The impact of diagnostic microbiology on de-escalation of antimicrobial therapy in hospitalised adults.

BACKGROUND: Minimising antimicrobial overuse is needed to limit antimicrobial resistance. There is little evidence on how often microbiological testing informs antimicrobial de-escalation (e.g. stopping, shortening duration, switching to narrower spectrum or intravenous to oral switch) at 48-72 h "review and revise". We performed a patient level analysis of diagnostic microbiology and antimicrobial prescribing to determine the impact of microbiology results on antimicrobial review outcomes. METHODS: Antimicrobial prescribing data were collected for hospitalised adults from across Brighton and Sussex University Hospitals NHS Trust using routine monthly audits of prescribing practice from July 2016 to April 2017. Microbiology testing data for cultures of blood, urine, sputum and cerebrospinal fluid (CSF) were gathered from the hospital pathology database and linked to prescriptions with matching patient identification codes. Antimicrobial prescriptions were grouped into "prescription episodes" (PEs), defined as one or more antimicrobials prescribed to the same patient for the same indication. Medical records were reviewed for all PEs with positive microbiology and a randomised sample of those with negative results to assess the impact of the microbiology result on the antimicrobial prescription(s). RESULTS: After excluding topical and prophylactic prescriptions, data were available for 382 inpatient antimicrobial prescriptions grouped into 276 prescription episodes. 162/276 (59%) had contemporaneous microbiology sent. After filtering likely contaminants, 33/276 (12%) returned relevant positive results, of which 20/33 (61%) had antimicrobials changed from empiric therapy as a result with 6/33 (18%) prompting de-escalation. Positive blood and CSF tended to have greater impact than urine or sputum cultures. 124/276 (45%) PEs returned only negative microbiology, and this was documented in the medical notes less often (9/40, 23%) than positive results (28/33, 85%). Out of 40 reviewed PEs with negative microbiology, we identified just one (~ 3%) in which antimicrobials were unambiguously de-escalated following the negative result. CONCLUSIONS: The majority of diagnostic microbiology tests sent to inform clinical management yielded negative results. However, negative microbiology contributed little to clinical decision making about antimicrobial de-escalation, perhaps reflecting a lack of trust in negative results by treating clinicians. Improving the negative predictive value of currently available diagnostic microbiology could help hospital prescribers in de-escalating antimicrobial therapy

Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013:a UK study

Purpose To describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999-2013 in the UK. Methods We used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to five years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI). Results 13,069 patients (76% female) diagnosed with a hip fracture during 1999-2013 were identified. 11% had any anti-osteoporosis drug prescription in the six months prior to the index hip fracture. In the 0-4 months following a hip fracture 5% of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51% in 2011 to then decrease to 39% in 2013. The independent predictors (OR (95%CI)) of treatment initiation included gender (male:0.42 (0.36-0.49)), BMI (0.98 per kg/m2 increase (0.97-1.00)) and geographic region (1.29 (0.89-1.87) North East vs. 0.56(0.43-0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally an additional 3,214 hip fracture patients would be initiated on therapy every year. Conclusions Significant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture. </p

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Objective: Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013

Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013: a UK study

Purpose To describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999-2013 in the UK. Methods We used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to five years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI). Results 13,069 patients (76% female) diagnosed with a hip fracture during 1999-2013 were identified. 11% had any anti-osteoporosis drug prescription in the six months prior to the index hip fracture. In the 0-4 months following a hip fracture 5% of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51% in 2011 to then decrease to 39% in 2013. The independent predictors (OR (95%CI)) of treatment initiation included gender (male:0.42 (0.36-0.49)), BMI (0.98 per kg/m2 increase (0.97-1.00)) and geographic region (1.29 (0.89-1.87) North East vs. 0.56(0.43-0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally an additional 3,214 hip fracture patients would be initiated on therapy every year. Conclusions Significant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture. </p

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013

Two-fold regional variation in initiation of anti-osteoporosis medication after hip fracture in the UK

Describe UK regional variation in prescription of anti-osteoporosis drug therapy before and after a primary hip fracture during 1999–2013

Impact of an intervention to control Clostridium difficile infection on hospital- and community-onset disease; an interrupted time series analysis

Strategies to reduce rates of Clostridium difficile infection (CDI) generally recommend isolation or cohorting of active cases and the reduced use of cephalosporin and quinolone antibiotics. Data supporting these recommendations come predominantly from the setting of epidemic disease caused by ribotype 027 strains. We introduced an initiative involving a restrictive antibiotic policy and a CDI-cohort ward at an acute, 820-bed teaching hospital where ribotype 027 strains account for only one quarter of all CDI cases. Antibiotic use and monthly CDI cases in the 12 months before and the 15 months after the initiative were compared using an interrupted time series analysis and segmented regression analysis. The initiative resulted in a reduced level of cephalosporin and quinolone use (22.0% and 38.7%, respectively, both p <0.001) and changes in the trends of antibiotic use such that cephalosporin use decreased by an additional 62.1 defined daily doses (DDD) per month (p <0.001) and antipseudomonal penicillin use increased by 20.7 DDD per month (p = 0.011). There were no significant changes in doxycycline or carbapenem use. Although the number of CDI cases each month was falling before the intervention, there was a significant increase in the rate of reduction after the intervention from 3% to 8% per month (0.92, 95% CI 0.86-0.99, p = 0.03). During the study period, there was no change in the proportion of cases having their onset in the community, nor in the proportion of ribotype 027 cases. CDI cohorting and restriction of cephalosporin and quinolone use are effective in reducing CDI cases in a setting where ribotype 027 is endemi

Hospital pharmacists' opinions on a risk prediction tool for medication-related harm in older people

Aim Older adults are particularly affected by medication-related harm (MRH) during transitions of care. There are no clinical tools predicting those at highest risk of MRH post-hospital discharge. The PRIME study (prospective study to develop a model to stratify the risk of MRH in hospitalized patients) developed and internally validated a risk-prediction tool (RPT) that provides a percentage score of MRH in adults over 65 in the eight-weeks following hospital discharge. This qualitative study aimed to explore the views of hospital pharmacists around enablers and barriers to clinical implementation of the PRIME-RPT. Methods Ten hospital pharmacists: (band 6 (n=3); band 7 (n=2); band 8 (n=5)) participated in semi-structured interviews at the Royal Sussex County Hospital (Brighton, UK). The pharmacists were presented with five case-vignettes each with a calculated PRIME-RPT score to help guide discussion. Case-vignettes were designed to be representative of common clinical encounters. Data were thematically analysed using a ‘framework’ approach. Results Seven themes emerged in relation to the PRIME-RPT: 1. providing a medicine-prioritisation aide; 2. acting as a deprescribing alert; 3. facilitating a holistic review of patient’s medication management; 4. simplifying communication of MRH to patients and the multidisciplinary team; 5. streamlining community follow-up and integration of risk discussion into clinical practice; 6. identifying barriers for the RPTs integration in clinical practice and 7. acknowledging its limitations. Conclusion Hospital pharmacists found the PRIME-RPT beneficial in identifying older patients at high-risk of MRH following hospital discharge, facilitating prioritising interventions to those at highest risk while still acknowledging its limitations