Determinants of Clinician and Patient to Prescription of Antimicrobials: Case of Mulanje, Southern Malawi

Background: Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. Methods: In-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. Results: Participants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance.Conclusion: Inappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

Reduction of drug-drug interaction and inappropriate prescription in polymedicated elderly who consult in the ambulatory

Introduction: Older adults or elderly people over 64 years of age are patients more vulnerable to suffering adverse events related to medication, and this can generate states of both physical and psychological discomfort, loss of autonomy, mental disorders, etc. Objectives: To analyze the drug-drug interaction and inappropriate prescription of drugs in the outpatient setting in the elderly and implement barriers to reduce this problem. Materials and methods: Quasi-experimental study, of the before after type. The Beers 2019 criteria were used to assess inappropriate drug prescribing. The Uptodate definition of drug-drug interactions and their classification were used. Results: 203 polypathological, sarcopenic elderly patients were studied. These patients attended the outpatient consultation during the 2016-2018 period. 99 patients participated in the pre-intervention and 104 in the post-intervention. The distribution by sex was: 110 (54.2%) women and 93 (45.8%) men. The mean age was 77.3 + 13.3 years. In the total sample analyzed before the intervention, 33 (33.3%) showed inappropriate prescription of drugs criteria. Drug interactions in the pre-intervention were present in 51 patients (51.5%). After the intervention that consisted of training doctors with the Beers criteria and editing a list with clinically relevant interactions in the elderly, which can cause adverse events, inappropriate prescription was reduced to 26 patients (25%), p = 0.05, and clinically relevant interactions were reduced from 51 (51.51%) to 12 (11.53%), p = 0.003. The association between inappropriate prescription and clinically relevant interactions is OR: 3.23 (95% CI 1.91-3.88). Conclusions: The proportion of patients with inappropriate prescription is within the ranges published by various authors as well as drug interactions, the intervention was good to reduce the two problems in this sample of patients.

Determinants of Clinician and Patient to prescription of antimicrobials: case of Mulanje, Southern Malawi

BackgroundAntimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. MethodsIn-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. ResultsParticipants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance. ConclusionInappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

884 Improving the Analgesia Prescribing Compliance to NICE Guidelines (NG118) In Suspected Renal Colic Patients Using a Proforma

Aim To improve analgesia prescribing for patients admitted with suspected renal colic in line with NICE guidelines (NG118) in an acute district general hospital using a proforma. Method In the first cycle, a retrospective review of 16 patients who presented with renal colic to the emergency department or surgical assessment unit was performed and the analgesia prescribing was recorded. A unique analgesia prescribing proforma was then developed using NICE guidelines (NG118) including the use of NSAIDS as first-line when there are no contra-indications, intravenous paracetamol, opioid analgesics and omitting antispasmodics. Following implementation of the proforma, a prospective review of 18 patients were included in the second cycle and the prescribing compliance were compared. Results Study included 34 patients who presented with suspected renal colic over a 3-month period. In the first cycle, 19% of patients had appropriate analgesia prescribed which were compliant with NICE guidelines. In cycle 2, 89% of patients had appropriate analgesia prescribed. In particular, the inappropriate prescription of antispasmodics has improved significantly (38 % in cycle 1 vs 0 % in cycle 2). Conclusions A proforma can serve as a useful ‘checklist’ for analgesia prescribing and improve the symptomatic relief for patients presenting with suspected renal colic in line with NICE quality standards.

Individualized Medication Review in Older People: Differences Due To Place of Residence Being Their Own Home or A Nursing Home

Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review in frail older people lead to optimize medication use. The aims of the study were to identify inappropriate prescription and to assess the results of a medication review in older people, according to their place of residence. Methods: This was a study with paired pre- and post-medication review data based on person-centered prescription, with a follow-up assessment at three months. We recruited patients who lived in the community, either in their own home or in a nursing home. We select patients of 65 years or more with multimorbidity whom his General Practitioner identified difficulties with the prescription management and the need of a medication review. Finally, a medication review was carried out through the application of the Patient-Centered Prescription model. Data collected were: age, sex, place of residence, morbidities, functional and cognitive status, frailty index, number of medications, therapeutical complexity, anticholinergic and/or sedative burden and monthly medication expenditure. The Chi-square test or Fisher's exact test were used to evaluate the relationship between qualitative variables and the patients’ place of residence. Student’s t-test was used to analyze the relationship between quantitative variables and the patients’ place of residence.Results: 428 patients. 90% of people presented at least one inappropriate prescription in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p<0.001)). Post-medication review, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity and in monthly medication expenditure (p<0.001). Conclusions: Patient-Centered Prescription model detected a high number of inappropriate prescriptions in both settings. However, once medication was reviewed and optimization proposals implemented, nursing-home patients presented

Prevalence of Polypharmacy and Inappropriate Medication in Adults With Intellectual Disabilities in a Hospital Setting in Switzerland

Background: Polypharmacy and inappropriate prescription are frequent in vulnerable and multi-morbid populations. Adults with intellectual disability (ID) are at risk of being polymedicated because they often present with multiple comorbidities and challenging behaviors.Aim: The objective of this study was thus to evaluate the prevalence of potentially inappropriate medications (PIM) and polypharmacy in a hospital unit dedicated to adults with ID.Methods: A 10-month prospective observational study took place at a hospital unit specializing in the care of adults with ID in Geneva, Switzerland. Once a week, health and prescription data were collected and screened for PIM according to preset definitions.Results: Fourteen patients consented to participate, leading to 20 hospitalization events assessed during the study. Hospitalizations lasted 12.8 weeks on average. ID severities ranged from mild to profound, all degrees of severity being equally represented. One hundred percent of the patients were polymedicated (defined as five drugs or more prescribed simultaneously). A mean number of 9.4 drugs were prescribed per week, including 5.3 psychotropic drugs. The number of prescribed drugs remained stable throughout the hospitalizations. Antipsychotics were the most prescribed drug class (19% of all prescribed drugs), followed by benzodiazepines (13%) and laxatives (12%). A total of 114 PIM were recorded with an average of 5.7 PIM per hospitalization.Conclusions: This study showed that polypharmacy and inappropriate prescription are very common in adults with ID, even though the literature and expert positions advocate for deprescription in these patients. Specific prescribing and deprescribing guidelines are needed for that specific population.

Inappropriate antibiotic use in the COVID-19 era: Factors associated with inappropriate prescribing and secondary complications. Analysis of the registry SEMI-COVID

Background Most patients with COVID-19 receive antibiotics despite the fact that bacterial co-infections are rare. This can lead to increased complications, including antibacterial resistance. We aim to analyze risk factors for inappropriate antibiotic prescription in these patients and describe possible complications arising from their use. Methods The SEMI-COVID-19 Registry is a multicenter, retrospective patient cohort. Patients with antibiotic were divided into two groups according to appropriate or inappropriate prescription, depending on whether the patient fulfill any criteria for its use. Comparison was made by means of multilevel logistic regression analysis. Possible complications of antibiotic use were also identified. Results Out of 13,932 patients, 3047 (21.6%) were prescribed no antibiotics, 6116 (43.9%) were appropriately prescribed antibiotics, and 4769 (34.2%) were inappropriately prescribed antibiotics. The following were independent factors of inappropriate prescription: February-March 2020 admission (OR 1.54, 95%CI 1.18–2.00), age (OR 0.98, 95%CI 0.97–0.99), absence of comorbidity (OR 1.43, 95%CI 1.05–1.94), dry cough (OR 2.51, 95%CI 1.94–3.26), fever (OR 1.33, 95%CI 1.13–1.56), dyspnea (OR 1.31, 95%CI 1.04–1.69), flu-like symptoms (OR 2.70, 95%CI 1.75–4.17), and elevated C-reactive protein levels (OR 1.01 for each mg/L increase, 95% CI 1.00–1.01). Adverse drug reactions were more frequent in patients who received ANTIBIOTIC (4.9% vs 2.7%, p < .001). Conclusion The inappropriate use of antibiotics was very frequent in COVID-19 patients and entailed an increased risk of adverse reactions. It is crucial to define criteria for their use in these patients. Knowledge of the factors associated with inappropriate prescribing can be helpful.

The burden of polypharmacy and drug–drug interactions in older cancer patients treated with immunotherapy

Introduction Polypharmacy is a common problem in older cancer patients, although the data about polypharmacy and potentially inappropriate prescription practices is limited in patients treated with immune checkpoint inhibitors (ICIs). Therefore, we aimed to evaluate the polypharmacy frequency and drug-drug interactions in older cancer patients (≥65 years) treated with ICIs. Methods A total of 70 geriatric patients with advanced cancer were included. The polypharmacy was defined as regular use of 5 or more drugs. The START/STOPP Criteria Version 2 was used for the potentially inappropriate medications (PIM) and potential prescription omissions (PPO). The Medscape Drug Interaction Checker was used for potential drug-drug interactions. Results The patients had a median of 6 regular drugs, and polypharmacy was present in 77.1%. The polypharmacy risk was significantly increased in patients over 75 years of age (p = 0.028) and with opioid use (p = 0.048). The 50% of patients had category D or X interactions. Patients with higher Charlson Comorbidity Index had significantly increased risk for drug interactions (CCI ≤10 vs. >10, p = 0.017). The PIMs were present in 44.3% and the PPOs in 68.6% of the patients. While the overall survival and immune related adverse events were similar according to polypharmacy, in patients using seven or more drugs, the acute kidney injury risk was increased (HR: 4.667, p = 0.038). Conclusion In this study, we observed a high rate of polypharmacy and inappropriate prescription practices in ICI-treated patients. These issues pointed out the need for improved general medical care and attention for better comedication management in ICI-treated patients.