Most of the prescriptions for antibiotics occurs in Primary care. Careful utilization of current antibiotics can decrease the growing problem about antibiotic resistance
Surveillance and early warning systems for climate sensitive diseases in Viet...ILRI
Presentation by Hung Nguyen-Viet, Hu Suk Lee and Delia Grace at the CGIAR Research Program on Climate Change, Agriculture and Food Security (CCAFS) Flagship 2 science meeting, New York, USA, 17 October 2016.
Surveillance and early warning systems for climate sensitive diseases in Viet...ILRI
Presentation by Hung Nguyen-Viet, Hu Suk Lee and Delia Grace at the CGIAR Research Program on Climate Change, Agriculture and Food Security (CCAFS) Flagship 2 science meeting, New York, USA, 17 October 2016.
For decades microbes, in particular bacteria, have become increasingly resistant to various antimicrobials.
The World Health Assembly’s endorsement of the Global Action Plan on Antimicrobial Resistance (AMR) in May 2015, and the Political Declaration of the High-Level Meeting of the General Assembly on AMR in September 2017, both recognize AMR as a global threat to public health.
These policy initiatives acknowledge overuse and misuse of antimicrobials as a main driver for development of resistance, as well as a need to optimize the use of antimicrobials.
The Global Action Plan on AMR sets out five strategic objectives as a blueprint for countries in developing national action plans (NAPs) on AMR:
Objective 1: Improve awareness and understanding of AMR through effective communication, education and training.
Objective 2: Strengthen the knowledge and evidence base through surveillance and research.
Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures.
Objective 4: Optimize the use of antimicrobial medicines in human and animal health.
Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Antimicrobial stewardship programmes optimize the use of antimicrobials, improve patient outcomes, reduce AMR and health-care-associated infections, and save health-care costs amongst others.
Today, AMS is one of three “pillars” of an integrated approach to health systems strengthening. The other two are infection prevention and control (IPC) and medicine and patient safety.
Linking all three pillars to other key components of infection management and health systems strengthening, such as AMR surveillance and adequate supply of quality assured medicines, promotes equitable and quality health care towards the goal of achieving universal health coverage
CDC has defined “Antimicrobial stewardship” as-
The right antibiotic
for the right patient,
at the right time,
with the right dose, and
the right route, causing
the least harm to the patient and future patients
Why AMSP is needed?
Antimicrobial Resistance (AMR)
Misuse and Over-use of Antimicrobials
Widespread Use of Antimicrobials in Other Sectors
Poor Antimicrobial Research
IMPLEMENTATION OF ANTIMICROBIAL STEWARDSHIP PROGRAM
Administrative Support (Leadership)
Formulating AMS Team
Infrastructure Support
Framing Antimicrobial Policy
Implementing AMS strategies
Education and Training
Should be publicly committed to the program.
Provide necessary funding and infrastructure support.
Multidisciplinary committee - responsible for framing, implementing and monitoring the compliance to antimicrobial policy of the hospital.
Led by the antimicrobial steward - infectious disease physician or infection control officer or clinical microbiologist.
Other members of AMS team - stewardship nurses
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
CDC Key Prevention Strategies for Antimicrobial Resistance Prevent Infection Step 1: Vaccinate Fact:
Influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections.
Step 2: Get the catheters out Fact:
Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections.
Diagnose & Treat Infection Effectively Step 3: Target the pathogen
Fact:
Appropriate antimicrobial therapy saves lives.
Step 4: Access the experts Fact:
Infectious diseases expert input improves the outcome of serious infections.
•
Use Antimicrobials Wisely
Step 5: Practice antimicrobial control Fact:
Programs to improve antimicrobial use are effective. (Antimicrobial Stewardship)
•
Step 6: Use local data
Fact:
The prevalence of resistance can vary by locality, patient population, hospital unit, and length of stay.
•
•
Step 7: Treat infection, not contamination Fact:
A major cause of antimicrobial overuse is “treatment” of contaminated cultures.
Step 8: Treat infection, not colonization Fact:
Step 9: Know when to say “no” to vancomycin Fact:
Vancomycin overuse promotes emergence, selection,and spread of resistant pathogens.
•
Step 10: Stop antimicrobial treatment Fact:
Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance.
Prevent Transmission
Step 11: Isolate the pathogen Fact:
Patient-to-patient spread of pathogens can be prevented.
•
Step 12: Break the chain of infection Fact:
Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient
Antimicrobial stewardship; is an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy…..
Why is Antimicrobial Stewardship Important?
200-300 million antibiotics are prescribed annually….45% for outpatient use
25-40% of hospitalized patients receive antibiotics
10-70% are unnecessary or suboptimal
5% of hospitalized patients who receive antibiotics experience an Adverse reaction.
Health insurance companies will no longer reimburse for hospital acquired conditions deemed preventable.
Why is an antibiotic policy necessary?
To improve patient care by considered use of antibiotics for prophylaxis and therapy.
To rationalize the use of antibiotics.
To prevent or retard the emergence of resistant strains.
To improve education of junior doctors by providing guidelines for appropriate therapy
What are the clinical uses of antibiotics :
1. Therapeutic use:-
It is administration of an antimicrobial agent where substantial microbial infection has occurred.
2. Prophylactic Use:-
It is the use of antimicrobial agent before any infection has occurred to prevent a subsequent infection.
The Antimicrobial Stewardship Program (ASP) should be administered by multidisciplinary team (AST) composed of:
an infectious diseases (ID)physician
a clinical pharmacist with ID training,
a clinical microbiologist,
an IC professional,
Antibioti
For decades microbes, in particular bacteria, have become increasingly resistant to various antimicrobials.
The World Health Assembly’s endorsement of the Global Action Plan on Antimicrobial Resistance (AMR) in May 2015, and the Political Declaration of the High-Level Meeting of the General Assembly on AMR in September 2017, both recognize AMR as a global threat to public health.
These policy initiatives acknowledge overuse and misuse of antimicrobials as a main driver for development of resistance, as well as a need to optimize the use of antimicrobials.
The Global Action Plan on AMR sets out five strategic objectives as a blueprint for countries in developing national action plans (NAPs) on AMR:
Objective 1: Improve awareness and understanding of AMR through effective communication, education and training.
Objective 2: Strengthen the knowledge and evidence base through surveillance and research.
Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures.
Objective 4: Optimize the use of antimicrobial medicines in human and animal health.
Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Antimicrobial stewardship programmes optimize the use of antimicrobials, improve patient outcomes, reduce AMR and health-care-associated infections, and save health-care costs amongst others.
Today, AMS is one of three “pillars” of an integrated approach to health systems strengthening. The other two are infection prevention and control (IPC) and medicine and patient safety.
Linking all three pillars to other key components of infection management and health systems strengthening, such as AMR surveillance and adequate supply of quality assured medicines, promotes equitable and quality health care towards the goal of achieving universal health coverage
CDC has defined “Antimicrobial stewardship” as-
The right antibiotic
for the right patient,
at the right time,
with the right dose, and
the right route, causing
the least harm to the patient and future patients
Why AMSP is needed?
Antimicrobial Resistance (AMR)
Misuse and Over-use of Antimicrobials
Widespread Use of Antimicrobials in Other Sectors
Poor Antimicrobial Research
IMPLEMENTATION OF ANTIMICROBIAL STEWARDSHIP PROGRAM
Administrative Support (Leadership)
Formulating AMS Team
Infrastructure Support
Framing Antimicrobial Policy
Implementing AMS strategies
Education and Training
Should be publicly committed to the program.
Provide necessary funding and infrastructure support.
Multidisciplinary committee - responsible for framing, implementing and monitoring the compliance to antimicrobial policy of the hospital.
Led by the antimicrobial steward - infectious disease physician or infection control officer or clinical microbiologist.
Other members of AMS team - stewardship nurses
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
CDC Key Prevention Strategies for Antimicrobial Resistance Prevent Infection Step 1: Vaccinate Fact:
Influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections.
Step 2: Get the catheters out Fact:
Catheters and other invasive devices are the # 1 exogenous cause of hospital-onset infections.
Diagnose & Treat Infection Effectively Step 3: Target the pathogen
Fact:
Appropriate antimicrobial therapy saves lives.
Step 4: Access the experts Fact:
Infectious diseases expert input improves the outcome of serious infections.
•
Use Antimicrobials Wisely
Step 5: Practice antimicrobial control Fact:
Programs to improve antimicrobial use are effective. (Antimicrobial Stewardship)
•
Step 6: Use local data
Fact:
The prevalence of resistance can vary by locality, patient population, hospital unit, and length of stay.
•
•
Step 7: Treat infection, not contamination Fact:
A major cause of antimicrobial overuse is “treatment” of contaminated cultures.
Step 8: Treat infection, not colonization Fact:
Step 9: Know when to say “no” to vancomycin Fact:
Vancomycin overuse promotes emergence, selection,and spread of resistant pathogens.
•
Step 10: Stop antimicrobial treatment Fact:
Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance.
Prevent Transmission
Step 11: Isolate the pathogen Fact:
Patient-to-patient spread of pathogens can be prevented.
•
Step 12: Break the chain of infection Fact:
Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient
Antimicrobial stewardship; is an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy…..
Why is Antimicrobial Stewardship Important?
200-300 million antibiotics are prescribed annually….45% for outpatient use
25-40% of hospitalized patients receive antibiotics
10-70% are unnecessary or suboptimal
5% of hospitalized patients who receive antibiotics experience an Adverse reaction.
Health insurance companies will no longer reimburse for hospital acquired conditions deemed preventable.
Why is an antibiotic policy necessary?
To improve patient care by considered use of antibiotics for prophylaxis and therapy.
To rationalize the use of antibiotics.
To prevent or retard the emergence of resistant strains.
To improve education of junior doctors by providing guidelines for appropriate therapy
What are the clinical uses of antibiotics :
1. Therapeutic use:-
It is administration of an antimicrobial agent where substantial microbial infection has occurred.
2. Prophylactic Use:-
It is the use of antimicrobial agent before any infection has occurred to prevent a subsequent infection.
The Antimicrobial Stewardship Program (ASP) should be administered by multidisciplinary team (AST) composed of:
an infectious diseases (ID)physician
a clinical pharmacist with ID training,
a clinical microbiologist,
an IC professional,
Antibioti
Dengue is a febrile illness caused by a flavivirus transmitted by Aedes aegypti or Aedes albopictus mosquitoes while taking a blood meal. There are four dengue virus (DENV) types (DENV-1, DENV-2, DENV-3, and DENV-4), all of which are capable of inducing severe disease (dengue hemorrhagic fever [DHF]/dengue shock syndrome [DSS]). Dengue is endemic in more than 125 countries in tropical and subtropical regions and causes an estimated 390 million infections annually worldwide, of which 96 million are clinically apparent
In dengue-endemic regions, suspected, probable, and confirmed cases of dengue infection should be reported to the relevant authorities as soon as possible, so that appropriate measures can be instituted to prevent dengue transmission
dengue fever is a disease endemic to southeast asia, americas, africa. an early diagnosis and appropiate classification of the syndrome, helps the physician to provide the most adequate treatment.
La muerte del primer paciente es algo que marcara la vida de todo medico. El estar preparado y saber que esto te va a pasar, ayudara mucho al futuro medico para tener herramientas para sobrellevar el duelo
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
2. ATM stewardship
• Systematic measurement and coordinated
interventions designed to promote the optimal
use of antimicrobial agents, including their
choice, dosing, route, and duration of
administration.
3. The misuse of antibiotics has contributed to the growing problem of
antibiotic resistance. Which has become one of the most serious &
growing threats to patient safety and public health
4. FACTS
• The majority of ATM use occurs in the
outpatient setting (30%)
• Most of the ATM resistant infections occur in the
community
• Most deaths happen in the healthcare setting
5. The primary goal of antimicrobial stewardship is
to optimize clinical outcomes while minimizing
unintended consequences of antimicrobial use
- toxicity
- selection of pathogenic MOO such as C difficile
- the emergence of antimicrobial resistance
ATM stewardship
23. Core elements of outpatient antibiotic
stewardship
Stewardship
Kg
Pressure to see
Patients fast
24.
25.
26. There is no silver bullet for ATM; we
need a robust, multifaceted approach
that includes infection prevention,
antimicrobial stewardship,
surveillance, research, innovation and
an expert workforce
27. There is no silver bullet for ATM; we
need a robust, multifaceted approach
that includes infection prevention,
antimicrobial stewardship,
surveillance, research, innovation and
an expert workforce
Deaths are as a direct result of an antibiotic resistant infection
The misuse of antibiotics has contributed to the growing problem of antibiotic resistance. Which has become one of the most serious & growing threats to patient safety and public health
Antibiotic use is the most important modifiable risk factor leading to antibiotic resistance worldwide
Resistance is never far behind the introduction of new ATB
Action to keep new resistance from developing and also to prevent the already existent resistant MOO to spread
Antibiotic use is the most important modifiable risk factor leading to antibiotic resistance worldwide
Resistance is never far behind the introduction of new ATB
Action to keep new resistance from developing and also to prevent the already existent resistant MOO to spread
Antibiotic use is the most important modifiable risk factor leading to antibiotic resistance worldwide
Resistance is never far behind the introduction of new ATB
Action to keep new resistance from developing and also to prevent the already existent resistant MOO to spread
Antibiotic use is the most important modifiable risk factor leading to antibiotic resistance worldwide
Resistance is never far behind the introduction of new ATB
Action to keep new resistance from developing and also to prevent the already existent resistant MOO to spread
1. Decreased cell perm. Bacteria have fewer opening or modified openings
2. Efflux pump- pump out the atb before it damages the bacteria
3. Altering the drug target- if an ATB cannot bind to the target it cannot kill the bacteria
4. Inactivating enzymes- attack the atb to make it less effective
BY preventing infection reduces the amount of atm needed to be used
Avoiding atm use decreases the risk of atm resistance bacteria spread and develop
Appropiate infection control practices to prevent spread
10 % males and 20% of women aged over 65 are estimated to have asymptomatic bacteriuria
Needs to be treated when found in preoperative assessment
1991- finland.
National recommendations to reduce macrolide use
2008 Scotland
Commitment — Clinicians can commit to antimicrobial stewardship by displaying a public statement in patient care areas describing ad
herence to appropriate antimicrobial use
high-priority conditions are those for which clinicians commonly deviate from best practices for antimicrobial prescribing; they include conditions for which antimicrobial are overprescribed, underprescribed, or misprescribed (with the wrong antimicrobial agent, dose, or duration).
Examples include:
●Conditions for which antimicrobials are not indicated (examples include acute bronchitis, the common cold, other nonspecific upper respiratory infection or viral pharyngitis, and asymptomatic urinary tract infection) [14,15]
●Conditions for which antimicrobials might be indicated but are overdiagnosed, such as a condition that is diagnosed without fulfilling diagnostic criteria (for example, prescribing antimicrobials for streptococcal pharyngitis without testing for group A Streptococcus) [14]
●Conditions for which antimicrobials might be indicated but for which the wrong antimicrobial class, agent, dose or duration is often selected [16-18]
●Conditions for which watchful waiting or delayed prescribing is appropriate but underused (examples include acute otitis media and acute uncomplicated sinusitis) [17,19,20]
These conditions are discussed further separately:
Clinician interventions — The following interventions may be pursued to improve antimicrobial prescribing [2,21]:
●Identify barriers that lead to deviation from best practices (examples include clinician knowledge gaps about clinical practice guidelines, clinician perception of patient expectations regarding antimicrobials, and perceived pressure to see patients quickly).
●Establish standards for antimicrobial prescribing; this might include implementation of national guidelines and/or developing facility-specific guidelines (if applicable) to establish clear expectations for appropriate antimicrobial prescribing. As an example, one study noted use of clinical pathways for common outpatient infections was associated with a reduction in antimicrobial prescriptions for acute respiratory infections [25].
Providers frequently prescribe antimicrobials for a longer duration than necessary. Clinical pathways can promote the shortest effective duration of therapy supported by evidence in order to limit unintended consequences of antimicrobial use. Pharmacist review of prescriptions could facilitate adherence to the preferred duration of therapy [26].
Prescriber education is necessary but insufficient to implement the changes required for improved antimicrobial prescribing [27,28]. One survey of primary care physicians, nurse practitioners, and physician assistants noted that providers frequently fail to comply with guidelines even when they are familiar with them [27]. Reasons included belief that nonrecommended antimicrobials were more effective, concern for complications, and patient satisfaction; concern about the general problem of antimicrobial resistance was not routinely factored into decisions about antimicrobial use.
●Use watchful waiting or delayed prescribing for patients with conditions that usually resolve without treatment but who can benefit from antimicrobials if symptoms do not improve; this approach can safely decrease antimicrobial use when used in accordance with clinical practice guidelines. In such cases, symptomatic relief should be provided with a clear plan for follow-up if symptoms worsen or do not improve (for example, the patient may be instructed to call or return for a prescription, or a postdated prescription may be provided with instructions to fill the prescription after a predetermined period).
●Reduce inappropriate diagnostic testing that frequently leads to inappropriate antimicrobial therapy [29,30]. As examples, urine cultures are not warranted in the absence of voiding symptoms or pyuria, and sputum cultures are not warranted for patients with acute bronchitis.
●Issues related to antimicrobial allergy assessment are discussed separately. (See "Antimicrobial stewardship in hospital settings", section on 'Antimicrobial allergy assessment'.)
Leadership interventions — Clinic and health care system leadership can pursue the following interventions to improve antimicrobial prescribing [2]:
●Provide clinician communications skills training to promote strategies for discussing benefits and harms of antimicrobial use, management of self-limiting conditions, patient concerns regarding prognosis, and clinician concerns regarding managing patient expectations for antimicrobials [24,31,32].
●Provide support for antimicrobial decision-making within the clinical workflow [25,33,34].
●Require written justification in the medical record for all antimicrobial prescriptions [35].
Tracking and reporting — Tracking and reporting clinician antimicrobial prescribing (also called audit and feedback) can guide changes in practice and be used to assess progress in improving antimicrobial prescribing. (See "Antimicrobial stewardship in hospital settings", section on 'Antimicrobial oversight'.)
Tracking and reporting for high-priority conditions can be used to assess whether appropriate diagnostic criteria were met, whether an antimicrobial was appropriate for the assigned diagnosis, whether the selected antimicrobial was the recommended agent, and whether the dose and duration were correct. (See 'Identify high-priority condition(s)' above.)
When possible, tracking of individual clinician antimicrobial prescribing (with provision of individualized feedback) is preferred [36]. Comparison of clinicians' performance with that of their top- and bottom-performing peers has been shown to be an effective feedback intervention [35-39].
In addition, tracking and reporting the complications of antimicrobial use (such as C. difficile infections, drug interactions, and adverse drug events) and antimicrobial resistance trends are useful.
Education and expertise — Education on appropriate antimicrobial use should involve patients and clinicians.
Clinicians can educate patients about appropriate antimicrobial use by:
●Educating patients about when antimicrobials are and are not needed – Patients should be informed that use of antimicrobials for viral infections provides no benefit and that certain bacterial infections (such as mild sinus and ear infections) might improve without antimicrobials. In addition, recommendations for symptom management and instructions for when to seek medical if symptoms worsen or do not improve should be provided [24].
●Educating patients about the potential harms of antimicrobial treatment; these include nausea, abdominal pain, diarrhea, C. difficile infection, and allergic reactions.
Provision of patient education materials can facilitate this process [40].
Clinic and health care system leaders can facilitate clinician education by providing formal educational training and continuing education opportunities and ensuring timely access to individuals with relevant expertise (such as pharmacists and infectious disease consultants).
