Advertisement

European Journal of Clinical Pharmacology

, Volume 70, Issue 8, pp 1011–1020 | Cite as

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

  • Rocío Fernández UrrusunoEmail author
  • Macarena Flores Dorado
  • Angel Vilches Arenas
  • Carmen Serrano Martino
  • Susana Corral Baena
  • Ma Carmen Montero Balosa
Pharmacoepidemiology and Prescription

Abstract

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.

Keywords

Appropriate prescription Antibiotics Infections Multifaceted interventions Primary care 

Notes

Acknowledgments

This work has received an award from the Spanish Society of Primary Care Pharmacy (SEFAP), sponsored by Chiesi: Research Award for Pharmaceutical Primary Care 2013. The authors wish to thank the people who have also participated in the implementation of the guide: M.T. Alonso Salas (specialist in Pediatry, Section Chief of Pediatric Emergencies, Hospital Virgen del Rocío), C. Bravo Escudero (Dentist, Distrito Sanitario Aljarafe), M. Chávez Caballero (specialist in Clinical Microbiology and Parasitology, Hospital San Juan de Dios del Aljarafe), R. Espinosa Calleja (specialist in Internal Medicine, Hospital San Juan de Dios del Aljarafe), A. Fernández Moyano (specialist in Internal Medicine, Chief Medical Service, Hospital San Juan de Dios del Aljarafe), M.J. Garabito Sánchez (specialist in Hospital Pharmacy, Chief Pharmacy Service, Hospital San Juan de Dios del Aljarafe), M. Martínez Granero (specialist in Family and Community Medicine, Distrito Sanitario Aljarafe), M. Olivencia Pérez (specialist in Otolaryngology, Chief Otolaryngology Service, Hospital San Juan de Dios del Aljarafe), M. Ramírez Arcos (specialist in Clinical Microbiology and Parasitology, Hospital San Juan de Dios del Aljarafe), M. Remírez de Esparza Otero (specialist in Hospital Pharmacy, Hospital San Juan de Dios del Aljarafe), V. Rodríguez Pappalardo (specialist in Family and Community Medicine, Distrito Sanitario Aljarafe), S. Taboada Prieto (specialist in Family and Community Medicine, Emergencies Service, Hospital San Juan de Dios del Aljarafe), and A. Vázquez Florido (specialist in Pediatry, Pediatric Emergencies Section, Hospital Virgen del Rocío).

Funding

This investigation was financially supported by two research projects: FISS Spanish Ministry of Health (project PI/10/01152) and Andalusian Regional Ministry of Health (project PI-0160-2010).

Conflict of interest

The authors declare that they have not conflicts of interest to disclose.

Ethics approval

This study has been approved by the Ethics Committee on Health Research of the Hospital Virgen del Rocío (Seville, Spain). This work complies with the current laws of the country in which it was performed.

References

  1. 1.
    Petersen I, Hayward AC, Surveillance Subgroup SACAR (2007) Antibacterial prescribing in primary care. J Antimicrob Chemother 60:43–47CrossRefGoogle Scholar
  2. 2.
    Serna MC, Ribes E, Real J, Galván L, Gascó E, Godoy P (2011) High exposure to antibiotics in the population and differences by sex and age. Aten Primaria 43:236–244 (in Spanish)PubMedCrossRefGoogle Scholar
  3. 3.
    Lallana-Alvarez MJ, Feja-Solana C, Armesto-Gómez J, Bjerrum L, Rabanaque-Hernández MJ (2012) Outpatient antibiotic prescription in Aragón and the differences by gender and age. Enferm Infecc Microbiol Clin 30:591–596 (in Spanish)PubMedCrossRefGoogle Scholar
  4. 4.
    Arroll B (2005) Antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respir Med 99:255–261PubMedCrossRefGoogle Scholar
  5. 5.
    Smith SM, Fahey T, Smucny J, Becker LA (2004) Antibiotics for acute bronchitis. Cochrane Database Syst Rev (4) Art. No.: CD000245. doi: 10.1002/14651858.CD000245.pub2
  6. 6.
    Puhan MA, Vollenweider D, Latshang T, Steurer J, Steurer-Stey C (2007) Exacerbations of chronic obstructive pulmonary disease: when are antibiotics indicated? A systematic review. Respir Res 8:30. doi: 10.1186/1465-9921-8-30 PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Ong DS, Kuyvenhoven MM, van Dijk L, Verheij TJ (2008) Antibiotics for respiratory, ear and urinary tract disorders and consistency among GPs. J Antimicrob 62:587–592CrossRefGoogle Scholar
  8. 8.
    Llor C, Cots JM, Gaspar MJ, Alay M, Rams N (2009) Antibiotic prescribing over the last 16 years: fewer antibiotics but the spectrum is broadening. Eur J Clin Microbiol Infect Dis 28:893–897PubMedCrossRefGoogle Scholar
  9. 9.
    Adriaenssens N, Coenen S, Versporten A, Muller A, Minalu G, Faes C, ESAC Project Group (2011) European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe (1997–2009). J Antimicrob Chemother 66(Suppl 6):vi3–vi12PubMedGoogle Scholar
  10. 10.
    Goossens H, Ferech M, Vander Stichele R, Elseviers M, ESAC Project Group (2005) Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 365:579–587PubMedCrossRefGoogle Scholar
  11. 11.
    Ojeniran M, Shouval R, Miskin IN, Moses AE, Shmueli A (2010) Costs of appropriate and inappropriate use of antibiotics in the emergency department. Isr Med Assoc J 12:742–746PubMedGoogle Scholar
  12. 12.
    Murphy M, Bradley CP, Byrne S (2012) Antibiotic prescribing in primary care, adherence to guidelines and unnecessary prescribing-an Irish perspective. BMC Fam Pract 13:43. doi: 10.1186/1471-2296-13-43 PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Martínez MA, Inglada L, Ochoa C, Villagrasa JR, Spanish Study Group On Antibiotic (2007) Treatments. Assessment of antibiotic prescription in acute urinary tract infections in adults. J Infect 54:235–244PubMedCrossRefGoogle Scholar
  14. 14.
    Tobia CC, Aspinall SL, Good CB, Fine MJ, Hanlon JT (2008) Appropriateness of antibiotic prescribing in veterans with community-acquired pneumonia, sinusitis, or acute exacerbations of chronic bronchitis: a cross-sectional study. Clin Ther 30:1135–1144PubMedCrossRefGoogle Scholar
  15. 15.
    Fernández Urrusuno R, Flores Dorado M, Vilches Arenas A, Serrano-Martino C, Corral-Baena S, Montero-Balosa MC (2013) Appropriateness of antibiotic prescribing in a primary care area: a cross-sectional study. Enferm Infecc Microbiol Clin. doi: 10.1016/j.eimc.2013.05.004, in SpanishPubMedGoogle Scholar
  16. 16.
    Shehan B, Patel PR, Srinivasan A, Budnitz DS (2008) Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 47:744–746CrossRefGoogle Scholar
  17. 17.
    Lee CC, Lee CH, Chuang MC, Hong MY, Hsu HC, Ko WC (2012) Impact of inappropriate empirical antibiotic therapy on outcome of bacteremic adults visiting the ED. Am J Emerg Med 30:1447–1456PubMedCrossRefGoogle Scholar
  18. 18.
    Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD (2010) Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 340:c2096PubMedCrossRefGoogle Scholar
  19. 19.
    Butler CC, Hillier S, Roberts Z, Dunstan F, Howard A, Palmer S (2006) Antibiotic-resistant infections in primary care are symptomatic for longer and increase workload: outcomes for patients with E coli UTIs. Br J Gen Pract 56:686–692PubMedCentralPubMedGoogle Scholar
  20. 20.
    Goossens H, Guillemot D, Ferech M, Schlemmer B, Costers M, van Breda M et al (2006) National campaigns to improve antibiotic use. Eur J Clin Pharmacol 62:373–379PubMedCrossRefGoogle Scholar
  21. 21.
    Lázaro-Bengoa E, Iglesias FJ, López-Navas A, Fernández-Cortizo MJ (2010) Use of antibiotics in Spain and regulatory framework for clinical development in the European Union. Enferm Infecc Microbiol Clin 28(Supl 4):10–16, in SpanishPubMedCrossRefGoogle Scholar
  22. 22.
    Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, Evans MR, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R, Hayes J, Hare M, Hood K (2012) Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. BMJ 344:d8173. doi: 10.1136/BMJ.D8173 PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Gjelstad S, Hoye S, Straand J, Brekke M, Dalen I, Lindbaek M (2013) Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (prescription peer academic detailling (Rx-PAD) study). BMJ 347:f4403PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Van Driel ML, Coenen S, Dirven K, Lobbestael J, Janssens I, Van Royen P, Haaijer-Ruskamp FM, De Meyere M, De Maeseneer J, Christianens T (2007) What is the role of quality circles in strategies to optimise antibiotic prescribing? A pragmatic cluster-randomised controlled trial in primary care. Qual Saf Health Care 16:197–202PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Martens JD, Winkens RAG, van der Weijden T, de Bruyn D, Severens JL (2006) Does a joint developement and dissemination of multidisciplinary guidelines improve prescribing behaviour: a pre/poststudy with concurrent control group and a randomised trial. BMC Health Serv Res 6:145. doi: 10.1186/1472-6963-6-145 PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Welschen I, Kuyvenhoven M, Hoes AW, Verherij TJM (2004) Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. BMJ. doi: 10.1136/bmj.38182.591238.EB PubMedCentralPubMedGoogle Scholar
  27. 27.
    Arnold SR, Straus SE (2005) Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev (4) Art. No.: CD003539. doi: 10.1002/14651858.CD003539.pub2
  28. 28.
    Ranji SR, Steinman MA, Shojania KG, Gonzalez R (2008) Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Med Care 46:847–862PubMedCrossRefGoogle Scholar
  29. 29.
    Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J (2012) Training family physicians is shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. doi: 10.1503/cmaj.120568 PubMedCentralPubMedGoogle Scholar
  30. 30.
    Little P, Stuart B, Francis N, Douglas E, Tonkin-Crine S, Anthierens S, Cals JW, Melbye H, Santer M, Moore M, Coenen S, Butler C, Hood K, Kelly M, Godycki-Cwirko M, Mierzecki A, Torres A, Llor C, Davies M, Mullee M, O’Reilly G, van der Velden A, Geraghty AW, Goossens H, Verheij T, Yardley L, on behalf of the GRACE consortium (2013) Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. Lancet S0140–6736(13):60994. doi: 10.1016/S0140-6736(13)60994-0 Google Scholar
  31. 31.
    Fernández Urrusuno R, Serrano Martino C, Corral Baena S et al (2012) Guía de Terapéutica Antimicrobiana del Área Aljarafe. Second edition. Sevilla: Distrito Sanitario Aljarafe y Hospital San Juan de Dios del Aljarafe. Available at: http://www.guiasalud.es/GPC/GPC_479_Antimicrobianos_Area-Aljarafe_2ed_2012.pdf. Available at: http://www.juntadeandalucia.es/servicioandaluzdesalud/guiaterapeuticaaljarafe/guiaTerapeuticaAljarafe/ (in Spanish)
  32. 32.
    Drug Information Center online, Spanish Agency of Drugs and Sanitary Products. Available at: http://www.aemps.gob.es/cima/fichasTecnicas.do?metodo=detalleForm (in Spanish)
  33. 33.
    Reyes-Morales H, Flores-Hernández S, Tomé-Sandoval P, Pérez-Cuevas R (2009) A multifaceted education intervention for improving family physician’s care management. Fam Med 41:277–284PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Rocío Fernández Urrusuno
    • 1
    Email author
  • Macarena Flores Dorado
    • 1
  • Angel Vilches Arenas
    • 2
    • 3
  • Carmen Serrano Martino
    • 4
  • Susana Corral Baena
    • 5
  • Ma Carmen Montero Balosa
    • 1
  1. 1.Service of PharmacyAljarafe-Sevilla Norte Primary Health Care AreaSevilleSpain
  2. 2.Service of EpidemiologySevilla Primary Health Care AreaSevilleSpain
  3. 3.Departamento de Medicina Preventiva y Salud PúblicaUniversidad de SevillaSevilleSpain
  4. 4.Service of MicrobiologySan Juan de Dios HospitalSevilleSpain
  5. 5.Service of PharmacySan Juan de Dios HospitalSevilleSpain

Personalised recommendations