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.

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

Las infecciones respiratorias representan la primera causa de morbilidad infecciosa tanto en adultos como en niños en atención primaria en España. Se tratan generalmente de infecciones autolimitadas, causadas principalmente por virus. Sin embargo, está documentado un alto porcentaje de prescripción antibiótica innecesaria. Las técnicas de diagnóstico rápido son pruebas biomédicas que puede ser utilizadas en la misma consulta con el paciente sin la necesidad de disponer de un laboratorio. El uso de estas pruebas, muchas de las cuales se han desarrollado recientemente, está aumentando rápidamente en atención primaria. No obstante, debemos reflexionar sobre si su uso contribuye siempre a que se realice un diagnóstico apropiado y de alta calidad por parte de los médicos de atención primaria. Presentamos un conjunto de criterios que pueden ser utilizados por los clínicos y se discuten las ventajas e inconvenientes de los instrumentos disponibles para el abordaje de las infecciones respiratorias y cómo utilizarlos (AU)

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 adecuadamente (AU)

[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.

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.

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

OBJETIVO: Analizar las características de la población que recibe tratamiento antibiótico y valorar la adecuación de estos tratamientos a sus indicaciones. MÉTODOS: DISEÑO: estudio descriptivo transversal de prescripción-indicación. EMPLAZAMIENTO: Un distrito de atención primaria en Andalucía. PARTICIPANTES: Pacientes adscritos a claves médicas del distrito. Se seleccionó una muestra por muestreo aleatorizado simple (nivel de confianza: 95%; precisión: 5%) de pacientes con prescripciones de antimicrobianos en 2009. Variable principal: adecuación de la prescripción de antibióticos a las recomendaciones de las guías locales. Los datos fueron obtenidos a través del sistema de facturación de recetas y la historia de salud digital. RESULTADOS: El 25% de la población del área recibió antibióticos durante 2009. La muestra (1.266 pacientes) presentó las siguientes características: el 57.9% eran mujeres, con una media de edad de 41 (± 1) años. El 39,3% eran pensionistas. La adecuación del tratamiento antibiótico fue del 19,9%, sin que se observaran diferencias de género. Se obtuvieron diferencias estadísticamente significativas relacionadas con la edad, y los mayores de 65años fueron el grupo de pacientes con mayor porcentaje de inadecuación. Los principales motivos de inadecuación fueron: no presentar registro de infección (44,5%), duración del tratamiento errónea (15,5%) y antibiótico incorrecto (11,5%). CONCLUSIÓN: Existe un alto grado de inadecuación en la prescripción de antibióticos en atención primaria. El alto grado de infra-registro, principalmente en pacientes de edades superiores, seguido de la utilización de pautas y tipo de antibióticos erróneos constituyen los principales motivos de inadecuación

OBJECTIVE: To assess the profile of patients receiving antibiotics and the appropriateness of these precriptions for the clinical conditions. METHODS: 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

[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.

Riesgos asociados a la utilización de antimicrobianos en personas mayores / No disponible

Objetivos: Describir los cambios fisiológicos más relevantes asociados al envejecimiento, las características de las infecciones en estos pacientes así como los efectos adversos más frecuentes e interacciones farmacológicas graves de los antimicrobianos en los mayores. Material y Métodos: Se realizó una revisión bibliográfica sobre los riesgos asociados al uso de antibióticos en ancianos. La información se apoyó en la actualización de la evidencia científica y la información de las Fichas Técnicas de los medicamentos. La búsqueda se limitó a los últimos 11 años, seleccionándose documentos publicados en español, inglés o francés. Se realizó una búsqueda electrónica de fuentes secundarias (revisiones sistemáticas) y una búsqueda manual “ad hoc”, partiendo de la bibliografía recuperada, estudios primarios, informes de agencias de evaluación de medicamentos, guías de práctica clínica y documentos de Sociedades Científicas. Se utilizaron como fuentes de información: Pubmed, Embase, Iowa Drug Information Service (IDIS), WinSPIRS 5.00, Up to Date, The Cochrane Library®. Resultados: Se localizaron 321 resultados, tras eliminar los que no cumplían criterios de inclusión 52 documentos, además de las fichas técnicas de todos los antibióticos citados, se incluyeron en la revisión bibliográfica. Conclusiones: Los pacientes mayores adquieren con mayor frecuencia infecciones por patógenos multi-resistentes y sufren más complicaciones graves de las infecciones. Los antibióticos son un grupo de fármacos especialmente sensibles a los cambios fisiológicos producidos por la edad, lo que puede condicionar la respuesta a los estos y exige en muchas ocasiones modificaciones posológicas con el fin de evitar intoxicaciones y/o fracasos terapéuticos. Este trabajo aporta información sobre estos cambios fisiológicos y los riesgos de los antibióticos en las personas mayores, aspectos necesarios para elegir un tratamiento adecuado (AU)

Aim: Describe the most important physiological changes associated with aging, the characteristics of infections in these patients and the most common side effects and severe interactions with antimicrobials in older people. Material and methods: We conducted a literature review on the risks associated with the use of antibiotics in the elderly. The information was based on the update of the scientific evidence and information from the drug Sheets. The search was limited to the past 11 years, selected papers published in English, Spanish or French. We performed an electronic search of secondary sources (systematic reviews) and a manual search “ad hoc” basis of the literature retrieved, primary studies, reports of drug evaluation agencies, clinical practice guidelines and documents of Scientific Societies. Information sources: Pubmed, Embase, Iowa Drug Information Service (IDIS), WinSPIRS 5.00, Up to Date, The Cochrane Library®. Results: We identified 321 results, after eliminating those who did not meet inclusion criteria 52 papers in addition to the technical specifications of all mentioned antibiotics were included in the literature review. Conclusion: Older patients can acquire infections more frequently multi-resistant pathogens and suffer more serious complications of infections. The antibiotics is a group of drugs sensitive to the physiological changes induced by aging, which may influence the response to these and often requires dosage modifications to avoid poisoning and / or therapeutic failures. This paper provides information on these physiological changes and risks of antibiotics in the elderly, aspects necessary to choose a proper treatment (AU)