Effect of tailored antibiotic stewardship programmes on the appropriateness of antibiotic prescribing in nursing homes.

OBJECTIVES: To evaluate the effect of tailored interventions on the appropriateness of decisions to prescribe or withhold antibiotics, antibiotic use and guideline-adherent antibiotic selection in nursing homes (NHs). METHODS: We conducted a quasi-experimental study in 10 NHs in the Netherlands. A participatory action research (PAR) approach was applied, with local stakeholders in charge of selecting tailored interventions based on opportunities for improved antibiotic prescribing that they derived from provided baseline data. An algorithm was used to evaluate the appropriateness of prescribing decisions, based on infections recorded by physicians. Effects of the interventions on the appropriateness of prescribing decisions were analysed with a multilevel logistic regression model. Pharmacy data were used to calculate differences in antibiotic use and recorded infections were used to calculate differences in guideline-adherent antibiotic selection. RESULTS: The appropriateness of 1059 prescribing decisions was assessed. Adjusting for pre-test differences in the proportion of appropriate prescribing decisions (intervention, 82%; control, 70%), post-test appropriateness did not differ between groups (crude: P = 0.26; adjusted for covariates: P = 0.35). We observed more appropriate prescribing decisions at the start of data collection and before receiving feedback on prescribing behaviour. No changes in antibiotic use or guideline-adherent antibiotic selection were observed in intervention NHs. CONCLUSIONS: The PAR approach, or the way PAR was applied in the study, was not effective in improving antibiotic prescribing behaviour. The study findings suggest that drawing prescribers' attention to prescribing behaviour and monitoring activities, and increasing use of diagnostic resources may be promising interventions to improve antibiotic prescribing in NHs.

Estimation of the serial interval of pertussis in Dutch households.

Increasing incidence has led to the re-appearance of pertussis as a public health problem in developed countries. Pertussis infection is usually mild in vaccinated children and adults, but it can be fatal in infants who are too young for effective vaccination (≤3 months). Tailoring of control strategies to prevent infection of the infant hinges on the availability of estimates of key epidemiological quantities. Here we estimate the serial interval of pertussis, i.e., the time between symptoms onset in a case and its infector, using data from a household-based study carried out in the Netherlands in 2007-2009. We use statistical methodology to tie infected persons to probable infector persons, and obtain statistically supported stratifications of the data by person-type (infant, mother, father, sibling). The analyses show that the mean serial interval is 20 days (95% CI: 16-23 days) when the mother is the infector of the infant, and 28 days (95% CI: 23-33 days) when the infector is the father or a sibling. These time frames offer opportunities for early mitigation of the consequences of infection of an infant once a case has been detected in a household. If preventive measures such as social distancing or antimicrobial treatment are taken promptly they could decrease the probability of infection of the infant.

Economic analysis of pertussis illness in the Dutch population: implications for current and future vaccination strategies.

To reduce pertussis disease burden new vaccination strategies are considered in many countries. Since not only health benefits, but also economical aspects play a role when introducing new vaccinations, we estimated medical costs of pertussis in the Netherlands. Besides, we retrospectively performed a cost-utility analysis of the preschool booster introduced in 2001. Our results show that annual costs for pertussis are still considerable (approximately c.1.77 million for a population of 16 million). Although infants represented only 5% of cases, they accounted for 50% of the total costs. Hence, the economic burden of pertussis is largely determined by costs per infant case (c.1490) and only to a limited degree by costs per patient in other age-groups (circa c.75). Despite a substantial reduction in the number of cases, the preschool booster was not considered cost-effective. The effectiveness of universal adolescent or adult booster strategies -- to prevent pertussis in infants -- should also be considered from an economical point of view before being implemented.

A prospective, community-based study on virologic assessment among elderly people with and without symptoms of acute respiratory infection.

BACKGROUND/OBJECTIVES: Community-based elderly studies concerning microbiology of acute respiratory infections are scarce. Data on subclinical infections are even totally absent, although asymptomatic persons might act as a source of respiratory infections. METHODS: In a 1-year community-based study, we prospectively investigated the possible virologic cause of acute respiratory infections in 107 symptomatic case episodes and 91 symptom-free control periods. Participants, persons >/=60 years, reported daily the presence of respiratory symptoms in a diary. Virologic assessment was performed by polymerase chain reaction (PCR) and serology. RESULTS: In 58% of the case episodes a pathogen was demonstrated, the most common being rhinoviruses (32%), coronaviruses (17%), and influenzaviruses (7%). The odds ratio for demonstrating a virus in cases with symptoms vs. controls without symptoms was 30.0 (95% confidence interval 10.2-87.6). In 4% of the symptom-free control periods a virus was detected. CONCLUSIONS: This study supports the importance of rhinovirus infections in community-dwelling elderly persons, whereas asymptomatic elderly persons can also harbor pathogens as detected by PCR, and thus might be a source of infection for their environment.