Informing antimicrobial stewardship: factors associated with inappropriate antimicrobial prescribing in primary care

Singer, Alexander; Fanella, Sergio; Kosowan, Leanne; Falk, Jamie; Dufault, Brenden; Hamilton, Kevin; Walus, Ashley

doi:10.1093/fampra/cmx118

Cited by 19 publications

(26 citation statements)

References 21 publications

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“…In rural and remote areas, inappropriate prescribing was reported to be highly prevalent, with 18-88% of antimicrobial prescriptions deemed inappropriate depending on the country [34][35][36][37][38]. Antibiotics were the antimicrobial agents most frequently incorrectly prescribed [35][36][37][38][39].…”

Section: Appropriateness Of Antimicrobial Prescribing In Rural and Remote Primary Health Carementioning

confidence: 99%

Antimicrobial stewardship in rural and remote primary health care: a narrative review

Yau

Thor

Tsai

et al. 2021

Antimicrob Resist Infect Control

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Background Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. Methods The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. Results Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. Conclusions Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

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Section: Appropriateness Of Antimicrobial Prescribing In Rural and Remote Primary Health Carementioning

confidence: 99%

Antimicrobial stewardship in rural and remote primary health care: a narrative review

Yau

Thor

Tsai

et al. 2021

Antimicrob Resist Infect Control

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“… 25 A small study from the Manitoba region in Canada, that focused on urinary tract infection, pharyngitis, skin or soft tissue infections, and pneumonia estimated that 15% of prescriptions with the appropriate antibiotic were for treatments longer than guideline based recommendations. 26 …”

Section: Introductionmentioning

confidence: 99%

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

Pouwels

Hopkins

Llewelyn

et al. 2019

BMJ

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ObjectiveTo evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations.DesignCross sectional study.SettingGeneral practices contributing to The Health Improvement Network database, 2013-15.Participants931 015 consultations that resulted in an antibiotic prescription for one of several indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis.Main outcome measuresThe main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication.ResultsThe most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines.ConclusionFor most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.

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“…12,13 Antimicrobial stewardship program implementation in primary care settings can reduce broad-spectrum antimicrobial use. 14 As studies keep identifying potentially inappropriate antimicrobials prescribed with duration of treatment outside of guideline-based range, 15 more collaboration among physicians and community pharmacists and greater involvement of community pharmacists in antimicrobial stewardship programs should be encouraged. This study included community pharmacists, family medicine other physicians.…”

Section: Introductionmentioning

confidence: 99%

Antimicrobial Resistance: Physicians' and Pharmacists' Perspective

Rušić

Božić

Bukic

et al. 2020

Microbial Drug Resistance

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The aim of this study was to evaluate pharmacists' and physicians' attitudes and knowledge about antimicrobial treatment and resistance and based on the results to identify possible gaps and suggest opportunities for collaboration between the two professions. Methods: The physician's questionnaire consisted of 47 items and the pharmacists' questionnaire consisted of 50 items. Participants were asked to identify situations in which they were more likely to prescribe/dispense an antimicrobial without a firm indication, to identify the greatest contributors to antimicrobial resistance (AMR) among health care workers, to rate statements related to AMR, how frequently they used different sources of information and to rate the possible causes of AMR. Furthermore, preparedness for specific actions in practice was self-rated and knowledge was evaluated. The questionnaires were anonymous and participation in the study was voluntary. Results: This research included 180 community pharmacists and 181 physicians. As many as 76 (42.0%) physicians stated they would prescribe an antimicrobial when unsure whether the infection was of viral or bacterial etiology. More than half of the participants considered family medicine doctors the greatest contributors to AMR (N = 216, 59.8%), followed by patients (N = 175, 48.5%). In questions focusing on knowledge, physicians scored significantly higher compared with pharmacists (4.06-1.01 vs. 3.71-1.08, p = 0.001). Conclusion: This research revealed practices among pharmacists and physicians that should be improved and it highlighted gaps in knowledge by both professions. More attention should be given to patient consultation when dispensing and prescribing an antimicrobial as this may reduce their contribution to AMR.

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Informing antimicrobial stewardship: factors associated with inappropriate antimicrobial prescribing in primary care

Cited by 19 publications

References 21 publications

Antimicrobial stewardship in rural and remote primary health care: a narrative review

Antimicrobial stewardship in rural and remote primary health care: a narrative review

Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

Antimicrobial Resistance: Physicians' and Pharmacists' Perspective

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