Assessment of physicians’ perception about antibiotic use and resistance and factors influencing antibiotic prescribing: a situational analysis from Pakistan

Abstract Background: Antimicrobial resistance (AMR), recognised as a serious and growing threat to global health, is driven by antibiotic use. Understanding factors influencing antibiotic use is essential to design and implement effective interventions to reduce unnecessary antibiotic use and AMR. This study aims to explore the practices and views of the key actors associated with the use of antibiotics for pig farming in Thailand, from local farmers to officers in central government institutions. Methods: A total of 31 in-depth interviews were conducted with pig farmers (n=13), drug retailers (n=5), veterinarians (n=7), and government officers (n=3) and representatives of health professional councils (n=2). Direct observations were conducted in pig farms. Thematic analysis based on practices, views and interests of actors regarding antibiotic use in pig production in Thailand. Results: There are various factors influencing the use of antibiotics. The factors may trigger greater antibiotic use including lack of knowledge and awareness about antibiotics and AMR, economic incentives, and loose regulatory frameworks. Farmers considered that antibiotics are necessary to maintain animal health, prevent and control diseases, and ensure economic gains, so using antibiotics was considered a worthwhile investment in pigs. There was limited information about antibiotic use in the curriculum and lack of clinical practice guidelines for health professionals. Veterinarians faced challenges in diagnosis and lacked antibiotic prescribing guidelines. Pharmaceutical companies applied market promotion strategies to increase sales; and used professionals as mediators with farmers. There was no control of antibiotic sale and prescription via the regulatory environment. The national policy on AMR could be facilitating factor to optimise use of antibiotics but its influence was weak relative to other influences which favoured antibiotic use. Conclusions: Our study highlights the need to improve antibiotic use in pig production in Thailand. Access to veterinary services and reliable information about animal health needs to be improved among farmers. Innovative low-cost investment in biosecurity could improve farm management and decrease reliance on antibiotics. Developing professional training and clinical guidelines, and establishing a code of conduct, are needed to improve practices in antibiotic prescription and sale amongst health professionals and industry.

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Testing for resistance: Point-of-care testing as a communicational tool in antibiotic prescribing

Communication & Medicine ◽

10.1558/cam.32191 ◽

2018 ◽

Vol 14 (3) ◽

pp. 229-240

Author(s):

Johanna Lindell

Keyword(s):

Point Of Care ◽

Rapid Test ◽

Antibiotic Use ◽

Treatment Recommendation ◽

Antibiotic Prescribing ◽

Communicative Practices ◽

Effective Strategies ◽

Reactive Protein ◽

Point Of Care Test ◽

Test Result

As antibiotic resistance becomes a growing health emergency, effective strategies are needed to reduce inappropriate antibiotic use. In this article, one such strategy – communicative practices associated with the C-reactive protein point-of care test – is investigated. Building on a collection of 31 videorecorded consultations from Danish primary care, and using conversation analysis, this study finds that the rapid test can be used throughout the consultation to incrementally build the case for a nonantibiotic treatment recommendation, both when the test result is forecast and reported. The study also finds that the format of reports of elevated results differs from that of ‘normal’ results, resulting in a subtle shift of authority from doctor to test.

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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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229. Hospitalists Antimicrobial Scorecard Improves Antibiotic Prescribing at a Community Teaching Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.273 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S116-S116

Author(s):

Julia Sessa ◽

Helen Jacoby ◽

Bruce Blain ◽

Lisa Avery

Keyword(s):

Patient Care ◽

Teaching Hospital ◽

Antimicrobial Stewardship ◽

Rank Order ◽

Antibiotic Use ◽

Outpatient Setting ◽

Antibiotic Prescribing ◽

Full Time ◽

Days Of Therapy ◽

The Impact

Abstract Background Measuring antimicrobial consumption data is a foundation of antimicrobial stewardship programs. There is data to support antimicrobial scorecard utilization to improve antibiotic use in the outpatient setting. There is a lack of data on the impact of an antimicrobial scorecard for hospitalists. Our objective was to improve antibiotic prescribing amongst the hospitalist service through the development of an antimicrobial scorecard. Methods Conducted in a 451-bed teaching hospital amongst 22 full time hospitalists. The antimicrobial scorecard for 2019 was distributed in two phases. In October 2019, baseline antibiotic prescribing data (January – September 2019) was distributed. In January 2020, a second scorecard was distributed (October – December 2019) to assess the impact of the scorecard. The scorecard distributed via e-mail to physicians included: Antibiotic days of therapy/1,000 patient care days (corrected for attending census), route of antibiotic prescribing (% intravenous (IV) vs % oral (PO)) and percentage of patients prescribed piperacillin-tazobactam (PT) for greater than 3 days. Hospitalists received their data in rank order amongst their peers. Along with the antimicrobial scorecard, recommendations from the antimicrobial stewardship team were included for hospitalists to improve their antibiotic prescribing for these initiatives. Hospitalists demographics (years of practice and gender) were collected. Descriptive statistics were utilized to analyze pre and post data. Results Sixteen (16) out of 22 (73%) hospitalists improved their antibiotic prescribing from pre- to post-scorecard (χ 2(1)=3.68, p = 0.055). The median antibiotic days of therapy/1,000 patient care days decreased from 661 pre-scorecard to 618 post-scorecard (p = 0.043). The median PT use greater than 3 days also decreased significantly, from 18% pre-scorecard to 11% post-scorecard (p = 0.0025). There was no change in % of IV antibiotic prescribing and no correlation between years of experience or gender to antibiotic prescribing. Conclusion Providing antimicrobial scorecards to our hospitalist service resulted in a significant decrease in antibiotic days of therapy/1,000 patient care days and PT prescribing beyond 3 days. Disclosures All Authors: No reported disclosures

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144. Little evidence of same-day, oral antibiotic prescribing at ambulatory surgery centers

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.189 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S82-S83

Author(s):

Laura M King ◽

Lauri Hicks ◽

Sarah Kabbani; Sharon Tsay ◽

Katherine E Fleming-Dutra

Keyword(s):

Surgical Procedures ◽

Ambulatory Surgery ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Oral Antibiotic ◽

Chi Square ◽

Convenience Sample ◽

Ambulatory Surgery Centers ◽

National Public Health ◽

Course Length

Abstract Background The objective of our study was to describe oral antibiotic prescriptions associated with procedures in ambulatory surgery centers (ASC) to evaluate if there are major national opportunities to improve antibiotic use in this setting. Methods We identified surgical procedures in ASCs and oral antibiotic prescriptions in the IBM® MarketScan® Commercial 2018 database, a large convenience sample of privately-insured individuals aged < 65 years. We excluded visits with same-day hospitalizations and those with infectious diagnoses that may warrant antibiotic treatment. We included only antibiotic prescriptions dispensed on the same day as an ASC visit. We calculated the number of visits and oral antibiotic prescriptions and the percent of visits with oral antibiotic prescriptions overall, and by patient age group (< 18 and 18–64 years), antibiotic class, and procedure type. We also calculated median antibiotic course length. Across-group comparisons were evaluated using chi-square tests. Results In 2018, 918,127 ASC visits with surgical procedure codes were captured, of which 37,032 (4.0%) were associated with same-day oral antibiotic prescriptions. The percent of visits with antibiotic prescriptions was significantly higher among children compared to adults (9.4% vs 3.8%; p< 0.01); however, adults accounted for 89% of prescriptions. Respiratory/nasal and urinary tract system procedures were most frequently associated with antibiotic prescriptions (Figure). Median course length was 5 (interquartile range 3–7) days. The most common antibiotic class was cephalosporins (49.6% of prescriptions), followed by penicillins (12.6%) and fluoroquinolones (10.9%). Figure. Percent of ambulatory surgery center visits with same-day antibiotic prescriptions by procedure category, IBM® MarketScan® Commercial Database, 2018 Conclusion Only 4% of ASC procedures were associated with same-day oral antibiotic prescriptions, suggesting antibiotics are not commonly prescribed in ASCs on the day of surgical procedures. Additionally, the observed 5-day median duration may suggest that some of these courses are intended for treatment rather than prophylaxis. Our estimates represent lower bounds for oral antibiotic prescriptions in this setting, as we only captured same-day prescriptions. However, our findings suggest that ASC facilities may not be high-impact targets for national, public health antibiotic stewardship efforts. Disclosures All Authors: No reported disclosures

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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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A Review of Evidence-Based Recommendations for Pericoronitis Management and a Systematic Review of Antibiotic Prescribing for Pericoronitis among Dentists: Inappropriate Pericoronitis Treatment Is a Critical Factor of Antibiotic Overuse in Dentistry

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18136796 ◽

2021 ◽

Vol 18 (13) ◽

pp. 6796

Author(s):

Jan Schmidt ◽

Martina Kunderova ◽

Nela Pilbauerova ◽

Martin Kapitan

Keyword(s):

Systematic Review ◽

Local Therapy ◽

Critical Factor ◽

Antibiotic Use ◽

Narrative Review ◽

Antibiotic Prescribing ◽

Evidence Based ◽

Antibiotic Overuse ◽

Clinically Significant

This work provides a narrative review covering evidence-based recommendations for pericoronitis management (Part A) and a systematic review of antibiotic prescribing for pericoronitis from January 2000 to May 2021 (Part B). Part A presents the most recent, clinically significant, and evidence-based guidance for pericoronitis diagnosis and proper treatment recommending the local therapy over antibiotic prescribing, which should be reserved for severe conditions. The systematic review includes publications analyzing sets of patients treated for pericoronitis and questionnaires that identified dentists' therapeutic approaches to pericoronitis. Questionnaires among dentists revealed that almost 75% of them prescribed antibiotics for pericoronitis, and pericoronitis was among the top 4 in the frequency of antibiotic use within the surveyed diagnoses and situations. Studies involving patients showed that antibiotics were prescribed to more than half of the patients with pericoronitis, and pericoronitis was among the top 2 in the frequency of antibiotic use within the monitored diagnoses and situations. The most prescribed antibiotics for pericoronitis were amoxicillin and metronidazole. The systematic review results show abundant and unnecessary use of antibiotics for pericoronitis and are in strong contrast to evidence-based recommendations summarized in the narrative review. Adherence of dental professionals to the recommendations presented in this work can help rapidly reduce the duration of pericoronitis, prevent its complications, and reduce the use of antibiotics and thus reduce its impact on patients' quality of life, healthcare costs, and antimicrobial resistance development.

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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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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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779. Clostridiodes difficile: Is it time for surveillance! Cost-benefit analysis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.969 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S434-S434

Author(s):

Mohamed Yassin ◽

Curtis Donskey ◽

Ricardo Arbulu ◽

Heather Dixon ◽

Kenneth Smith

Keyword(s):

Cost Saving ◽

Current Practice ◽

Cost Benefit Analysis ◽

Cost Benefit ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Carrier Status ◽

Local Data ◽

Healthcare Perspective ◽

Hospital Perspective

Abstract Background Clostridiodes difficile infection (CDI) has substantial morbidity, mortality and expense. Hospital surveillance to detect CD carriers could affect antibiotic use and determination of community-associated vs hospital-associated CDI. Methods A decision tree examined the cost-effectiveness of hospital CD surveillance compared to current practice (testing as indicated). Costs for CD testing, community-associated CDI and hospital-associated CDI came from US databases. CD carrier and infection probabilities came from literature and local data. Analyses examined potential benefits from 1) knowledge of CD carrier status affecting antibiotic use (healthcare perspective) and 2) avoiding penalties for hospital-acquired CDI (hospital perspective). Results From the healthcare perspective, if antibiotic use is unchanged by CD status, surveillance costs $39/patient than current practice with unchanged CDI risk. However, if knowing CD status changed antibiotic prescribing such that CDI risk decreased by 10% or 20%, then cost/CDI avoided becomes $15,519 and $3,822 respectively, with CD surveillance becoming cheaper and more effective current practice if CDI risk decreased ≥30%. From the hospital perspective, using published CDI incidence (2.7%) and a hospital-associated CDI penalty of $30,000, surveillance cost $336/patient less than current practice if patients colonized on admission were not considered hospital-associated CDI and $476/patient less with local data (incidence 4.2%). Conclusion Hospital CD surveillance is potentially a cost-effective or cost-saving strategy depending on perspective taken and clinical usage of these data. This strategy could be implemented hospital-wide or in high-risk populations. CD surveillance could be both cost-saving and decrease CDI risk if more appropriate antibiotic use results from its use. Disclosures All Authors: No reported disclosures

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