Defining appropriate antibiotic prescribing in primary care: A modified Delphi panel approach

Abstract

BACKGROUND: Antimicrobial overuse contributes to antimicrobial resistance. In the ambulatory setting, where more than 90% of antibiotics are dispensed, there are no Canadian benchmarks for appropriate use. This study aims to define the expected appropriate outpatient antibiotic prescribing rates for three age groups (<2, 2-18, >18 years) using a modified Delphi method. METHODS: We developed an online questionnaire to solicit from a multidisciplinary panel (community-academic family physicians, adult-paediatric infectious disease physicians, and antimicrobial stewardship pharmacists) what percentage of 23 common clinical conditions would appropriately be treated with systemic antibiotics followed with in-person meetings to achieve 100% consensus. RESULTS: The panelists reached consensus for one condition online and 22 conditions face-to-face, which took an average of 2.6 rounds of discussion per condition (range, min-max 1-5). The consensus for appropriate systemic antibiotic prescribing rates were, for pneumonia, pyelonephritis, non-purulent skin and soft tissue infections (SSTI), other bacterial infections, and reproductive tract infections,

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data

“…We calculated averages of antibiotic prescribing rates, weighted by the number of encounters, by age group. Using the results from the modified Delphi panel on expected antibiotic prescribing rates (Appendix 1, Supplemental Table S1), 19 we calculated the percent of unnecessary antibiotic prescribing by subtracting the expected prescribing rate for a given condition and age group from the actual prescribing rate. Tier 1 conditions were constrained to having unnecessary antibiotic prescribing rates of 0%.…”

“…As a result, we recently defined expected antibiotic prescribing rates using a modified Delphi method to enable less biased evaluation of unnecessary antibiotic prescribing in Canadian primary care settings. 19 Our objective in the present study was to use these predefined expected rates of antibiotic prescribing to quantify the overall and the condition-specific rates of unnecessary antibiotic prescribing in a Canadian primary care setting. These data could be used to identify targets for anti microbial stewardship efforts to reduce ambulatory antibiotic prescribing safely and appropriately in order to slow the emergence of antimicrobial resistance.…”

“…We used a predefined list of expected antibiotic prescribing rates for 23 common conditions based on point estimates that were previously established from a modified Delphi process. 19 All other diagnoses were excluded, as appropriateness of antibiotic prescribing could not be assessed reliably. If there was more than 1 diagnosis for a particular encounter, we used a diagnostic hierarchy of assigning the diagnosis with the highest expected rate of antibiotic prescribing (Appendix 1, Supplemental Table S1, available at www.cmajopen.ca/content/8/2/ E360/suppl/DC1).…”

“…If there was more than 1 diagnosis for a particular encounter, we used a diagnostic hierarchy of assigning the diagnosis with the highest expected rate of antibiotic prescribing (Appendix 1, Supplemental Table S1, available at www.cmajopen.ca/content/8/2/ E360/suppl/DC1). 19 For example, if a patient was seen on day 1 and diagnosed with a common cold and then seen again on day 3 and diagnosed with pneumonia, these visits were grouped into a single encounter and assigned a diagnosis of pneumonia. We used physician diagnosis and did not incorporate other clinical, laboratory or diagnostic imaging results.…”

“…We grouped diagnoses into tiers as previously defined (Appendix 1, Supplemental Table S2). 19 Tier 1 included conditions for which antibiotics are always indicated (expected prescribing rate 100%), tier 2a included conditions for which antibiotics are frequently indicated (expected prescribing rate 51%-99%), tier 2b included conditions for which antibiotics are sometimes indicated (expected prescribing rate 21%-50%), tier 2c included conditions for which antibiotics are rarely indicated (expected prescribing rate 1%-20%), and tier 3 included conditions for which antibiotics are never indicated (expected prescribing rate 0%).…”