Stewardship antibióticos

Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study.

Health Technol Assess. 2019 Mar;23(11):1-70

Authors: Gulliford MC, Juszczyk D, Prevost AT, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore M, Yardley L, Ashworth M, Charlton J

Abstract
BACKGROUND: Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance.
OBJECTIVES: To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs).
INTERVENTIONS: A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing.
DESIGN: A parallel-group, cluster randomised controlled trial.
SETTING: The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD).
PARTICIPANTS: All registered patients were included.
MAIN OUTCOME MEASURES: The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period.
COHORT STUDY: A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014.
RESULTS: There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices.
LIMITATIONS: The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended.
CONCLUSIONS: This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly.
FUTURE WORK: Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed.
TRIAL REGISTRATION: Current Controlled Trials ISRCTN95232781.
FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 11. See the NIHR Journals Library website for further project information.

PMID: 30900550 [PubMed - in process]

Reprint of: Blood culture time-to-positivity: making use of the hidden information.

Clin Microbiol Infect. 2019 Mar 18;:

Authors: Lamy B

PMID: 30898587 [PubMed - as supplied by publisher]

Apparent overuse of antibiotics in the management of watery diarrhoea in children in Abakaliki, Nigeria.

BMC Infect Dis. 2019 Mar 21;19(1):275

Authors: Efunshile AM, Ezeanosike O, Nwangwu CC, König B, Jokelainen P, Robertson LJ

Abstract
BACKGROUND: Diarrhoea remains an important cause of childhood mortality in Nigeria, with Rotavirus and Cryptosporidium reported to have the highest contribution. However, high use of antibiotics for treatment of paediatric diarrhoea has been observed, although World Health Organization guidelines discourage the use of antibiotics for treating acute diarrhoea. Here we investigated more closely management and treatment practices for acute paediatric diarrhoea, both in home and healthcare settings.
METHODS: Children under 5 years of age (n = 199) presenting at healthcare centres in Abakaliki, Nigeria with acute watery diarrhoea were included in the study. Background information on the children was collected by questionnaire, including home treatments, and clinical information including symptoms and treatment were provided by the healthcare centres. Analysis of faecal samples from the children indicated that over 90% had Rotavirus infection and over 6% Cryptosporidium infection. Data were compiled in a spreadsheet and analysed for associations between variables and use of antibiotics using logistic regression analysis.
RESULTS: Although most children were treated supportively (oral rehydration solution and intravenous fluids at home and in healthcare settings, respectively) over 15% were given anti-diarrhoea drugs at home and over 85% were also prescribed antibiotics at the healthcare centre, mostly ciproflaxin, but also metronidazole and gentamycin. The only variable positively associated with antibiotic prescription was diarrhoea more than three times per 24 h at admission.
CONCLUSIONS: It is clear that young children presenting with acute watery diarrhoea to healthcare centres in Abakaliki are likely to be prescribed antibiotics, despite there being no obvious reason that this treatment is appropriate. Our study results support the need for institution-based antimicrobial stewardship being implemented in Nigeria.

PMID: 30898105 [PubMed - in process]