Clinicians’ adherence to local antibiotic guidelines for upper respiratory tract infections in the ear, nose & throat casualty department of a public general hospital

Background: In Malta, resistance to antibiotics constitutes a major threat to public health. This study aims to assess clinicians’ adherence to local antibiotic guidelines when treating cases of acute otitis media, acute tonsillitis and rhinosinusitis, that present to the ear, nose and throat (ENT) casualty department in Malta’s public general hospital, as well as to recommend methods for improving adherence and minimising overprescribing. Methodology: Data on first line antibiotic prescribing regimens was retrieved from ENT casualty sheets between February and March 2015 for adult patients (>12years) diagnosed with acute otitis media, acute tonsillitis and persistent rhinosinusitis. On an audit form, aspects of the prescribed antibiotic were benchmarked to local infection control antibiotic guidelines of 2011 to evaluate adherence. Results: From 1010 casualty records, 188 were antibiotic prescriptions, of which 93 (49.4%) were correctly indicated as per guidelines. From the indicated prescriptions 81 (87%) were assessable, out of which full adherence was only observed in 6 (7%) of prescriptions. All of these were for rhinosinusitis. Full adherence in rhinosinusitis was found to be 43%, whilst no adherence was found in the other infections. The most prescribed antibacterial for all three infections was co-amoxiclav. Conclusion: The current antibiotic guidelines have not been adequately implemented as adherence to antibiotic choice alone was low in all infections. This may have an impact on antibiotic-resistant rates and infection incident rates. Hence to improve adherence to local antibiotic guidelines, it is recommended that these should be clear, regularly updated, well disseminated and reinforced. The addition of a care pathway may further improve appropriate antibiotic use.peer-reviewe

Does a simple educational exercise influence practice in acute tonsillitis in children?

Aim: To assess the concordance of treatment of children attending with tonsillitis in Paediatric Accident and Emergency with established guidelines, and subsequent review of the management of this condition after a simple educational exercise. Methods: An audit on children with tonsillitis was carried out amongst doctors working in the Paediatric Accident and Emergency Department during a three month period in 2009. Eleven doctors completed an anonymous questionnaire requesting details on presentation, symptoms, investigations and treatment of children presenting with acute tonsillitis. The results obtained from this questionnaire were compared to NICE guidelines and modified Centor (McIsaac) criteria, and fed back to the participating doctors together with copies of these guidelines via a simple, structured educational exercise. Three months later, a second identical questionnaire was again completed by the same cohort of doctors. Results: The first questionnaire showed that there was a tendency towards unnecessary prescription of antibiotics and investigations in children with acute tonsillitis, when compared to recommendations in the guidelines. Following educational feedback, the second questionnaire showed a reduction in antibiotic prescriptions by 9% (p=0.5) and investigations by 37% (p=0.1). Compliance with guidelines had improved significantly with regard to non-prescribing of antibiotics with a fever of 1cm and presence of underlying disease although these changes were not statistically significant. Conclusion: Although doctors were initially only partly compliant with established guidelines for children with acute tonsillitis, compliance improved significantly after a simple educational exercise.peer-reviewe

Shared decision making and antibiotic benefit-harm conversations: an observational study of consultations between general practitioners and patients with acute respiratory infections

Abstract Background Little research has examined whether shared decision making (SDM) occurs in consultations for acute respiratory infections (ARIs), including what, and how, antibiotic benefits and harms are discussed. We aimed to analyse the extent and nature of SDM in consultations between GPs and patients with ARIs, and explore communication with and without the use of patient decision aids. Methods This was an observational study in Australian general practices, nested within a cluster randomised trial of decision aids (for acute otitis media [AOM], sore throat, acute bronchitis) designed for general practitioners (GPs) to use with patients, compared with usual care (no decision aids). Audio-recordings of consultations of a convenience sample of consenting patients seeing a GP for an ARI were independently analysed by two raters using the OPTION-12 (observing patient involvement in decision making) scale (maximum score of 100) and 5 items (about communicating evidence) from the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool (maximum score of 5). Patients also self-completed a questionnaire post-consultation that contained items from CollaboRATE-5 (perceptions of involvement in the decision-making process), a decisional conflict scale, and a decision self-efficacy scale. Descriptive statistics were calculated for each measure. Results Thirty-six consultations, involving 13 GPs, were recorded (20 for bronchitis, 10 sore throat, 6 AOM). The mean (SD) total OPTION-12 score was 29.4 (12.5; range 4–54), with item 12 (need to review decision) the highest (mean = 3) and item 10 (eliciting patients’ preferred level of decision-making involvement) the lowest (mean = 0.1). The mean (SD) total ACEPP score was 2 (1.6), with the item about discussing benefits scoring highest. In consultations where a decision aid was used (15, 42%), compared to the 21 usual care consultations, mean observer-assessed SDM scores (OPTION-12, ACEPP scores) were higher and antibiotic harms mentioned in all (compared to only 1) consultations. Patients generally reported high decision involvement and self-efficacy, and low decisional conflict. Conclusions The extent of observer-assessed SDM between GPs and patients with ARIs was generally low. Balanced discussion of antibiotic benefits and harms occurred more often when decision aids were used

PRImary care Streptococcal Management (PRISM) study:In vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study

Background: Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. Objective: This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. Design: The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. Setting: The setting was UK primary care general practices. Participants: Participants were patients aged ≥ 3 years with acute sore throat. Interventions: An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. Main outcome measures: The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). Results: The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. Conclusions: Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed

The Differences in Antibiotic Decision-making Between Acute Surgical and Acute Medical Teams: An Ethnographic Study of Culture and Team Dynamics

Background Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties. Methods An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015–May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings. Results In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use. Conclusions In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs

A mixed-methods study of antibiotics use and prescribing dynamics in Indonesian hospitals: implications for antimicrobial stewardship

Antimicrobial resistance (AMR) is an accelerating public health problem, with antimicrobial agents, including their inappropriate use, being one of the key drivers. In Indonesian hospitals, there is a fragmented picture of antibiotic use and of the drivers of prescribing patterns. This thesis aimed to fill this knowledge gap by assessing patterns and quality indicators of antibiotic prescribing for hospitalised patients, mapping their drivers and dynamics, and exploring the factors influencing the implementation of antimicrobial stewardship (AMS) programmes. Using an explanatory sequential mixed-method approach, data collection was conducted in six hospitals in Jakarta, between March 2019 and October 2020. A quantitative survey found high proportions of hospitalised patients receiving systemic antibiotics, that guideline compliance was poor, use of blood cultures was low, and that prolonged surgical prophylaxis was common. The qualitative findings revealed multidimensional social-cultural factors influenced antibiotic prescribing, such as disjunctions between drivers of AMR and day-to-day clinical practice, antibiotic prescribing as risk aversion vis-à-vis concerns of poor clinical outcomes, the ‘pull’ of conformity to normative, suboptimal group prescribing practices, and suboptimal operations of microbiology and surgical facilities. Effective AMS programme implementation was challenged by ineffective resourcing and institutional buy-in, cost-prohibitive culture testing, entangled hospital priorities to generate profits, and a non-collegial communication approach to AMS execution. Three identified areas of improvement are addressing hierarchical cultural norms in the medical profession, encouraging ownership of the AMR problem and solution among all stakeholders, and developing sustainable context-specific AMS strategies. Based on the complex adaptive system (CAS) concept, I formulated four recommendations: 1) identifying the agents of influence; 2) evaluating the problem using a CAS lens; 3) developing health system resilience; and 4) identifying leverage points. In conclusion, this thesis contributed to the development of a conceptual framework showing how multilevel and multidimensional social-cultural factors interact to influence antibiotic prescribing and AMS implementation

Defining empirical management of acute febrile illness in Myanmar

Fever is a common presenting symptom in primary care in low- and middle- income countries (LMICs). Non-malaria pathogens are now responsible in most cases after a decline of malaria in previously malaria endemic regions of Myanmar. It is important to provide appropriate treatment to those patients after malaria is ruled out by rapid tests or microscopy. The overall aim of this thesis is to improve management of acute non-malaria febrile illness in Myanmar. Empirical treatment strategies with selected antibiotics were devised and their cost-effectiveness was evaluated using a decision tree modelling approach. A systematic review on infectious neglected tropical diseases (NTDs) was conducted to collate all reports of NTDs in Myanmar (Chapter 2). The review identified diseases (rickettsial infection and leptospirosis) commonly associated with acute fever and this finding partly informed selection of antibiotics for empirical treatment. A cost- effectiveness analysis of empirical treatment showed empirical treatments being cost- saving and C-reactive protein (CRP) guided empirical treatments being highly cost- effective compared to current practice of care in rural Myanmar (Chapter 3). Alongside this, antibiotic use for acute febrile illness was also explored from the prescriber’s perspective by secondary analysis of the data derived from a clinical trial (Chapter 4) and the user’s perspective by public engagement activities (Chapter 6). The secondary data analysis found a substantial variation of antibiotic prescription among primary care doctors for acute febrile illness and the variation remained after accounting for patients’ clinical presentations and CRP test results. Widespread environmental distribution of Burkholderia pseudomallei, the causal organism of melioidosis, which commonly presents as community acquired pneumonia and sepsis, was confirmed by a large nationwide study (Chapter 5). In conclusion, this thesis uses a multifaceted approach to improve management of acute febrile illness in Myanmar. Findings from this thesis point towards an empirical antibiotic treatment strategy as a potential approach for management of non-malaria febrile illness in rural Myanmar which could be evaluated in field trials