Surveillance of antimicrobial utilization in Africa: a systematic review and meta-analysis of prescription rates, indications, and quality of use from point prevalence surveys.

BACKGROUND: Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities. METHODS: A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias. RESULTS: Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I2 = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies. CONCLUSION: This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

Impact of an antimicrobial stewardship programme on antibiotic utilization and resistance burden in patients with acute leukaemia: an 11-year longitudinal cohort study using interrupted time-series analysis.

BACKGROUND: Antimicrobial resistance (AMR), driven by inappropriate and overuse of antibiotics, poses a significant threat, especially to patients with acute leukaemia. OBJECTIVES: To evaluate the impact of antimicrobial stewardship programmes (ASPs) on antibiotic use and analyse temporal changes in bloodstream infections (BSI) caused by AMR organisms. METHODS: We performed a retrospective, interventional, longitudinal cohort study spanning an 11-year period. ASPs included optimizing antibiotic use, enhancing tracking and reporting systems and delineating leadership and accountability. A segmented regression model of interrupted time series was used to evaluate the trend of antibiotic consumption and BSI with AMR organisms after the interventions. RESULTS: A total of 3296 BSI episodes with 454 419 days of therapy (DOT) from 7754 patients were obtained. ASPs were significantly associated with an immediate reduction [-70.03 DOT/1000 patient-days (PD), P = 0.036] and a decreasing trend (-11.65 DOT/1000 PD per quarter, P < 0.001) in overall antibiotic use. The increasing incidence of BSI with AMR before ASP intervention was notably curbed and revealed a decreasing trend (slope change: -0.06 BSI/1000 PD per quarter, P = 0.002). The decreasing trend was more significant for Enterobacterales: ciprofloxacin-resistant and ESBL-producing isolates showed a slope change of -0.06 BSI/1000 PD and -0.08 BSI/1000 PD per quarter, respectively (all P < 0.05). However, Pseudomonas aeruginosa BSI increased. CONCLUSIONS: Multidimensional ASPs effectively reduced both the immediate and trends in overall antibiotic usage even in patients with acute leukaemia. Additionally, there was a notable decrease in the incidence of BSI caused by AMR organisms, particularly among Enterobacterales.

Impact of the introduction of the national antimicrobial stewardship standard across Queensland Health hospitals: ecological observational study exploring patterns of antimicrobial use.

BACKGROUND: Antimicrobial stewardship programmes are a critical tool for addressing the rising threat of antimicrobial resistance. AIM: To determine changes in patterns of antimicrobial use in Queensland public hospitals following introduction of the National Safety and Quality Health Service antimicrobial stewardship standard. METHODS: A retrospective pre/post intervention study was conducted across Queensland public hospitals at the ecological level using Queensland Health's MedTRx database. An interrupted time-series analysis was performed using linear regression models to determine rates of antimicrobial use by quarterly aggregated defined daily dose per 1000 patient-days, for groups of hospitals stratified by peer group classification. Pre-defined time-periods for antimicrobial stewardship programme implementation in response to the introduction of the standard were analysed. FINDINGS: In the post-intervention period, there was a decrease in overall use of systemic antimicrobials, glycopeptides, carbapenems and fluoroquinolones in principal referral and public acute group A hospitals. A decrease in overall use was also observed for smaller regional and remote public acute group C and D hospitals; however, increases in glycopeptide and fluoroquinolone use were observed. Third-generation cephalosporin use was unchanged for all hospital peer groups. The proportion of overall use that was accounted for by narrow-spectrum penicillin was low for all facilities, with modest improvements in the post-intervention period observed in principal referral facilities only. CONCLUSION: These findings add to current knowledge on the effectiveness of legislative quality standards on antimicrobial stewardship at the macro level and highlight gaps to target for future programmes.

Impacts of pharmacist-led multi-faceted antimicrobial stewardship on antibiotic use and clinical outcomes in urology department of a tertiary hospital in Guangzhou, China: an interrupted time-series study.

BACKGROUND: Research on the effectiveness of pharmacist-led antimicrobial stewardship programmes (ASPs) in the urology department is limited. AIM: To evaluate the impact of pharmacist-led multi-faceted ASPs on antibiotic use and clinical outcomes. METHODS: A prescription review of inpatients receiving one or more antibiotics in the urology department of a large teaching hospital in Guangzhou, China, was conducted from April 2019 to March 2023. The pharmacist-led multi-faceted ASP intervention included guideline development, training, medication consultation, review of medical orders, indicator monitoring, and consultation. The primary outcome was antibiotic consumption. The data were analysed using interrupted time-series (ITS) analysis. FINDINGS: Following the implementation of ASPs, an immediate decrease was observed in total antibiotic consumption, antibiotic use rate, second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones, and WHO Watch category antibiotics. No differences were observed in mortality rate before and after the intervention, and no significant short- or long-term effects were found on length of hospital stay (LOS) using ITS. However, there was a significant short-term effect on average antibiotic cost. CONCLUSION: The implementation of pharmacist-led multi-faceted ASPs had positive impacts on reducing antimicrobial consumption without increasing LOS, antibiotic cost, or mortality rate.

The practice and evaluation of antifungal stewardship programs at a tertiary first-class hospital in China.

BACKGROUND: The sharp increase in fungal infections, insufficient diagnostic and treatment capabilities for fungal infections, poor prognosis of patients with fungal infections as well as the increasing drug resistance of fungi are serious clinical problems. It is necessary to explore the implementation and evaluation methods of antifungal stewardship (AFS) to promote the standardized use of antifungal drugs. METHODS: The AFS programme was implemented at a tertiary first-class hospital in China using a plan-do-check-act (PDCA) quality management tool. A baseline investigation was carried out to determine the utilization of antifungal drugs in pilot hospitals, analyse the existing problems and causes, and propose corresponding solutions. The AFS programme was proposed and implemented beginning in 2021, and included various aspects, such as team building, establishment of regulations, information construction, prescription review and professional training. The management effectiveness was recorded from multiple perspectives, such as the consumption of antifungal drugs, the microbial inspection rate of clinical specimens, and the proportion of rational prescriptions. The PDCA management concept was used for continuous improvement to achieve closed-loop management. RESULTS: In the first year after the implementation of the AFS programme, the consumption cost, use intensity and utilization rate of antifungal drugs decreased significantly (P < 0.01). The proportion of rational antifungal drug prescriptions markedly increased, with the proportion of prescriptions with indications increasing from 86.4% in 2019 to 97.0% in 2022, and the proportion of prescriptions with appropriate usage and dosage increased from 51.9 to 87.1%. In addition, after the implementation of the AFS programme, physicians' awareness of the need to complete microbial examinations improved, and the number of fungal cultures and serological examinations increased substantially. Statistics from drug susceptibility tests revealed a decrease in the resistance rate of Candida to fluconazole. CONCLUSION: This study indicated that the combination of AFS and the PDCA cycle could effectively reduce antifungal consumption and promote the rational use of antifungal drugs, providing a reference for other health care systems to reduce the overuse of antifungal drugs and delay the progression of fungal resistance.

Pediatric Antimicrobial Stewardship Programs Reduce Antibiotic Use at Combined Adult-Pediatric Hospitals.

Implementation of dedicated pediatric antimicrobial stewardship programs (ASPs) at 2 combined adult-pediatric hospitals with existing ASPs was associated with sustained decreases in pediatric antibiotic use out of proportion to declines seen in adult inpatient units. ASPs in combined hospitals may not detect excessive pediatric antibiotic use without incorporating pediatric expertise.

A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England.

OBJECTIVES: To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). METHODS: A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. FINDINGS: Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. CONCLUSIONS: Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.

Validação da tecnologia educacional sobre uso racional de medicamentos para agentes comunitários de saúde ribeirinhos / Validación de la tecnología educativa sobre uso racional de medicamentos para agentes comunitarios de salud ribereños / Validation of educational technology on rational use of medicines for riverside community health workers

Objetivo: validar o conteúdo de uma tecnologia educacional sobre uso racional de medicamentos para Agentes Comunitários de Saúde ribeirinhos. Método: pesquisa metodológica guiada pelo modelo de Pasquali para a validação de conteúdo e a produção da versão final do manual. Na coleta de dados foram utilizados dois questionários para juízes especialistas. Para a análise utilizou-se a estatística do Índice de Validação de Conteúdo e o Escore Suitability Assessment of Materials. Resultados: o Índice de Validação de Conteúdo Global foi de 87,25% em uma única rodada, sendo no primeiro bloco referente aos objetivos com 96,80%, no segundo bloco de apresentação e estrutura com 84,80% e no terceiro bloco de relevância do material com 87,30%. O Escore Suitability Assessment of Materials obtido foi de 100,0%. Conclusão: o conteúdo do manual foi validado e a produção está adequada para subsidiar a educação permanente em saúde dos Agentes Comunitários de Saúde Ribeirinhos.

Objetivo: validar el contenido de una tecnología educativa sobre uso racional de medicamentos para Agentes Comunitarios de Salud ribereños. Método: investigación metodológica guiada por el modelo de Pasquali para la validación de contenido y la producción de la versión final del manual. En la recopilación de datos se utilizaron dos cuestionarios para jueces expertos. Para el análisis se utilizó la estadística del Índice de Validación de Contenido y el Escore Suitability Assessment of Materials. Resultados: el Índice de Validación de Contenido Global fue de 87,25% en una sola ronda, siendo en el primer bloque referente a los objetivos con 96,80%, en el segundo bloque de presentación y estructura con 84,80% y en el tercer bloque de relevancia del material con 87,30%. El Escore Suitability Assessment of Materials obtenido fue de 100,0%. Conclusión: el contenido del manual fue validado y la producción está adecuada para subsidiar la educación permanente en salud de los Agentes Comunitarios de Salud Ribereños.

Objective: to validate the content of an educational technology on the rational use of medicines for riverine Community Health Workers. Method: methodological research guided by the Pasquali model for content validation and production of the final version of the manual. In the data collection two questionnaires were used for expert judges. For the analysis, the statistics of the Content Validation Index and the Suitability Assessment of Materials Score were used. Results: the Global Content Validation Index was 87.25% in a single round, being the first block referring to the objectives with 96.80%, the second block of presentation and structure with 84.80% and the third block of relevance of the material with 87.30%. The Suitability Assessment of Materials score obtained was 100.0%. Conclusão: the content of the manual was validated and the production is adequate to subsidize the permanent health education of the Riverside Community Health Workers.

Use of Feedback Data to Reduce Surgical Site Infections and Optimize Antibiotic Use in Surgery: A Systematic Scoping Review.

OBJECTIVE: Surgical site infection (SSI) prevention remains significant, particularly in the era of antimicrobial resistance. Feedback on practices and outcomes is known to be key to reduce SSI rates and optimize antibiotic usage. However, the optimal method, format and frequency of feedback for surgical teams remains unclear. The objective of the study is to understand how data from surveillance and audit are fed back in routine surgical practice. METHODS: A systematic scoping review was conducted, using well-established implementation science frameworks to code the data. Two electronic health-oriented databases (MEDLINE, EMBASE) were searched to September 2019. We included studies that assessed the use of feedback as a strategy either in the prevention and management of SSI and/or in the use of antibiotics perioperatively. RESULTS: We identified 21 studies: 17 focused on SSI rates and outcomes and 10 studies described antimicrobial stewardship for SSI (with some overlap in focus). Several interventions were reported, mostly multimodal with feedback as a component. Feedback was often provided in written format (62%), either individualized (38%) or in group (48%). Only 25% of the studies reported that feedback cascaded down to the frontline perioperative staff. In 65% of the studies, 1 to 5 implementation strategies were used while only 5% of the studies reported to have utilized more than 15 implementation strategies. Among studies reporting antibiotic usage in surgery, most (71%) discussed compliance with surgical antibiotic prophylaxis. CONCLUSIONS: Our findings highlight the need to provide feedback to all levels of perioperative care providers involved in patient care. Future research in this area should report implementation parameters in more detail.

Application of the anatomical chemical system/defined daily doses: Challenges and way forward for resource-limited countries.

WHAT IS KNOWN AND OBJECTIVE: The Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) methodology is a WHO gold standard for ensuring systematic Drug Utilization Research (DUR) and has been mainly used in the developed world. This article examines the challenges and way forward for using this methodology in resource-limited countries. CONTENT: The ATC/DDD is superior over other methods employed in DUR as it offers a unified medicines regulation and management system at all care levels. The ATC/DDD allows access to standardized and validated information on DUR by: assessing patterns of utilization, defining optimal use levels, identification of gaps, aggregating and analysing statistics for reporting adverse drug reactions, as well as assisting in developing rational medicines use interventions and monitoring their outcomes. WHAT IS NEW AND CONCLUSION: Application of the ATC/DDD methodology is crucial for improved patient management, optimal consumption of national pharmaceutical budgets and policy formulation in resource-limited countries.

Medicamentos off-label e não licenciados no âmbito pediátrico: uma revisão descritiva dos últimos dez anos / Off-label and unlicensed drugs in the pediatric field: a descriptive review of the last ten years

A falta de medicamentos contendo bulas prevendo o tratamento de pacientes pediátricos representa um problema frequentemente observado em hospitais, principalmente nos setores de unidade de terapia intensiva (UTI) pediátrica e neonatais. Sabe-se que, para que um tratamento seja considerado seguro e eficaz, uma série de estudos clínicos são necessários, no entanto, relata-se um baixo número dessas pesquisas envolvendo crianças, principalmente devido a questões éticas que dificultam a condução das mesmas. Assim, poucos são os medicamentos que provam ser adequados para o tratamento desses pacientes, tornando necessário recorrer ao uso de medicamentos off-label e não licenciados. Os medicamentos são classificados como off-label quando seu uso se dá de maneira que difere de suas especificações aprovadas, por sua vez, produtos não licenciados são classificados desta forma por não possuírem aprovação para sua comercialização no país ou não possuírem comprovação de segurança e eficácia. O preparo de protocolos de estudo organizados, relato de informações aos pais e à criança de maneira clara e objetiva, aproximação entre pesquisadores e pais para o estabelecimento de uma relação de confiança e a condução das pesquisas em momentos de disponibilidade da família demonstram-se estratégias importantes para facilitar a realização dos ensaios clínicos.

The lack of medicines containing drug information leaflets considering the treatment of pediatric patients is a problem frequently observed in hospitals, especially in the pediatric and neonatal intensive care unit (ICU) sectors. It is known that, for a treatment to be considered safe and effective, a series of clinical studies are necessary; however, a low number of these studies involving children are reported, mainly due to ethical issues that make conducting them difficult. Thus, few drugs prove to be suitable for treating these patients, making it necessary to resort to using off-label and unlicensed drugs. Drugs are classified as off-label when their use differs from their approved specifications, in turn, unlicensed products are classified in this way due to not having approval for marketing in the country or do not have proof of safety and efficacy. Preparation of organized study protocols, reporting information to parents and the child in a clear and objective way, bringing researchers and parents closer to establish a relationship of trust and conducting research at moments when the family is available are important strategies to facilitate conducting clinical trials.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic.

BACKGROUND: Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring. OBJECTIVE: To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic. METHODS: With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England. RESULTS: 20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420). CONCLUSIONS: Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective.

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

Establishing Benchmarks for Antimicrobial Use in Canadian Children's Hospitals: Results From 2 National Point Prevalence Surveys.

BACKGROUND: Point prevalence surveys (PPS) are potentially useful to measure antimicrobial use across institutions. The objectives of the study were to describe and compare antimicrobial use between pediatric hospitals in Canada. METHODS: Fifteen pediatric hospitals all with pediatric infectious diseases service participated in 2 single-day PPS in 2018/19. Children <18 years of age who were inpatients were included. Age, service, clinical diagnosis as well as name, route, and start date for each antimicrobial was collected. Antibiotics were grouped according to the World Health Organization AWaRe classification. RESULTS: There were 3924 inpatient patients-days representing 2729 children and 1195 infants in neonatal intensive care units (NICU) surveyed. Among non-NICU patients, 1210 (44.3%) received 1830 antimicrobials of which 73.9% were for empiric or pathogen-directed therapy and 25.6% for prophylaxis. The mean proportion of core Access and Watch group antibiotics was 45.8% and 63.5%, respectively, with no differences in means between tertiary and quaternary care sites. Among 1195 infants in NICU, 19.7% received 410 antimicrobials of which 17.1% were for prophylaxis and a mean of 45.4% were Watch group antibiotics. Of patients admitted for community-acquired pneumonia, 32.7% received penicillin or aminopenicillins only with variability among sites. CONCLUSIONS: PPS of antimicrobial use in Canadian pediatric hospitals revealed a high proportion of Watch group (broader spectrum) antibiotics, even among children with community-acquired pneumonia. This study demonstrates the feasibility of PPS to document antimicrobial use and potentially to use this data to establish goals for decreasing both overall and Watch group antibiotics.

Antibiotic Utilization and Efficacy Associated With Treating Pediatric Urinary Tract Infections in Texas Medicaid Patients in the First Year of Life.

BACKGROUND: Historically, amoxicillin (Amoxil) has been used as a first-line agent to treat pediatric urinary tract infections (UTIs). However, emerging antibiotic resistance in urinary pathogens has led to broader treatment options, such as cefdinir (Omnicef). This shift in prescribing practices is predicted to vary among place of service and gender due to differing institutional protocols and antimicrobial stewardship practices. OBJECTIVE: This study aimed to describe the antibiotic utilization patterns associated with treating pediatric UTIs in Texas Medicaid patients and to assess the real-world efficacy of the antibiotics that were prescribed. METHODS: Texas Medicaid prescription and medical claims data for patients under 1 year of age were included in the analysis if they presented with a UTI to the healthcare practitioner's office or the emergency department (ED) and were treated with an outpatient antibiotic. Treatment efficacy was assessed by whether a patient received a second (different) antibiotic within 7 days of their initial antibiotic fill. RESULTS: A total of 12,795 visits met inclusion criteria; 12,561 visits included prescriptions for the top 4 antibiotics prescribed: cefdinir (50%), amoxicillin (25%), cephalexin (Keflex; 13%), and amoxicillin-clavulanate (Augmentin; 12%). Cefdinir utilization predominated in both places of service [office (50%) and ED (55%)], and gender [males (47%) and females (52%)]. Controlling for gender and place of service, initial treatment with amoxicillin when compared with cefdinir (OR = 2.54; 95% confidence intervals: 1.84­3.54; P < 0.001) was associated with a greater rate of treatment failure. CONCLUSIONS: In this study of Texas Medicaid patients, the widespread utilization of cefdinir may be appropriate for the empiric treatment of uncomplicated UTIs because of its low rate of treatment failure compared to other commonly used antibiotics.

Non-Adherence to Antihypertensive Guidelines in Patients with Asymptomatic Carotid Stenosis.

IMPORTANCE: Hypertension and carotid stenosis are both risk factors for stroke, but the presence of carotid stenosis might dampen enthusiasm for tight control of hypertension because of concerns for hypoperfusion. OBJECTIVE: To determine the extent to which there are opportunities to potentially improve pharmacotherapy for hypertension in patients known to have asymptomatic high-grade carotid stenosis. DESIGN: We examined anti-hypertensive medication prescription and adherence to evidence-based hypertension treatment guidelines in a cross-sectional analysis of baseline data of patients enrolled in a clinical trial. SETTING: The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a multicenter prospective randomized open blinded end-point clinical trial of intensive medical management with or without revascularization by endarterectomy or stenting for asymptomatic high-grade carotid stenosis. PARTICIPANTS: 1479 participants (38.6% female; mean age 69.8 years) from 132 clinical centers enrolled in the CREST-2 trial as of April 6, 2020 who were taking ≥1 antihypertensive drug at baseline. EXPOSURES: Pharmacotherapy for hypertension. MAIN OUTCOME: Adherence to evidence-based guidelines for treating hypertension. RESULTS: Of 1458 participants with complete data, 26% were on one, 31% on 2, and 43% on ≥3 antihypertensive medications at trial entry. Thirty-two percent of participants were prescribed thiazide; 74%, angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB); 38%, calcium channel blocker (CCB); 56%, a beta blocker; 11%, loop diuretic; and 27%, other. Of those prescribed a single antihypertensive medication, the proportion prescribed thiazide was 5%; ACEI or ARB, 55%, and CCB, 11%. The prevalence of guideline-adherent regimens was 34% (95% CI, 31-36%). CONCLUSIONS AND RELEVANCE: In a diverse cohort with severe carotid disease and hypertension, non-adherence to hypertension guidelines was common. All preferred classes of antihypertensive drug were under-prescribed. Using staged iterative guideline-based care for hypertension, CREST-2 will characterize drug tolerance and stroke rates under these conditions. TRIAL REGISTRATION: ClinicalTrials.gov Number NCT02089217.

Nationwide cross-sectional study of antimicrobial stewardship and antifungal stewardship programs in inpatient settings in Japan.

BACKGROUND: To prevent antimicrobial resistance, both antimicrobial stewardship (AMS) and antifungal stewardship (AFS) in inpatient settings are needed in small/middle-sized hospitals as well as large hospitals. METHODS: We conducted the web-based, self-administered, nationwide cross-sectional study regarding AMS and AFS in inpatient settings in Japan, targeting hospitals that participated in a hospital epidemiology workshop conducted in July 2018. The questionnaire was composed of intervention protocols for use of broad-spectrum antimicrobials and antifungals within 7 or 28 d of beginning usage. These broad-spectrum antimicrobial and antifungal protocols were compared between large (≥501beds) and small/middle-sized (≤500 beds) hospitals. RESULTS: Of 240 hospitals surveyed, 39 (16%; 18 large and 21 small/middle-sized) responded. The number of hospitals that intervened in the use of broad-spectrum antimicrobials within 7 and 28 d were 17 (44%) and 34 (87%), respectively; those that intervened for antifungals were 3 (8%) and 10 (26%), respectively. Interventions for use of broad-spectrum antimicrobials within 7 d were significantly more frequent in small/middle-sized hospitals compared to large hospitals [13 (61. 9%) vs. 4 (22. 2%), odds ratio = 5.7, 95% confidence interval = 1.4-23.3, p = 0.023]. CONCLUSIONS: Small/middle-sized hospitals had more frequent interventions within 7 d of broad-spectrum antimicrobial use than large hospitals. More effort to improve AFS is needed among all hospitals.

Changes in Metronidazole and Vancomycin Utilization for Nonsevere Clostridioides difficile Infection Among Institutions Caring for Children.

Clostridioides difficile infection guidelines were published in final format on April 1, 2018. Among 4962 and 3545 C. difficile infection cases in children the year before and after publication, oral metronidazole use decreased from 63.0% to 44.3% (P < 0.001) and oral vancomycin use increased from 27.3% to 47.7% (P < 0.001). Quarterly metronidazole utilization decreased postguidelines among 117 institutions, incidence rate ratios 0.86 (95% confidence intervals: 0.78-0.96).

Influence of government-driven quality assessment program on patients with chronic obstructive pulmonary disease.

BACKGROUND: The Korean Health Insurance Review and Assessment Service (HIRA) has launched the Chronic Obstructive Pulmonary Disease (COPD) Quality Assessment Program (CQAP) since 2014. We aimed to reveal the influence of this national program on clinical outcomes and the burden of COPD in Korea. METHODS: The CQAP is conducted annually. We used healthcare claims data linked with the results of the program provided by HIRA between May 2014 and April 2017. Patients were considered to have COPD if they visited a hospital for COPD management during the assessment term. Those who visited a medical institution for COPD and were prescribed COPD medications at least twice were assessed by the CQAP (assessed subjects, AS; not-assessed subjects, NAS). CQAP evaluated the pulmonary function test conduction rate, regular visitation rate, and prescription rates of COPD medications. RESULTS: Among the 560,000 patients with COPD, about 140,000 were assessed by the CQAP annually. In both groups, the pulmonary function test conduction rate and inhaled bronchodilator prescription rate improved since 2014. Compared to the NAS group, the risk of admission and all-cause mortality rate in the AS group were significantly reduced by 21.2% and 40.7%, respectively. In patients who were assessed for 3 consecutive years, all of the above variables were high at baseline and were not improved much from implementation of CQAP. In matching analysis, we observed this improvement to be limited in the COPD quality assessment year. CONCLUSIONS: The CQAP by the health insurance bureau has improved the management protocol and prognosis of COPD.