Practice-Level Association between Antibiotic Prescribing and Resistance: An Observational Study in Primary Care

A direct relation between antibiotic use and resistance has been shown at country level. We aim to investigate the association between antibiotic prescribing for patients from individual Dutch primary care practices and antibiotic resistance of bacterial isolates from routinely submitted urine samples from their patient populations. Practices’ antibiotic prescribing data were obtained from the Julius Network and related to numbers of registered patients. Practices were classified as low-, middle- or high-prescribers and from each group size-matching practices were chosen. Culture and susceptibility data from submitted urine samples were obtained from the microbiology laboratory. Percentages of resistant isolates, and resistant isolates per 1000 registered patients per year (population resistance) were calculated and compared between the groups. The percentages of resistant Escherichia coli varied considerably between individual practices, but the three prescribing groups’ means were very similar. However, as the higher-prescribing practices requested more urine cultures per 1000 registered patients, population resistance was markedly higher in the higher-prescribing groups. This study showed that the highly variable resistance percentages for individual practices were unrelated to antibiotic prescribing levels. However, population resistance (resistant strains per practice population) was related to antibiotic prescribing levels, which was shown to coincide with numbers of urine culture requests. Whether more urine culture requests in the higher-prescribing groups were related to treatment failures, more complex patient populations, or to general practitioners’ testing behaviour needs further investigation.

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Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study

BJGP Open ◽

10.3399/bjgpopen20x101052 ◽

2020 ◽

Vol 4 (3) ◽

pp. bjgpopen20X101052 ◽

Cited By ~ 1

Author(s):

Philip Emeka Anyanwu ◽

Koen Pouwels ◽

Anne Walker ◽

Michael Moore ◽

Azeem Majeed ◽

...

Keyword(s):

Primary Care ◽

Financial Incentives ◽

Financial Incentive ◽

Diabetes Prevalence ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Practice Characteristics ◽

Antibiotic Drugs ◽

Care Practices ◽

Primary Care Practices

BackgroundIn 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%–23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015–2016.AimTo investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.Design & settingLongitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.MethodLinear generalised estimating equations models were fitted, examining the effect of the 2015–2016 QP on the number of antibiotic items per specific therapeutic group age–sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.ResultsAntibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015–2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015–2016 QP compared with other practices (interaction p<0.001).ConclusionIn high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

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Knowledge, Attitudes and Intentions to Prescribe Antibiotics: A Structural Equation Modeling Study of Primary Care Institutions in Hubei, China

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16132385 ◽

2019 ◽

Vol 16 (13) ◽

pp. 2385 ◽

Cited By ~ 5

Author(s):

Chenxi Liu ◽

Chaojie Liu ◽

Dan Wang ◽

Xinping Zhang

Keyword(s):

Primary Care ◽

Antibiotic Resistance ◽

Primary Care Physicians ◽

Structural Equation ◽

Antibiotic Use ◽

Equation Modeling ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Motivation To Change ◽

Attitudes And Practices

The aim of this paper is to measure the knowledge and attitudes of primary care physicians toward antibiotic prescriptions and their impacts on antibiotic prescribing. A questionnaire survey was conducted on 625 physicians from 67 primary care facilities in Hubei, China. Structural equation modelling (SEM) was applied to test the theoretical framework derived from the Knowledge, Attitudes, and Practices (KAP) theory. Physicians’ knowledge, five sub-types of attitudes, and three sub-types of behavioral intentions towards antibiotic use were measured. Physicians had limited knowledge about antibiotic prescriptions (average 54.55% correct answers to 11 questions). Although they were generally concerned about antibiotic resistance (mean = 1.28, SD = 0.43), and were reluctant to be submissive to pressures from consumer demands for antibiotics (mean = 1.29, SD = 0.65) and the requirements of defensive practice (mean = 1.11, SD = 0.63), there was a lack of motivation to change prescribing practices (mean = −0.29, SD = 0.70) and strong agreement that other stakeholders should take the responsibility (mean = −1.15, SD = 0.45). The SEM results showed that poor knowledge, unawareness of antibiotic resistance, and limited motivation to change contributed to physicians’ high antibiotics prescriptions (p < 0.001). To curb antibiotic over-prescriptions, improving knowledge itself is not enough. The lack of motivation of physicians to change needs to be addressed through a systematic approach.

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2071. A Survey of Antibiotic Prescribing Practices Among Adult Primary Care Physicians in Idaho

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1751 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S698-S698

Author(s):

Anubhav Kanwar ◽

Susan Heppler ◽

Karl Madaras-Kelly ◽

Martha Jaworski ◽

Curtis Donskey

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Primary Care Physicians ◽

Healthcare Facility ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Prescription Data ◽

Prescribing Practices ◽

Diagnostic Uncertainty ◽

Test Ordering

Abstract Background Prescribing an antibiotic is a complex process involving an interplay of prescriber’s knowledge, diagnostic acumen and patient factors. Understanding the prescriber rationale is key to provide feedback which might improve appropriateness of antibiotic prescribing. Currently, there are limited data on prescribing and test ordering practices among primary care physicians. Methods We surveyed primary care physicians taking care of adults (age 18 years and above). Physicians were contacted through the Idaho State Medical Board by a one-time email containing the survey link. The survey consisted of 25 questions under 2 major themes of diagnostic and antimicrobial stewardship (AS). It assessed physicians’ practice setting, ordering of diagnostic tests and antibiotics for common infections, delivery of patient education regarding antibiotics, availability of antibiogram and antimicrobial stewardship services, and assessment of penicillin allergy. Two infectious diseases physicians independently reviewed the results for appropriateness of testing and antibiotic prescribing per IDSA guidelines. Results Of 929 physicians surveyed, 157 (17%) responded. Of the respondents, 95 (61%) were male, the mean age was 50 years, and 72% worked in outpatient settings and were family medicine specialists. Only 55% of physicians reported having an AS program at their healthcare facility. Test-of-cure for C. difficile infection (24%) and UTI (13%) and use of superficial culture data to guide the treatment of osteomyelitis (27%) were the most common reasons for inappropriate testing. Longer than recommended duration, antibiotic combinations with overlap of spectrum, and guideline-discordant indications for prescribing antibiotics were the main reasons for inappropriate antibiotic use. The main factors influencing the decision to prescribe an antibiotic were diagnostic uncertainty (42%), being unsure of patient follow-up (23%) and cost of testing (21%). Conclusion The survey results highlight the need for prescriber education for decreasing inappropriate test ordering and antibiotic prescribing. Additional studies involving a review of patient records, lab and prescription data are needed to confirm these practices. Disclosures All authors: No reported disclosures.

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General practitioners’ accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices

BMC Family Practice ◽

10.1186/s12875-019-1065-x ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 4

Author(s):

Marieke M. van der Zande ◽

Melanie Dembinsky ◽

Giovanni Aresi ◽

Tjeerd P. van Staa

Keyword(s):

Public Health ◽

Primary Care ◽

General Practitioners ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Structured Interviews ◽

North West ◽

Care Practices ◽

Primary Care Practices ◽

Supportive Practice

Abstract Background Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners’ (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices. Methods Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically. Results This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics. Conclusions Insight into GPs’ negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.

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A retrospective audit of antibiotic prescriptions in a Lebanese Hospital

International Journal of Infection Control ◽

10.3396/ijic.v15i1.001.19 ◽

2019 ◽

Vol 15 (1) ◽

Author(s):

Mohamad Ibrahim ◽

Zeinab Bazzi

Keyword(s):

Epidemiological Data ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Team Approach ◽

Strong Correlations ◽

Prescribing Practices ◽

Antimicrobial Drugs ◽

Stewardship Program ◽

Retrospective Audit ◽

Attending Physician

Despite the frequent alarms that have been published about the adverse effects of antibiotic use and misuse, physicians prescribe to patients approximately fifty percent of unnecessary antimicrobials. In an attempt to decrease the emergence of antimicrobial resistance and increase awareness, a team approach is required to address this prescribing phenomenon in a feasible manner. A retrospective study was done at a one-hundred-forty-bed hospital with a representative sample size of 368 patients. Patient data was collected and analyzed by a stewardship team. The overall antibiotic inappropriate rate was 45.8%, which is relatively high and consistent with the findings of other studies mentioned in the literature. This study aimed to provide baseline epidemiological data on the use of antibiotics in a Lebanese hospital and has revealed several notable patterns of antibiotic prescribing practices among Lebanese physicians such as the use of antimicrobial drugs example penicillin was consistently high. Strong correlations were identified between the type of attending physician and antibiotic appropriateness. These findings will be important in constructing an antimicrobial stewardship program to reduce antibiotic misuse.

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Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices

BMC Family Practice ◽

10.1186/s12875-021-01371-6 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Aleksandra J. Borek ◽

◽

Anne Campbell ◽

Elle Dent ◽

Christopher C. Butler ◽

...

Keyword(s):

Focus Groups ◽

Point Of Care ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Focus Group Study ◽

Clinical Uncertainty ◽

Reactive Protein ◽

Clinical Tools ◽

The Many

Abstract Background Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. Methods This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. Results Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience – participants viewed the strategies as having limited value as ‘clinical tools’, perceiving them as useful only in ‘rare’ instances of clinical uncertainty and/or for those less experienced. Strategies as ‘social tools’ – participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities – participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context – various other situational and practical issues were raised with implementing the strategies. Conclusions High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful ‘clinical tools’ in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as ‘social tools’ to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.

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Antibiotic Susceptibility of Common Organisms Isolated from Urine Cultures of Nursing Home Residents

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.626 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s118-s120

Author(s):

Austin R. Penna ◽

Taniece R. Eure Eure ◽

Nimalie D. Stone ◽

Grant Barney ◽

Devra Barter ◽

...

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Antibiotic Susceptibility ◽

Clinical Decision Making ◽

Service Providers ◽

Urine Culture ◽

Nursing Home Residents ◽

Antibiotic Prescribing ◽

E Coli ◽

Susceptibility Data

Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.Disclosures: NoneFunding: 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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Prescribers’ Knowledge, Attitudes and Behaviors on Antibiotics, Antibiotic Use and Antibiotic Resistance in Jordan

Antibiotics ◽

10.3390/antibiotics10070858 ◽

2021 ◽

Vol 10 (7) ◽

pp. 858

Author(s):

Reema A. Karasneh ◽

Sayer I. Al-Azzam ◽

Mera Ababneh ◽

Ola Al-Azzeh ◽

Ola B. Al-Batayneh ◽

...

Keyword(s):

Antibiotic Resistance ◽

Antibiotic Use ◽

Cross Sectional Study ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Online Questionnaire ◽

Cross Sectional ◽

Attitudes And Behaviors ◽

And Behaviors ◽

Ease Of Access

More research is needed on the drivers of irrational antibiotic prescribing among healthcare professionals and to ensure effective prescribing and an adequate understanding of the issue of antibiotic resistance. This study aimed at evaluating prescribers’ knowledge, attitudes and behaviors about antibiotic use and antibiotic resistance. A cross-sectional study was conducted utilizing an online questionnaire and included physicians and dentists from all sectors in Jordan. A total of 613 prescribers were included (physicians n = 409, dentists n = 204). Respondents’ knowledge on effective use, unnecessary use or associated side effects of antibiotics was high (>90%), compared with their knowledge on the spread of antibiotic resistance (62.2%). For ease of access to the required guidelines on managing infections, and to materials that advise on prudent antibiotic use and antibiotic resistance, prescribers agreed in 62% and 46.1% of cases, respectively. 28.4% of respondents had prescribed antibiotics when they would have preferred not to do so more than once a day or more than once a week. Among respondents who prescribed antibiotics, 63.4% would never or rarely give out resources on prudent use of antibiotics for infections. The findings are of importance to inform antibiotic stewardships about relevant interventions aimed at changing prescribers’ behaviors and improving antibiotic prescribing practices.

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Antibiotic prescribing practices in three neonatology units in Kigali, Rwanda. – an observational study

African Health Sciences ◽

10.4314/ahs.v20i4.17 ◽

2020 ◽

Vol 20 (4) ◽

pp. 1646-54

Author(s):

Peter Thomas Cartledge ◽

Fidel Shofel Ruzibuka ◽

Florent Rutagarama ◽

Samuel Rutare ◽

Tanya Rogo

Keyword(s):

Risk Factors ◽

Median Duration ◽

Neonatal Sepsis ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Second Line ◽

Prescribing Practices ◽

Urban District ◽

Membrane Rupture ◽

Significant Difference

Introduction: There is limited published data on antibiotic use in neonatal units in resource-poor settings. Objectives: This study sought to describe antibiotic prescribing practices in three neonatology units in Kigali, Rwanda. Methods: A multi-center, cross-sectional study conducted in two tertiary and one urban district hospital in Kigali, Rwan- da. Participants were neonates admitted in neonatology who received a course of antibiotics during their admission. Data collected included risk factors for neonatal sepsis, clinical signs, symptoms, investigations for neonatal sepsis, antibiotics prescribed, and the number of deaths in the included cohort. Results: 126 neonates were enrolled with 42 from each site. Prematurity (38%) followed by membrane rupture more than 18 hours (25%) were the main risk factors for neonatal sepsis. Ampicillin and Gentamicin (85%) were the most commonly used first-line antibiotics for suspected neonatal sepsis. Most neonates (87%) did not receive a second-line antibiotic. Cefotaxime (11%), was the most commonly used second-line antibiotic. The median duration of antibiotic use was four days in all sur- viving neonates (m=113). In neonates with negative blood culture and normal C-reactive protein (CRP), the median duration of antibiotics was 3.5 days; and for neonates, with positive blood cultures, the median duration was 11 days. Thirteen infants died (10%) at all three sites, with no significant difference between the sites. Conclusion: The median antibiotic duration for neonates with normal lab results exceeded the recommended duration mandated by the national neonatal protocol. We recommend the development of antibiotic stewardship programs in neo- natal units in Rwanda to prevent the adverse effects which may be caused by inappropriate or excessive use of antibiotics. Keywords: (MeSH): Antimicrobial stewardship; anti-bacterial agents; neonatal sepsis; sepsis; infant mortality; neonatal intensive care units; Africa; Rwanda.

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