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.

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.

[Recommendations for the use of rapid diagnosis techniques in respiratory infections in primary care]. / Recomendaciones de utilización de técnicas de diagnóstico rápido en infecciones respiratorias en atención primaria.

Respiratory tract infections rank first as causes of adult and paediatric infectious morbidity in primary care in Spain. These infections are usually self-limiting and are mainly caused by viruses. However, a high percentage of unnecessary antibiotic prescription is reported. Point-of-care tests are biomedical tests, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is rapidly increasing in general practice. Notwithstanding, we must mull over whether they always contribute to an effective and high-quality diagnostic process by primary care clinicians. We present a set of criteria that can be used by clinicians and discuss the pros and cons of the instruments available for the management of respiratory tract infections and how to use them appropriately.

Active offer of vaccinations during hospitalization improves coverage among splenectomized patients: An Italian experience.

In 2014, an Italian hospital implemented a protocol for pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines offer to splenectomized patients during their hospitalization. After 1 year, coverage for recommended vaccinations increased from 5.7%-66.7% and the average time between splenectomy and vaccines administration decreased from 84.7-7.5 days.

Immunization coverage among splenectomized patients: Results of an ad hoc survey in Puglia Region (South of Italy).

Patients with anatomic or functional asplenia have a 10-50 times higher risk than general population to develop Overwhelming Post-Splenectomy Infection. Evidences are unanimous in recommending splenectomised patients to receive meningococcal, antipneumococcal and Haemophilus influenzae type B vaccinations according to a specific timing. In Italy there are no current data on the immunisation coverage in these patients. This study aims to investigate immunisation coverage in patients undergoing elective or urgent splenectomy for 2012-2013 in the 3 Apulian hospitals. The patients discharged with the code ICD-9-CM 41.5 - "Total splenectomy" were enrolled. The administration of vaccines was verified through consultation of medical records, archives of general practitioners and vaccination offices. In the study period, 166 subjects underwent splenectomy and none of them received vaccinations during hospitalization. 25 splenectomised patients (15.1%) received at least one of the recommended vaccinations. 21 patients (12.6%) received vaccine against Streptococcus pneumonia, 13 (7.8%) meningococcal vaccine, 10 patients (6%) Haemophilus influenzae type B vaccine. The low vaccination coverage could be due both to poor perception of the risk of infection and to a lack of knowledge on vaccinations by surgeons. For this reason it is necessary to draw up and share operational protocols that establish the administration of vaccines.

Improving the appropriateness of antimicrobial use in primary care after implementation of a local antimicrobial guide in both levels of care.

OBJECTIVE: This study aims to assess the effectiveness of multiple interventions carried out during the implementation of a guide, on the improvement of the appropriateness of antimicrobial prescribing in primary care. DESIGN: This is a cross-sectional before/after study carried out in Aljarafe Health Care Area (Andalusia, Spain), with a population of 368,728 inhabitants assisted in 37 health centers. SUBJECTS: Subjects include patients with antibiotic prescriptions during 2009 (pre-intervention phase) or 2012 (postintervention phase) selected by simple random sampling (confidence level, 95%; accuracy, 5%), with infections registered in the electronic clinical history. INTERVENTIONS: This study involve training sessions in primary care centers and hospital services, incorporation of the electronic guide to the Health Care Service Websites, and incorporation of the guide to the Digital Health History as a tool to support decision making. MAIN OUTCOME: Difference on appropriate antibiotic prescribing before and after interventions resulted from the study. Other variables also include age, gender, type of pharmacy, antibiotic prescribed, number of treatments per year, infection site, and main comorbidities SOURCES: In addition, this study uses computerized pharmacy records of reimbursed and dispensed drugs and electronic medical histories. RESULTS: The percentage of appropriate antibiotic prescribing increased from 36% in 2009 to 57% in 2012 (p < 0.001) is shown. The improvement was observed in all age patients of any sex and was higher among working-age patients and patients with comorbidities. The best results were observed in the group of beta-lactams and in the treatment of respiratory and skin infections. CONCLUSION: The realization of multifactorial interventions involving professionals from both levels of care could be an effective strategy to improve the use of antimicrobials in primary care.

[Appropriateness of antibiotic prescribing in a primary care area: a cross-sectional study]. / Adecuación de la prescripción de antibióticos en un área de atención primaria: estudio descriptivo transversal.

OBJECTIVE: To assess the profile of patients receiving antibiotics and the appropriateness of these prescriptions for the clinical conditions. DESIGN: Cross-sectional study of prescription-indication. SETTING: A primary health care area in Andalusia. SUBJECTS: Patients assigned to primary care centres. Patients with antibiotic prescriptions during 2009 were selected by simple random sampling (confidence level: 95%, accuracy: 5%). Primary endpoint: appropriateness of antibiotics prescribing to recommendations included in local guidelines. Data were obtained through the billing computerised prescriptions system and medical histories. RESULTS: Twenty-five per cent of the population area received antibiotics during 2009. The 1,266 patient samples showed the following characteristics: 57.9% were women, with a mean age of 41 (±1) years. There were 39.3% pensioners. The percentage of appropriate antibiotic prescriptions was 19.9%, with no difference due to gender. Statistically significant differences were related to age, being those over 65 years the group of patients with the highest percentage of inappropriateness. The main reasons for inappropriateness were: no recording of the infectious process (44.5%), a wrong treatment duration (15.5%), and the use of an inadequate antibiotic (11.5%). CONCLUSION: There is a high level of inappropriateness in antibiotic prescribing in primary care. The high level of under-recording of diagnoses, mainly in elderly patients, followed by the use of wrong schedules, and the wrong type of antibiotics were the main reasons of inappropriateness.

More than training: Community-based participatory research to reduce injuries among hispanic construction workers.

BACKGROUND: Workplace mortality and severe injury are disproportionately distributed among foreign born and Hispanic construction workers. Worker Centers (WCs) provide services and advocacy for low-wage workers and a way for investigators to reach them. The goal of this project is to prevent occupational injuries by increasing awareness of hazards and self-efficacy among foreign born, Hispanic construction workers and by expanding the agenda of WCs to include occupational health and safety (H&S). METHODS: Investigators partnered with eight WCs in seven cities to train worker leaders to deliver a modified OSHA 10-hr curriculum to their peers. RESULTS: Thirty-two worker leaders trained 446 workers over 3 years. There was a demonstrated improvement in knowledge, hazard identification, self-efficacy, and sustainable H&S activities. CONCLUSIONS: This study provides evidence for successful implementation of a training intervention for low wage, low literacy Hispanic construction workers using a community-based participatory research approach.

Evaluating goals in worker health protection using a participatory design and an evaluation checklist.

Spanish-speaking immigrant workers in construction are considered hard to reach and at high risk for work-related injury and fatality. This evaluation study describes the use of participatory methods and an evaluation checklist to consider a health and safety (H&S) training program for these workers. A previously developed training manual and model were disseminated to eight worker centers (WCs) through participatory research collaboration. It incorporated H&S training for workers while strengthening the role of WCs as sources for leadership development and worker empowerment. Design, delivery, reaction, application, and extension were assessed through individual interviews with participants, trained trainers, and center staff and through observation of training sessions and partner debriefs; pre- and post-training tests assessed participant learning. Results indicate moderate learning and application by participants and strong evidence for structural gains in and among WCs. We conclude that such partnerships and models are valuable tools for collaborating with hard-to-reach workers.

Beyond the classroom: a case study of immigrant safety liaisons in residential construction.

Latino day laborers often work at dangerous construction sites with little power to change conditions. We describe the development, implementation, and early-stage results of a program to train immigrant day laborers as safety liaisons. These are construction workers prepared to recognize and respond to health and safety hazards. Based in Newark, NJ, the project involves collaboration between New Labor, a membership-based worker center, and university researchers and labor educators. Safety liaisons undergo training and receive ongoing support for their roles. Both qualitative and quantitative data are collected to monitor progress. Although lacking in formal authority, safety liaisons have prompted improvements at specific sites, filed OSHA complaints, and developed a local worker council. Participatory training methods, opportunities for leadership outside the classroom, and participation in project planning have strengthened liaisons' effectiveness, leadership skills, and commitment. The safety liaison approach could be adapted by worker centers and their partner organizations.

The impact of a peer-led participatory health and safety training program for Latino day laborers in construction.

BACKGROUND: Immigrant Latino day laborers working in residential construction are at particularly high risk of fatal and non-fatal traumatic injury and benefit from targeted training. OBJECTIVE: To understand the impact of a participatory, peer-facilitated health and safety awareness training customized to the needs of Latino day laborers. METHODS: Baseline surveys exploring exposures, PPE use, attitudes, work practices and work-related injuries were collected from more than 300 New Jersey Latino day laborers in construction prior to their participation in a one day (minimum of six hour) Spanish language health and safety training class. The classes, led by trained worker trainers, engaged participants in a series of tasks requiring teamwork and active problem solving focused on applying safe practices to situations they encounter at their worksites. Follow-up surveys were difficult to obtain among mobile day laborers, and were collected from 70 men (22% response rate) 2-6 months following training. Chi-square analysis was used to compare pre- and post-intervention PPE use, self protective actions, and self-reported injury rates. Focus groups and in-depth interviews addressing similar issues provided a context for discussing the survey findings. RESULTS: At baseline, the majority of day laborers who participated in this study reported great concern about the hazards of their work and were receptive to learning about health and safety despite limited influence over employers. Changes from baseline to follow-up revealed statistically significant differences in the use of certain types of PPE (hard hats, work boots with steel toes, safety harnesses, and visible safety vests), and in the frequency of self-protective work practices (e.g., trying to find out more about job hazards on your own). There was also a suggestive decrease in self-reported injuries (receiving an injury at work serious enough that you had to stop working for the rest of the day) post-training based on small numbers. Sixty-six percent of workers surveyed post-training reported sharing information from their safety workbook with friends and co-workers. Focus groups and interview results generally confirmed the quantitative findings. CONCLUSIONS: Participatory, peer led training tailored to the needs of construction day laborers may have a positive effect on Latino immigrant workers' attitudes, work practices, and self reported injury rates, but major changes would require employer engagement. IMPACT ON INDUSTRY: Health and safety researchers have identified reducing the number of traumatic injuries among the immigrant construction workforce as an increasingly important priority. This project provides one model for collaboration between university-based researchers, a union, and a community-based organization. The specific elements of this project-participatory curriculum customized to the needs of day laborers in residential construction, training day laborers to facilitate training classes, and involving peer leaders in outreach and research-could be adapted by other organizations. The findings of this study suggest that the Latino day laborers have a strong interest in and some ability to act on health and safety information. Widespread implementation of this type of training, especially if supported with cooperation from residential contractors, could lead to reduced rates of traumatic injury in the residential construction industry.

Immigrant Latino day laborers in New Jersey: baseline data from a participatory research project.

This study reflects the collaborative efforts of university-based researchers, New Labor, a non-profit, membership-based worker center, the Laborers' International Union of North America New Jersey Chapter (LIUNA), and the N.J. Laborers Health and Safety Fund to develop a greater understanding of the needs, experiences, attitudes, and practices of the Latino day-labor workforce in New Jersey. Survey and qualitative data presented in this study address several questions about which there is currently very little information. These results strongly suggest that a significant subgroup of day laborers are both aware of and concerned about the dangers they face, open to opportunities for Spanish language training, and despite challenges, ready to use what they learn about health and safety. As a reflection of the perceptions and reports of roughly 150 day laborers, this project provides further validation of the importance of stakeholder involvement in research and training among hard-to-reach worker populations.