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Session Overview
4h. AMR: Improving Antibiotic Prescribing
Time: Wednesday, 16/Nov/2011: 3:15pm - 4:15pm
Session Moderator: Cecilia Stålsby Lundborg, Karolinska Institutet, Sweden
Session Moderator: Eva Miriam Ombaka, Private, Tanzania, United Republic of
Session Rapporteur: Sujith John Chandy, Christian Medical College, Vellore, India
Location: Amazonit


Physician as Primary Target in Improving Antibiotic Use in Primary Care: Review of Behavioural Interventions (CHAMP)

Alike W. van der Velden1, Marijke M. Kuyvenhoven1, Paul Little2, Theo J.M. Verheij1

1University Medical Center Utrecht, The Netherlands, Julius Center for Health Sciences and Primary Care; 2University of Southampton, UK, Primary Care Department

Problem statement: Overuse of antibiotics is a global problem resulting in resistance, unnecessary costs, and patients’ re-consultation. Guidelines on appropriate antibiotic treatment of infectious diseases, of which numerous were published, appeared not sufficient to restrict antibiotic use. Literature reviews are ambiguous in which interventions are most effective in improving antibiotic prescription.

Objective: To present an up-to-date overview of interventions to improve antibiotic prescribing for respiratory tract infections in primary care, with analyses on effectiveness and its determinants.

Design and setting: Literature review on studies targeted at primary care physicians and their patients in high-income countries (1990-2009). A broad range of designs was included: (quasi) randomised controlled trials, controlled before-after studies, and interrupted time series.

Methods: The extracted outcome was prescription of (first choice) antibiotics in DDD, packages or percentages. The intervention effectiveness was determined by the difference of differences (studies with a control group), or the difference (studies without a control group or without a before measurement). Associations of intervention characteristics and elements with effectiveness were analysed in multivariate regression analysis.

Results: 58 useful papers described 87 interventions, containing an average of 3 interventional elements; most often used elements were educational material for physicians (70%), educational material for patients (61%), educational meetings (56%), and audit/feedback (37%). Interventions aimed at decreasing overall prescription were more frequently effective (73%) than interventions aimed at increasing first-choice prescription (32%). On average, total antibiotic prescription was reduced by 11.6% (range: -72%-19%), and first-choice prescription increased by 9.6% (range: -5%-41%). Multiple interventions (OR: 6.5; 90% CI: 2-24) with at least ‘educational material for the physician’ (OR: 5.5; 90% CI: 2-18) are most often effective. No significant added value was found from multifaceted interventions containing patient-related elements. Furthermore, ‘near-patient testing’ and ‘training communication skills’ seem very promising; high effectiveness was seen in the limited number of studies using these elements.

Conclusions: This review emphasises the importance of physician education in improving rational use of antibiotics. Therefore, the physician should have a central role in giving access to antibiotics. The first steps in the comprehensive multilevel approach to decrease antibiotic use will be providing guidelines and teaching these guidelines and their background to (primary care) physicians. Monitoring of prescribing will be essential. Provision of near-patient tests (strep A, procalcitonin, C-reactive protein) will provide the physician with effective (communication) tools.

Funding sources: Work described is part of the CHAMP project (Changing Behaviour of Health Care Professionals and the General Public Towards a More Prudent Use of Antimicrobial Agents), a European Union 6th framework programme.

863-van der Velden-_a.pdf
863-van der Velden-_b.ppt
863-van der Velden-_c.pdf

Understanding and Optimising Antibiotic Prescription in Primary Care: Guidelines, Education, and Audit/Feedback in a Multiple Intervention

Alike W. van der Velden, Marijke M. Kuyvenhoven, Theo J.M. Verheij

University Medical Center Utrecht, The Netherlands, Julius Center for Health Sciences and Primary Care

Problem statement: The Netherlands has a tight primary care organisation with its own guidelines. Within Europe, The Netherlands has the lowest antibiotic use. Respiratory tract infections (RTIs), mostly viral and self-limiting, are nonetheless often treated with antibiotics, despite numerous studies concluding that treatment effects are modest to negligible.

Objectives: The ARTI (antibiotics in RTIs) project, consisting of 4 consecutive studies, aims to assess over-prescription of antibiotics for RTIs and to investigate the effectiveness of multiple interventions to optimise prescription of antibiotics for RTIs.

Designs: 1 observational study, 1 controlled before-after study, 2 randomised controlled trials (RCT)

Setting: Primary care practices in The Netherlands

Intervention: The interventions consisted of education of general practitioners (GP) by using guidelines, literature and communicative aspects, audit/feedback on prescribing data/behaviour, and information material for patients.

Outcome measures: Antibiotic prescription (rates or via pharmacies) and prescribing behaviour via registration (otitis, tonsillitis, sinusitis, bronchitis), were collected the year before and after the intervention

Results: GPs registered 2800 RTI consultations (patient characteristics, clinical presentation, management), revealing that 50% of prescriptions were not in accordance with Dutch guidelines. Overprescribing was highest for bronchitis and was independently associated with inflammation signs, the GPs’ perception of the severity of illness, and the GPs’ perception of the patients’ wish for an antibiotic. The first RCT (90 GPs) investigating the effectiveness of the multiple intervention showed a decrease of 12% in the antibiotic prescribing rate (95% CI: 4-19) without affecting patients’ satisfaction. In the CBA study (141 practices), education was given to larger groups of GPs, without feedback on prescribing behaviour. This larger scale implementation showed no reduction in antibiotic prescription. In the currently running RCT (90 practices), education is given at practice level and includes detailed feedback. In addition, a practice-specific antibiotic improvement plan is embedded within the quality assurance cycle of the Dutch college of GPs. The year after the intervention, prescription of antibiotics for RTIs and prescription of second-choice antibiotics decreased by 12% and 13.5%, respectively, whereas in the control group a decrease of 3% (p = 0.03) and an increase of 1% (p = 0.03) were seen.

Conclusions: GPs overestimate symptoms and patients’ expectations when choosing antibiotic therapy for RTIs. Education based on guidelines is not enough to change their prescribing behaviour. Monitoring and detailed feedback during an interactive education significantly reduce antibiotic prescription. Education should contain a patient-centred element on how to efficiently communicate a clear take-home message and how to deal with patients’ concerns and expectations.

Funding source: ZonMw, The Netherlands organisation for health research and development (implementation)

868-van der Velden-_a.pdf
868-van der Velden-_b.ppt
868-van der Velden-_c.pdf

Economic Burden and Health Consequences of Antibiotic Resistance in Patients at a Tertiary Care Hospital, Vellore, South India

Sujith John Chandy1,2, Thomas Kurien1, Thomas Nalloor1, V Balaji1, Solomon Christopher1, Cecilia Stalsby Lundborg2

1Christian Medical College, Vellore, India; 2Karolinska Institutet, Stockholm, Sweden

Problem statement: The phenomenon of antibiotic resistance is rising, which has not just health consequences, but cost implications, especially in low- and middle-income countries like India, where many patients cannot afford basic hospital treatment. It is important to study the extra costs patients have to bear due to bacterial resistance. This information could be used to convince policy makers about the need for stricter guidelines and awareness programs on rational use of antibiotics.

Objective: To estimate the economic burden and health consequences due to antibiotic resistance in hospital inpatients in a tertiary care hospital at Vellore, South India

Design: Descriptive cost analysis

Setting: Christian Medical College (CMC) Hospital, a private, mission university teaching hospital in Vellore, South India with 1,957 beds and 4500 outpatients per day that caters to all strata of society.

Study population: All inpatients admitted to the medical wards of CMC during a one- year period with a diagnosis of septicemia, prescribed an empirical antibiotic, and with a culture and sensitivity test report were included in the study which is ongoing.

Outcome measures: Information on admission details, diagnosis, co-morbidities, medicine use, culture and susceptibility results, intensive care admission, and time to hospital discharge were collected through the hospital computer system. The costs of antibiotics, other medicines, labor, laboratory, bed and dietary charges, intensive care, and other miscellaneous charges were determined. To assess the economic burden of resistance, the overall cost to patients when empirical antibiotic therapy is effective was compared with the overall cost to patients for whom the empirical antibiotic had to be changed due to resistance. Intensive care admissions and hospital stay were also compared.

Results: Among the 204 patients, 36% had E. coli as the main infective organism (isolated through blood) and 27% received piperacillin-tazobactam as the main empirical antibiotic. Costs for patients in the resistant group were 44% more than for those in the susceptible group, which amounts to approximately Rs. 37,804. Though there was no appreciable difference in mortality and length of stay, intensive care unit admission, antibiotic costs, the costs of oxygen, ventilator support, intensive care, medicines, special procedures, dialysis, and laboratory work were all higher for resistant patients compared to the susceptible group. This demonstrates that there are also appreciable differences in health consequences.

Conclusion: Bacterial resistance has a significant impact on the cost burden to patients and their health. Policy makers can use the evidence presented here to strategize interventions and key messages.

Funding source: EMECW Lot 15 scholarship was granted to first author. Permission was granted by IRB, CMC Hospital, Vellore.


Antibiotic Prescribing Practices of Primary Care Prescribers for Acute Respiratory Tract Infections and Diarrhoea in New Delhi, India

Anita Kotwani1, Ranjit Roy Chaudhury2, Kathleen Holloway3

1V. P. Chest Institute, University of Delhi, Delhi, India; 2Apollo Hospitals Educational and Research Foundation, New Delhi, India; 3World Health Organization, Regional Office for South East Asia, New Delhi, India

Problem statement: The rapid emergence of antimicrobial resistance in the community has become a major global health problem. Excessive use of antibiotics in ambulatory care settings, especially for conditions that do not require antibiotics, is one of the major contributing factors to the emergence and spread of antibiotic-resistant bacteria in the community.

Objective: To obtain information on current prescribing rates of antibiotics in acute respiratory tract infections (ARIs) and acute diarrhoea in the community, conditions where misuse of antibiotics are common.

Design: Cross-sectional study

Setting: 10 primary care public facilities and 20 private clinics in 4 residential localities of Delhi

Study population: After consultation with a prescriber, patients were asked if they had cough/common cold/sore throat (symptoms of ARI) or acute diarrhoea without any blood. Patients with any of these symptoms were enrolled for an exit interview and his/her prescription was monitored. Antibiotic use data was collected per month over one year (December 2007–November 2008).

Outcome measure: The percentage of patients receiving antibiotics and the pattern of consumption of antibiotics was analyzed by using the Anatomical Therapeutic Chemical classification and the defined daily dose.

Results: At public facilities, 45.3% (746/1646), and at private facilities, 56.7% (259/457), of patients with ARIs were prescribed at least one antibiotic. In the public sector, macrolides, J01FA (29.3%), penicillins, J01C (26.3%), and cephalosporins, J01DA (16.2%); and in the private sector, cephalosporins (40%), fluoroquinolones (21.7%), and penicillins (19.7%) were mainly prescribed. At public facilities, the main members from macrolides were roxithromycin and erythromycin; for penicillins, amoxicillin and amoxicillin+clavulinic acid; for cephalosporins, cefuroxime and cephalexin were used. At private clinics, for cephalosporins, cefuroxime, cefpodoxime proxetil, cefixime, cefixime+clavulinic acid; for fluoroquinolones, levofloxacin and ofloxacin; and for the penicillins group, amoxicillin+clavulinic acid were prescribed. For acute diaarhoea, at public facilities 43% (171/398) and at private facilities 69% (76/110) of patients were prescribed at least one antibiotic. The number of diarrhoea patients increased during the humid summer months. The main antibiotic class that was prescribed in both public and private sector facilities was fluoroquinolones, J01MA (91.5% and 96%). In the private sector, pediatricians prescribed antibiotics to 51.5% (17/33) of children, and in the public sector, antibiotics (fluoroquinolone) were prescribed to 23% of children with diarrhoea. At public facilities, the most commonly prescribed fluoroquinolone was norfloxacin, followed by ofloxacin and ciprofloxacin. At private clinics, it was ofloxacin followed by ciprofloxacin.

Conclusions: This study clearly shows irrational use of antibiotics for treatment of acute diarrhoea and ARI that warrants interventional strategies.

Funding source: WHO