Background In most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level. Aim Our objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs’ performance scores and their clinimetric properties using a large regional reimbursement database. Methods A recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties). Results The 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential. Conclusions The set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.

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Background – The literature shows that the prescription of antibiotics in dental care is often unnecessary or inappropriate. Indicators estimating the appropriateness of antibiotics prescribed by dentists based on routine databases are however not available in the literature. Our objectives were to: (i) design proxy indicators estimating the appropriateness of antibiotics prescribed by dentists; (ii) evaluate their clinimetric properties; and (iii) provide results for these proxy indicators for dentists located in a north-eastern French region. Methods – We selected and adapted proxy indicators from the literature. Using 2019 Regional Health Insurance data, we evaluated the proxy indicators’ clinimetric properties (measurability, applicability, and potential room for improvement), their results with performance scores (% of dentists who reached the target value), and the case-mix stability. Results – We included 3,014 general dental practitioners, who prescribed a total of 373,975 antibiotics to 308,123 patients in 2019. We identified four proxy indicators estimating antibiotic prescribing appropriateness in dental care. All proxy indicators had good clinimetric properties. Performance scores were generally low (10.5 to 73.0%, depending on the indicator), suggesting an important room for improvement. These results showed large variations between dentists (large interquartile ranges) and according to the patients’ characteristics (case-mix stability). Conclusion – These four proxy indicators might be used to guide antibiotic stewardship interventions in dental care.

Objectives Monitoring the appropriateness of antibiotic prescriptions with indicators based on reimbursement data is required to guide antibiotic stewardship (AMS) interventions in nursing homes (NHs). Quantity metrics (QMs) monitor the volume of prescriptions while proxy indicators (PIs) reflect the appropriateness of antibiotic use. Our objectives were: (i) to provide a relevant consensual set of indicators to be used in French NHs; and (ii) to assess the feasibility of their implementation at the national and local scale. Methods Nine French professional organizations implicated in AMS in NHs were asked to nominate at least one member to create a national expert panel of 20 physicians. Twenty-one recently published QMs and 11 PIs were assessed by the expert panel. Indicators were evaluated using a RAND-modified Delphi procedure comprising two online surveys and a videoconference meeting. Indicators were kept in the final list if &gt;70% of stakeholders validated their relevance for estimating the volume (QMs) and appropriateness (PIs) of prescriptions. Results Of the 21 QM indicators submitted to the panel, 14 were selected, describing the consumption of antibiotics overall (n = 3), broad-spectrum (n = 6) and second-line antibiotics (n = 2). The three remaining QMs evaluated the route of administration (n = 1) and urine culture prescriptions (n = 2). Ten PIs (six modified, two rejected, one new) were selected to assess the appropriateness of prescriptions for urinary tract infections (n = 2), seasonal variations in prescriptions (n = 2), repeated prescriptions of fluoroquinolones (n = 1), cephalosporins’ route of administration (n = 1), duration of treatment (n = 1), rate of second-line antibiotics (n = 1), co-prescriptions with non-steroidal anti-inflammatory drugs (n = 1), and flu vaccine coverage (n = 1). The panel was in favour of using these indicators for regional and facility level AMS programmes (91%), feedback to NH prescribers (82%), benchmarking by health authorities (55%) and public reporting at the facility level (9%). Conclusions This consensual list of indicators, covering a wide range of frequent clinical situations, may be used as part of the French national AMS strategy for monitoring antibiotic prescriptions in NHs at the national and local levels. Regional AMS networks might manage this selected list to guide personalized action plans with concrete objectives of reducing the quantity and improving the quality of antibiotic prescriptions.

Background Antibiotic resistance is a growing issue in nursing homes (NHs). Antibiotic stewardship (ABS) programmes can reduce antibiotic use in NHs, but few studies have assessed to what extent they are implemented in NHs. Objectives To describe ABS current practices and describe the opinion of NH stakeholders regarding ABS and opportunities for improvement in one French region. Methods We invited by e-mail the medical and nurse coordinators of all NHs of the Grand Est region, France, to participate in our survey in 2019. The online questionnaire included 35 questions covering four topics: NH characteristics, current ABS practices, attitudes towards ABS and opinions on strategies to promote ABS. A score evaluating implementation of core ABS elements was calculated using the current ABS practice responses. Results Out of 417 NHs, 75 (18%) participated in our survey. The three most implemented ABS activities were antibiotic consumption monitoring (65%), antibiotic plan documentation (56%) and antibiotic prescription guide distribution (54%). Audit and feedback, training sessions or identification of a local ABS leader ranged from 13% to 29%. Participants positively perceived ABS and most suggestions to improve ABS programmes in NH, with maximal interest in training, audit and feedback interventions. The median score for implementation of core ABS elements was 3.3 (IQR = 2.3–5.4; theoretical range 0–11), and the score distribution was not associated with any NH characteristic. Conclusions While there is still room for improvement, NHs had a positive attitude towards ABS strategies. Some regional and national initiatives to promote ABS in NHs exist and should be actively promoted.