Effect of E-Learning on Appropriate Antibiotic Prescribing by Medical Students: A Quasi-Experimental Study during COVID-19 Pandemic

Aims: This study aimed to determine the effect of E-learning on the understanding of appropriate antibiotic prescribing (AAP) by medical students and to assess their satisfaction with this method. Materials and Methods: This quasi-experimental study was conducted among the physiopathology students of Kashan University of Medical Sciences in the first and second semesters of 2020-2021. Students were divided into E-learning education as an intervention group (IG) and face-to-face education as a control group (CG). After the final examination, the mean scores of students in both groups were compared. In addition, the level of students' satisfaction in the IG with E-learning method was assessed using a standard questionnaire. Data were analyzed using SPSS 22. Results: We included 85 and 47 students in the CG and IG. The mean and standard deviation (SD) of the understanding score about antibiotics in the E-learning group and the face-to-face education group were 18.8 +/- 1.26 and 17.16 +/- 1.93 out of 19, respectively, which were statistically significantly different (P = 0.004). The mean and SD of the overall score of satisfaction of the students in the IG was 85.48 +/- 23.08 out of 130 points (medium level). Furthermore, the level of satisfaction of male students was significantly higher than female students (P = 0.009). Conclusion: E-learning was effective in improving the process of educating students to the AAP. This education method can be used as an alternative or complementary of face-to-face education, especially in critical conditions such as the pandemic of diseases including COVID-19.

Assessment of antibiotic prescribing patterns at dental and primary health care clinics according to WHO Access, Watch, Reserve (AWaRe) classification.

BACKGROUND: The 2019 WHO Access, Watch, Reserve (AWaRe) antibiotic classification framework aims to prevent irrational prescribing of antibiotics used to treat widespread infections. This study explored antibiotic prescribing pattern for appropriate indications by family physicians and general dentists in primary health care practices. METHODS: A retrospective review of patients' electronic medical records was conducted over 6 months, from May 1, 2020, to November 30, 2020. The data were collected from 24 general family medicine and dental practices within the North West Armed Forces in Tabuk city. Antibiotic prescribing for systemic use (J01) was assessed by the number of prescriptions and the number defined daily doses (DDDs) and then analyzed according to the AWaRe classification. The prescribing of antibiotics for appropriate indications was assessed through comparing the prescription pattern with the recently published and relevant clinical guidelines. Multivariate logistic regression analysis was used to predict the association between the prescribing of AWaRe category and some demographic and disease-related factors. RESULTS: In total, 752 prescriptions of antibiotics were collected. Watch-group antibiotics such as second-generation cephalosporin and macrolides were more likely prescribed (51.1%) based on the number of prescriptions and (52.2%) based on DDDs compared with Access-group antibiotics (48.9%) and (47.8%), respectively. The percentages of Watch group antibiotics for children and adults were 66.7% and 42.9%, respectively. Adherence to prescribing guidelines was poor for children (27.2%) and adults (64%). Being a child (adjusted odds ratio [OR]: 2.89; 95% confidence interval [CI] = 1.46-5.78), diagnosis with acute respiratory tract infection (adjusted OR, 2.62; 95% CI = 1.03-6.69), and urinary tract infection (adjusted OR, 4.69; 95% CI = 2.09-10.56) were associated with higher prescriptions of Watch-group antibiotics. CONCLUSIONS: a higher prescribing of Watch-group antibiotics and poor adherence to antibiotic guidelines were observed, especially for children. The findings of this study identified targets for further improvement and interventions needed to develop better antibiotic-prescribing practices.

Clinical and ecological impact of an educational program to optimize antibiotic treatments in nursing homes (PROA-SENIOR): a cluster randomized controlled trial and interrupted time-series analysis.

BACKGROUND: Antimicrobial stewardship programs (ASPs) are recommended in nursing homes (NHs), although data are limited. This study aimed to determine the clinical and ecological impact of an ASP for NHs. METHODS: We performed a cluster randomized controlled trial and a before-after study with interrupted time-series analyses in 14 NHs, for 30 consecutive months from July 2018 to December 2020, in Andalusia, Spain. Seven facilities implemented an ASP with a bundle of five educational measures (general-ASP) and 7 added one-to-one educational interviews (experimental-ASP). The primary outcome was the overall use of antimicrobials, calculated monthly, as defined daily doses (DDD) per 1000 residents-day (DRD). RESULTS: During the ASP implementation, the total mean antimicrobial consumption decreased by 31.2% (-16.72 DRD; p = 0.045) with respect to the pre-intervention period; the overall use of quinolones and amoxicillin-clavulanic acid dropped by 52.2% (p = 0.001) and 42.5% (p = 0.006) respectively; and the overall prevalence of MDRO decreased from 24.7% to 17.4% (p = 0.012). During the intervention period, 12.5 educational interviews per doctor were done in the experimental ASP-group; no differences were found in the total mean antimicrobial use between groups (-14.62 DRD; p = 0.25) and two unexpected SARS-CoV-2 waves affected the participating centers with significant increases in the overall mean use of total antimicrobials of 40% (51.56 DRD; p < 0.0001). CONCLUSION: This study suggests that an ASP for NHs appears to be associated with a decrease in total consumption of antimicrobials and prevalence of MDRO. This trial did not find benefits associated with educational interviews probably due to the COVID-19 pandemic.

Validity of Coronavirus Disease 2019 International Classification of Diseases, Tenth Revision in the Urgent Care Setting and Impact on Antibiotic Prescribing Rates.

We validated  different coronavirus disease 2019 (COVID-19) International Classification of Diseases, Tenth Edition (ICD-10) encounter definitions across 2 urgent care clinics. Sensitivity of definitions varied throughout the pandemic. Inclusion of COVID-19 and COVID-19-like illness (CLI) ICD-10s rendered highest sensitivity but lowest specificity. Antibiotic prescribing rates were low for COVID-19 ICD-10 encounters, increasing with CLI ICD-10 encounters.

Identifying Antibiotic Use Targets for the Management of Antibiotic Resistance Using an Extended-Spectrum ß-Lactamase-Producing Escherichia coli Case: A Threshold Logistic Modeling Approach.

The aim of this study was to develop a logistic modeling concept to improve understanding of the relationship between antibiotic use thresholds and the incidence of resistant pathogens. A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-level incidence rates of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli (E. coli). Threshold logistic models identified thresholds for fluoroquinolones (61.1 DDD/1000 occupied bed days (OBD)) and third-generation cephalosporins (9.2 DDD/1000 OBD) to control hospital ESBL-producing E. coli incidence. The 60th percentile of ESBL-producing E. coli was determined as the cutoff for defining high incidence rates. Threshold logistic analysis showed that for every one-unit increase in fluoroquinolones and third-generation cephalosporins above 61.1 and 9.2 DDD/1000 OBD levels, the average odds of the ESBL-producing E. coli incidence rate being ≥60th percentile of historical levels increased by 4.5% and 12%, respectively. Threshold logistic models estimated the risk scores of exceeding the 60th percentile of a historical ESBL-producing E. coli incidence rate. Threshold logistic models can help hospitals in defining critical levels of antibiotic use and resistant pathogen incidence and provide targets for antibiotic consumption and a near real-time performance monitoring feedback system.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada.

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: -0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: -0.8, p < 0.001); and doxycycline (-0.2, p = 0.005) and penicillin (-0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

Antibiotic prescribing trends in the US during the first 11 months of the COVID-19 pandemic.

BACKGROUND: The study aims to compare antibiotic prescribing trends for U.S. COVID-19 patients, categorized by disease severity, and non-COVID-19 population with similar symptoms during 2019-2020 pandemic. METHODS: A retrospective observational cohort design using Symphony Health (January-November 2020). Sample population included about 13.3 million patients with at least one prescription claim ±6 months from date of diagnosis of COVID-19 or COVID-19 like symptom. Cohorts were categorized based on diagnosis codes; COVID-19 positive cohorts 1 to 3 with severe, mild, and no symptoms, respectively and non-COVID-19 cohorts 4 and 5 with severe and mild symptoms, respectively. Descriptive statistics were calculated for demographic characteristics and acute antibiotic utilization (≤7 days) including total number of antibiotics, weekly rate of prescribing, and proportion of fills in three "appropriateness" categories (always appropriate, potentially appropriate, never appropriate). RESULTS: Three cohorts with a positive COVID-19 diagnosis code constituted a total of about 1.8 million patients (13.53%). About 22.79% of COVID-19 positive groups had severe symptoms, 24.43% had moderate symptoms and the majority, 52.78%, had no symptoms. In the analytical sample of 13 million, about 4.2 million antibiotic prescriptions were prescribed to 2.5 million patients (19%) within 7 days of the first diagnosis of either COVID-19 or COVID-19-like symptoms. Within the COVID-19 positive cohorts, about 11% received an antibiotic prescription, while the non-COVID-19 cohorts, about 19.70% received an antibiotic. Among patients with antibiotic prescriptions, about 37.01% were prescribed an antibiotic "appropriately", 39.46% were prescribed a "potentially appropriate" antibiotic and about 22.64% received an "inappropriate" antibiotic. Among patients prescribed antibiotics, azithromycin was the most common, ranging from 21.80 to 44.80% for each cohort. CONCLUSIONS: Although the overall proportion of COVID-19 patients receiving antibiotics was much lower than non-COVID-19 patients, the findings suggest use of antibiotics persisted despite guidelines against widespread use, particularly for patients with moderate and mild COVID-19 symptoms.

The use of postal audit and feedback among Irish General Practitioners for the self - management of antimicrobial prescribing: a qualitative study.

OBJECTIVE: Inappropriate use of antibiotics has been acknowledged as a significant contributor to the proliferation of antimicrobial resistance worldwide. Physician prescribing of antibiotics has been identified as a factor in the inappropriate use of antibiotics. One methodology that is used in an attempt to alter physician prescribing behaviours is audit and feedback. This study aimed to explore the perceptions of Irish General Practitioners (GPs) towards the national introduction of postal feedback on their antibiotic prescribing behaviours beginning in 2019. DESIGN: A qualitative descriptive methodology was used. Semi-structured interviews were conducted with GPs in receipt of postal audit and feedback. METHOD: GPs working in Ireland and in receipt of postal audit and feedback on their antibiotic prescribing behaviours participated in phone-based interviews. The interviews were recorded and transcribed verbatim. The collected data was then analysed using an inductive thematic analysis. RESULTS: Twelve GPs participated in the study (female = 5). Three themes were identified from the analysis. The themes identified were the reliability and validity of the feedback received, feedback on antibiotic prescribing is useful but limited and feedback needs to be easily digestible. CONCLUSION: While the postal audit and feedback were broadly welcomed by the participants, the themes identified a perceived limitation in the quality of the feedback data, the perception of a likely low public health impact of the feedback and difficulties with efficiently processing the audit and feedback information. These findings can help refine future audit and feedback interventions on antibiotic prescribing.

Interprofessional Collaboration between ICU Physicians, Staff Nurses, and Hospital Pharmacists Optimizes Antimicrobial Treatment and Improves Quality of Care and Economic Outcome.

(1) Background: Antibiotic resistance is a worldwide health threat. The WHO published a global strategic plan in 2001 to contain antimicrobial resistance. In the following year, a workshop identified crucial barriers to the implementation of the strategy, e.g., underdeveloped health infrastructures and the scarcity of valid data as well as a lack of implementation of antibiotic stewardship (ABS) programs in medical curricula. Here, we show that interprofessional learning and education can contribute to the optimization of antibiotic use and preserving antibiotic effectiveness. We have initiated interprofessional rounds on a medical intensive care unit (MICU) with a focus on gastroenterology, hepatology, infectious diseases, endocrinology, and liver transplantation. We integrated ICU physicians, hospital pharmacists, nursing staff, and medical students as well as students of pharmacy to broaden the rather technical concept of ABS with an interprofessional approach to conceptualize awareness and behavioral change in antibiotic prescription and use. Methods: Clinical performance data and consumption figures for antibiotics were analyzed over a 10-year period from 2012 to 2021. The control period covered the years 2012-2014. The intervention period comprised the years 2015-2021, following the implementation of an interprofessional approach to ABS at a MICU of a German university hospital. Data from the hospital pharmacy, hospital administration, and hospital information system were included in the analyses. A specific electronic platform was developed for the optimization of documentation, interprofessional learning, education, and sustainability. The years 2020 and 2021 were analyzed independently due to the SARS-CoV-2 pandemic and the care of numerous COVID-19 patients at the MICU. Results: Implementation of an interprofessional ABS program resulted in the optimization of antibiotic management at the MICU. The suggestions of the hospital pharmacist for optimization can be divided into the following categories (i) indication for and selection of therapy (43.6%), (ii) optimization of dosing (27.6%), (iii) drug interactions (9.4%), (iv) side effects (4.1%), and (v) other pharmacokinetic, pharmacodynamic, and pharmacoeconomic topics (15.3%). These suggestions were discussed among the interprofessional team at the MICU; 86.1% were consequently implemented and the prescription of antibiotics was changed. In addition, further analysis of the intensive care German Diagnosis Related Groups (G-DRGs) showed that the case mix points increased significantly by 31.6% during the period under review. Accordingly, the severity of illness of the patients treated at the ICU as measured by the Simplified Acute Physiology Score (SAPS) II increased by 21.4% and the proportion of mechanically ventilated patients exceeded 50%. Antibiotic spending per case mix point was calculated. While spending was EUR 60.22 per case mix point in 2015, this was reduced by 42.9% to EUR 34.37 per case mix point by 2019, following the implementation of the interprofessional ABS program on the MICU. Through close interprofessional collaboration between physicians, hospital pharmacists, and staff nurses, the consumption of broad-spectrum antibiotics, e.g., carbapenems, was significantly reduced, thus improving patient care. In parallel, the case mix and case mix index increased. Thus, the responsible use of resources and high-performance medicine are not contradictory. In our view, close interprofessional and interdisciplinary collaboration between physicians, pharmacists, and nursing staff will be of outstanding importance in the future to prepare health care professionals for global health care to ensure that the effectiveness of our antibiotics is preserved.

Sustained Reduction in Urgent Care Antibiotic Prescribing During the Coronavirus Disease 2019 Pandemic: An Academic Medical Center's Experience.

We compared antibiotic prescribing before and during the -coronavirus disease 2019 (COVID-19) pandemic at 2 academic urgent care clinics and found a sustained decrease in prescribing driven by respiratory encounters and despite transitioning to telemedicine. Antibiotics were rarely prescribed during encounters for COVID-19 or COVID-19 symptoms. COVID-19 revealed opportunities for outpatient stewardship programs.

Reducing Inappropriate Antibiotic Prescribing for Upper Respiratory Infections

Acute upper respiratory infections account for most urgent care visits, and most do not require antibiotics. A quality improvement project was conducted at an urgent care clinic in Texas over a 1-month period with the intent of improving antibiotic prescribing practices for acute upper respiratory infections. The rates of antibiotic prescribing before and after the implementation were compared, and focus group discussions were conducted for insight. A significant decrease in the rates of antibiotics prescribed was noted when prescribing rates before and after implementation were compared. Insightful information was collected from the focus groups.

Non-Visit-Based and Non-Infection-Related Antibiotic Use in the US: A Cohort Study of Privately Insured Patients During 2016-2018.

BACKGROUND: Ambulatory antibiotic prescriptions without a clinic visit or without documentation of infection could represent overuse and contribute to adverse outcomes. We aim to describe US ambulatory antibiotic prescribing, including those without an associated visit or infection diagnosis. METHODS: We conducted an observational cohort study using data of all patients receiving antibacterial, antibiotic prescriptions from 04/01/2016 to 06/30/2018 in a large US private health insurance plan. We identified outpatient antibiotic prescriptions as (1) associated with a clinician visit and an infection-related diagnosis; (2) associated with a clinician visit but no infection-related diagnosis; or (3) not associated with an in-person clinician visit in the 7 days before the prescription (non-visit-based). We then assessed whether non-visit-based antibiotic prescriptions (NVBAPs) differed from visit-based antibiotics by patient, clinician, or antibiotic characteristics using multivariable models. RESULTS: The cohort included 8.6M enrollees who filled 22.3M antibiotic prescriptions. NVBAP accounted for 31% (6.9M) of fills, and non-infection-related prescribing accounted for 22% (4.9M). NVBAP rates were lower for children than for adults (0-17 years old, 16%; 18-64 years old, 33%; >65 years old, 34%). Among most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). Specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine (20%), and pediatricians (10%). In multivariable models, NVBAP was associated with increasing age, and NVBAP was less likely for patients in the South, those with more baseline clinical visits, or those with chronic lung disease. CONCLUSIONS: Over half of ambulatory antibiotic use was either non-visit-based or non-infection-related. Particularly given health care changes due to the coronavirus disease 2019 pandemic, efforts to improve antibiotic prescribing must account for non-visit-based and non-infection-related prescribing.

Antimicrobial stewardship in the UK during the COVID-19 pandemic: a population-based cohort study and interrupted time-series analysis.

BACKGROUND: The COVID-19 pandemic has altered the context for antimicrobial stewardship in primary care. AIM: To assess the effect of the pandemic on antibiotic prescribing, accounting for changes in consultations for respiratory and urinary tract infections (RTIs/UTIs). DESIGN AND SETTING: Population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD database from January 2017 to September 2020. METHOD: Interrupted time-series analysis evaluated changes in antibiotic prescribing and RTI/UTI consultations adjusting for age, sex, season, and secular trends. The authors assessed the proportion of COVID-19 episodes associated with antibiotic prescribing. RESULTS: There were 253 655 registered patients in 2017 and 232 218 in 2020, with 559 461 antibiotic prescriptions, 216 110 RTI consultations, and 36 402 UTI consultations. Compared with prepandemic months, March 2020 was associated with higher antibiotic prescribing (adjusted rate ratio [ARR] 1.13; 95% confidence interval [CI] = 1.11 to 1.16). Antibiotic prescribing fell below predicted rates between April and August 2020, reaching a minimum in May (ARR 0.73; 95% CI = 0.71 to 0.75). Pandemic months were associated with lower rates of RTI/UTI consultations, particularly in April for RTIs (ARR 0.23; 95% CI = 0.22 to 0.25). There were small reductions in the proportion of RTI consultations with antibiotic prescribed and no reduction for UTIs. Among 25 889 COVID-19 patients, 2942 (11%) had antibiotics within a COVID-19 episode. CONCLUSION: Pandemic months were initially associated with increased antibiotic prescribing, which then fell below expected levels during the national lockdown. Findings are reassuring that antibiotic stewardship priorities have not been neglected because of COVID-19. Research is required into the effects of reduced RTI/UTI consultations on incidence of serious bacterial infections.

Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review.

PURPOSE: To provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. METHODS: Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. RESULTS: Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable. CONCLUSION: Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis.

BACKGROUND: The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance. OBJECTIVE: The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19. DATA SOURCES: We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing. PARTICIPANTS: The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult). METHODS: The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis. RESULTS: We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3-80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03-0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18-1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15-1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7-15.2%) from 31 studies. CONCLUSIONS: Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.