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      Successful improvement of antibiotic prescribing at Primary Care in Andalusia following the implementation of an antimicrobial guide through multifaceted interventions: An interrupted time-series analysis

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          Abstract

          Background

          Most effective strategies designed to improve antimicrobial prescribing have multiple approaches. We assessed the impact of the implementation of a rigorous antimicrobial guide and subsequent multifaceted interventions aimed at improving antimicrobial use in Primary Care.

          Methods

          A quasi-experimental study was designed. Interventions aimed at achieving a good implementation of the guide consisted of the development of electronic decision support tools, local training meetings, regional workshops, conferences, targets for rates of antibiotic prescribing linked to financial incentives, feedback on antibiotic prescribing, and the implementation of a structured educational antimicrobial stewardship program. Interventions started in 2011, and continued until 2018. Outcomes: rates of antibiotics use, calculated into defined daily doses per 1,000 inhabitants-day (DID). An interrupted time-series analysis was conducted. The study ran from January 2004 until December 2018.

          Results

          Overall annual antibiotic prescribing rates showed increasing trends in the pre-intervention period. Interventions were followed by significant changes on trends with a decline over time in antibiotic prescribing. Overall antibiotic rates dropped by 28% in the Aljarafe Area and 22% in Andalusia between 2011 and 2018, at rates of -0.90 DID per year (95%CI:-1.05 to -0.75) in Aljarafe, and -0.78 DID (95%CI:-0.95 to -0.60) in Andalusia. Reductions occurred at the expense of the strong decline of penicillins use (33% in Aljarafe, 25% in Andalusia), and more precisely, amoxicillin clavulanate, whose prescription plummeted by around 50%. Quinolones rates decreased before interventions, and continued to decline following interventions with more pronounced downward trends. Decreasing cephalosporins trends continued to decline, at a lesser extent, following interventions in Andalusia. Trends of macrolides rates went from a downward trend to an upward trend from 2011 to 2018.

          Conclusions

          Multifaceted interventions following the delivering of a rigorous antimicrobial guide, maintained in long-term, with strong institutional support, could led to sustained reductions in antibiotic prescribing in Primary Care.

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          Most cited references19

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          Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial

          Summary Background Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England. Methods In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed. Findings Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126·98 (95% CI 125·68–128·27) in the feedback intervention group and 131·25 (130·33–132·16) in the control group, a difference of 4·27 (3·3%; incidence rate ratio [IRR] 0·967 [95% CI 0·957–0·977]; p<0·0001), representing an estimated 73 406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135·00 [95% CI 133·77–136·22] in the patient-focused intervention group and 133·98 [133·06–134·90] in the control group; IRR for difference between groups 1·01, 95% CI 1·00–1·02; p=0·105). Interpretation Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes. Funding Public Health England.
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            Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailing (Rx-PAD) study)

            Objective To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics. Design Cluster randomised controlled study. Setting Existing continuing medical education groups were recruited and randomised to intervention or control. Participants 79 groups, comprising 382 general practitioners, completed the interventions and data extractions. Interventions The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner’s antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients. Main outcome measures Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls. Results In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm. Conclusions The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners. Trial registration Clinical trials NCT00272155.
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              Lessons learnt during 20 years of the Swedish strategic programme against antibiotic resistance

              Abstract Increasing use of antibiotics and rising levels of bacterial resistance to antibiotics are a challenge to global health and development. Successful initiatives for containing the problem need to be communicated and disseminated. In Sweden, a rapid spread of resistant pneumococci in the southern part of the country triggered the formation of the Swedish strategic programme against antibiotic resistance, also known as Strama, in 1995. The creation of the programme was an important starting point for long-term coordinated efforts to tackle antibiotic resistance in the country. This paper describes the main strategies of the programme: committed work at the local and national levels; monitoring of antibiotic use for informed decision-making; a national target for antibiotic prescriptions; surveillance of antibiotic resistance for local, national and global action; tracking resistance trends; infection control to limit spread of resistance; and communication to raise awareness for action and behavioural change. A key element for achieving long-term changes has been the bottom-up approach, including working closely with prescribers at the local level. The work described here and the lessons learnt could inform countries implementing their own national action plans against antibiotic resistance.
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                Author and article information

                Contributors
                Role: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: Methodology
                Role: Data curationRole: Validation
                Role: Data curationRole: Project administrationRole: SupervisionRole: Validation
                Role: Data curationRole: Validation
                Role: Funding acquisitionRole: Project administrationRole: Supervision
                Role: Funding acquisitionRole: Project administrationRole: Supervision
                Role: Data curationRole: SupervisionRole: Validation
                Role: Formal analysisRole: MethodologyRole: SupervisionRole: Validation
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                15 May 2020
                2020
                : 15
                : 5
                : e0233062
                Affiliations
                [1 ] Clinical Unit Primary Care Pharmacy Sevilla, Aljarafe-Sevilla Norte Primary Health Care Area, Andalusian Public Health Care Service, Seville, Spain
                [2 ] Service of Pharmacy, Ouest Primary Health Care Area, Madrid Public Health Service, Madrid, Spain
                [3 ] Promotion and Rational Use of Drugs Service, General Direction of Pharmacy, Andalusian Public Health Care Service, Seville, Spain
                [4 ] Microbiology Service, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain
                [5 ] General Direction of Health Care and Health Outcomes, Andalusian Public Health Care Service, Seville, Spain
                [6 ] Coordination Unit of the Spanish National Action Plan on Antimicrobial Resistance, Spanish Medicines Agency and Health Products, Madrid, Spain
                [7 ] Clinical Unit Camas, Andalusian Public Health Care Service, Camas, Seville, Spain
                University of Lincoln, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that not competing interests exist.

                [¤]

                Current address: Service of Pharmacy, University Hospital Virgen Macarena, Andalusian Public Health Care Service, Seville, Spain

                Author information
                http://orcid.org/0000-0002-6261-6869
                Article
                PONE-D-20-02048
                10.1371/journal.pone.0233062
                7228088
                32413054
                65937d42-1923-49dd-9881-d399490c5bdb
                © 2020 Fernández-Urrusuno et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 27 January 2020
                : 27 April 2020
                Page count
                Figures: 1, Tables: 2, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
                Award ID: PI/10/01152
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100010566, Consejería de Salud, Junta de Andalucía;
                Award ID: PI-0160-2010
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100003751, Ministerio de Sanidad, Servicios Sociales e Igualdad;
                Award ID: Fondos de Cohesión, 2011
                Award Recipient :
                This work was supported by a research project from Instituto de Salud Carlos III (FISS), Spanish Ministry of Health (PI/10/01152), co-financed by the European Development Regional Found (FEDER); a research project from the Andalusian Regional Ministry of Health (PI-0160-2010), and by the Spanish Ministry of Health for the Implementation of Strategies for Patient Safety from the National Health System (Fondos de Cohesión, 2011), through the project “Prevention of bacterial resistances and the appropriate use of antimicrobials in the Andalusian Public Health Care System Centres”. RFU received PI/10/01152 and PI-0160-2010. JLM received “Fondos de Cohesión, 2011”.
                Categories
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