we will rank order the arms based upon their impact on the trial’s primary outcome (for both stages): reduction in inappropriate prescribing (via discontinuation or tapering). In stage 2, we will randomize (a) stage 1 usual care providers in a 1:1 ratio to one of the up to 5 most promising stage 1 interventions or continue usual care and (b) stage 1 providers in the unselected arms in a 1:1 ratio to one of the 5 most promising interventions or usual care. Secondary and tertiary outcomes include quantities of medication prescribed and utilized and clinically significant adverse outcomes. Discussion Stage 1 launched in October 2020. We plan to complete stage 2 follow-up in December 2021. These results will advance understanding about how behavioral science can optimize EHR decision support to improve prescribing and health outcomes. Adaptive trials have rarely been used in implementation science, so these findings also provide insight into how trials in this field could be more efficiently conducted. Trial registration Clinicaltrials.gov (NCT04284553, registered: February 26, 2020)

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Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1187 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s506-s507

Author(s):

Patricia Cummings ◽

Rita Alajajian ◽

Larissa May ◽

Russel Grant ◽

Hailey Greer ◽

...

Keyword(s):

Patient Education ◽

Influenza Season ◽

Action Plan ◽

Inappropriate Prescribing ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Intervention Period ◽

National Action Plan ◽

Its Analysis ◽

Urgent Care Centers

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.Funding: NoneDisclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva

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