Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis
There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-sp...
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| Veröffentlicht in: | The Lancet infectious diseases 2020-02, Vol.20 (2), p.199-207 |
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| creator | Peñalva, Germán Fernández-Urrusuno, Rocío Turmo, José María Hernández-Soto, Rocío Pajares, Ignacio Carrión, Lucía Vázquez-Cruz, Inmaculada Botello, Blanca García-Robredo, Beatriz Cámara-Mestres, Manuel Domínguez-Camacho, Juan Carlos Aguilar-Carnerero, Manuel María Lepe, José Antonio de Cueto, Marina Serrano-Martino, María Carmen Domínguez-Jiménez, María Carmen Domínguez-Castaño, Ana Cisneros, José Miguel Alcántara, Juan deDios Álvarez-Marín, Rocío Cos-Vega, Ana Delgado-Cuesta, Juan Fajardo, José María Garrucho-Moreno, Joaquín Hevia, Elena Irastorza, Aránzazu Mestraitúa-Vázquez, Ainhoa Molina, Jose Montero, Emilio Palma-Aguilar, José Luis Remesal, Tomás Retamar, Pilar Taboada-Prieto, Salomé Toral, Javier Torres-Moreno, Joaquín |
| description | There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use.
We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.
The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012–13 and an intervention period of 2014–17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p |
| doi_str_mv | 10.1016/S1473-3099(19)30573-0 |
| format | Article |
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We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.
The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012–13 and an intervention period of 2014–17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect −15·9%, 95% CI −23·9 to −8·0) and cephalosporins (−22·6%, −35·9 to −9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by −0·028 cases per 1000 inhabitants (95% CI −0·034 to −0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of −65·6% (−68·2 to −63·0) 4 years later.
Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care.
Instituto de Salud Carlos III, Spanish Government (PI14/01523).</description><identifier>ISSN: 1473-3099</identifier><identifier>EISSN: 1474-4457</identifier><identifier>DOI: 10.1016/S1473-3099(19)30573-0</identifier><identifier>PMID: 31767423</identifier><language>eng</language><publisher>OXFORD: Elsevier Ltd</publisher><subject>Ambulatory care ; Amoxicillin ; Antibiotics ; Antiinfectives and antibacterials ; Antimicrobial agents ; Cephalosporins ; Ciprofloxacin ; Drug resistance ; E coli ; Ecological effects ; Ecological monitoring ; Education ; Epidemiology ; Escherichia coli ; Fosfomycin ; Health care ; Health care facilities ; Health services ; Hospitals ; Infectious Diseases ; Inhabitants ; Intervention ; Interviews ; Laboratories ; Life Sciences & Biomedicine ; Pharmacists ; Pharmacy ; Physicians ; Prescriptions ; Primary care ; Questionnaires ; Reduction ; Regional government ; Science & Technology ; Studies ; Sustainability ; Time series ; Trometamol ; Urinary tract diseases ; Urinary tract infections ; Urine ; Urogenital system</subject><ispartof>The Lancet infectious diseases, 2020-02, Vol.20 (2), p.199-207</ispartof><rights>2020 Elsevier Ltd</rights><rights>Copyright © 2020 Elsevier Ltd. All rights reserved.</rights><rights>2020. Elsevier Ltd</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>true</woscitedreferencessubscribed><woscitedreferencescount>41</woscitedreferencescount><woscitedreferencesoriginalsourcerecordid>wos000510486100037</woscitedreferencesoriginalsourcerecordid><citedby>FETCH-LOGICAL-c393t-3bf7d6ee461e24db30786c2a8624ce493fef5b249b2a84728fef8a9c549ad80d3</citedby><cites>FETCH-LOGICAL-c393t-3bf7d6ee461e24db30786c2a8624ce493fef5b249b2a84728fef8a9c549ad80d3</cites><orcidid>0000-0002-7101-2514</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.proquest.com/docview/2348267315?pq-origsite=primo$$EHTML$$P50$$Gproquest$$H</linktohtml><link.rule.ids>315,782,786,3554,27933,27934,28257,46004,64394,64396,64398,72478</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31767423$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Peñalva, Germán</creatorcontrib><creatorcontrib>Fernández-Urrusuno, Rocío</creatorcontrib><creatorcontrib>Turmo, José María</creatorcontrib><creatorcontrib>Hernández-Soto, Rocío</creatorcontrib><creatorcontrib>Pajares, Ignacio</creatorcontrib><creatorcontrib>Carrión, Lucía</creatorcontrib><creatorcontrib>Vázquez-Cruz, Inmaculada</creatorcontrib><creatorcontrib>Botello, Blanca</creatorcontrib><creatorcontrib>García-Robredo, Beatriz</creatorcontrib><creatorcontrib>Cámara-Mestres, Manuel</creatorcontrib><creatorcontrib>Domínguez-Camacho, Juan Carlos</creatorcontrib><creatorcontrib>Aguilar-Carnerero, Manuel María</creatorcontrib><creatorcontrib>Lepe, José Antonio</creatorcontrib><creatorcontrib>de Cueto, Marina</creatorcontrib><creatorcontrib>Serrano-Martino, María Carmen</creatorcontrib><creatorcontrib>Domínguez-Jiménez, María Carmen</creatorcontrib><creatorcontrib>Domínguez-Castaño, Ana</creatorcontrib><creatorcontrib>Cisneros, José Miguel</creatorcontrib><creatorcontrib>Alcántara, Juan deDios</creatorcontrib><creatorcontrib>Álvarez-Marín, Rocío</creatorcontrib><creatorcontrib>Cos-Vega, Ana</creatorcontrib><creatorcontrib>Delgado-Cuesta, Juan</creatorcontrib><creatorcontrib>Fajardo, José María</creatorcontrib><creatorcontrib>Garrucho-Moreno, Joaquín</creatorcontrib><creatorcontrib>Hevia, Elena</creatorcontrib><creatorcontrib>Irastorza, Aránzazu</creatorcontrib><creatorcontrib>Mestraitúa-Vázquez, Ainhoa</creatorcontrib><creatorcontrib>Molina, Jose</creatorcontrib><creatorcontrib>Montero, Emilio</creatorcontrib><creatorcontrib>Palma-Aguilar, José Luis</creatorcontrib><creatorcontrib>Remesal, Tomás</creatorcontrib><creatorcontrib>Retamar, Pilar</creatorcontrib><creatorcontrib>Taboada-Prieto, Salomé</creatorcontrib><creatorcontrib>Toral, Javier</creatorcontrib><creatorcontrib>Torres-Moreno, Joaquín</creatorcontrib><creatorcontrib>PIRASOA-FIS team</creatorcontrib><creatorcontrib>PIRASOA-FIS Team</creatorcontrib><title>Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis</title><title>The Lancet infectious diseases</title><addtitle>LANCET INFECT DIS</addtitle><addtitle>Lancet Infect Dis</addtitle><description>There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use.
We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.
The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012–13 and an intervention period of 2014–17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect −15·9%, 95% CI −23·9 to −8·0) and cephalosporins (−22·6%, −35·9 to −9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by −0·028 cases per 1000 inhabitants (95% CI −0·034 to −0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of −65·6% (−68·2 to −63·0) 4 years later.
Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care.
Instituto de Salud Carlos III, Spanish Government (PI14/01523).</description><subject>Ambulatory care</subject><subject>Amoxicillin</subject><subject>Antibiotics</subject><subject>Antiinfectives and antibacterials</subject><subject>Antimicrobial agents</subject><subject>Cephalosporins</subject><subject>Ciprofloxacin</subject><subject>Drug resistance</subject><subject>E coli</subject><subject>Ecological effects</subject><subject>Ecological monitoring</subject><subject>Education</subject><subject>Epidemiology</subject><subject>Escherichia coli</subject><subject>Fosfomycin</subject><subject>Health care</subject><subject>Health care facilities</subject><subject>Health services</subject><subject>Hospitals</subject><subject>Infectious Diseases</subject><subject>Inhabitants</subject><subject>Intervention</subject><subject>Interviews</subject><subject>Laboratories</subject><subject>Life Sciences & Biomedicine</subject><subject>Pharmacists</subject><subject>Pharmacy</subject><subject>Physicians</subject><subject>Prescriptions</subject><subject>Primary care</subject><subject>Questionnaires</subject><subject>Reduction</subject><subject>Regional government</subject><subject>Science & Technology</subject><subject>Studies</subject><subject>Sustainability</subject><subject>Time series</subject><subject>Trometamol</subject><subject>Urinary tract diseases</subject><subject>Urinary tract infections</subject><subject>Urine</subject><subject>Urogenital 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Escherichia coli in the community: an interrupted time-series analysis</title><author>Peñalva, Germán ; Fernández-Urrusuno, Rocío ; Turmo, José María ; Hernández-Soto, Rocío ; Pajares, Ignacio ; Carrión, Lucía ; Vázquez-Cruz, Inmaculada ; Botello, Blanca ; García-Robredo, Beatriz ; Cámara-Mestres, Manuel ; Domínguez-Camacho, Juan Carlos ; Aguilar-Carnerero, Manuel María ; Lepe, José Antonio ; de Cueto, Marina ; Serrano-Martino, María Carmen ; Domínguez-Jiménez, María Carmen ; Domínguez-Castaño, Ana ; Cisneros, José Miguel ; Alcántara, Juan deDios ; Álvarez-Marín, Rocío ; Cos-Vega, Ana ; Delgado-Cuesta, Juan ; Fajardo, José María ; Garrucho-Moreno, Joaquín ; Hevia, Elena ; Irastorza, Aránzazu ; Mestraitúa-Vázquez, Ainhoa ; Molina, Jose ; Montero, Emilio ; Palma-Aguilar, José Luis ; Remesal, Tomás ; Retamar, Pilar ; Taboada-Prieto, Salomé ; Toral, Javier ; Torres-Moreno, Joaquín</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c393t-3bf7d6ee461e24db30786c2a8624ce493fef5b249b2a84728fef8a9c549ad80d3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Ambulatory care</topic><topic>Amoxicillin</topic><topic>Antibiotics</topic><topic>Antiinfectives and antibacterials</topic><topic>Antimicrobial agents</topic><topic>Cephalosporins</topic><topic>Ciprofloxacin</topic><topic>Drug resistance</topic><topic>E coli</topic><topic>Ecological effects</topic><topic>Ecological monitoring</topic><topic>Education</topic><topic>Epidemiology</topic><topic>Escherichia coli</topic><topic>Fosfomycin</topic><topic>Health care</topic><topic>Health care facilities</topic><topic>Health services</topic><topic>Hospitals</topic><topic>Infectious Diseases</topic><topic>Inhabitants</topic><topic>Intervention</topic><topic>Interviews</topic><topic>Laboratories</topic><topic>Life Sciences & Biomedicine</topic><topic>Pharmacists</topic><topic>Pharmacy</topic><topic>Physicians</topic><topic>Prescriptions</topic><topic>Primary care</topic><topic>Questionnaires</topic><topic>Reduction</topic><topic>Regional government</topic><topic>Science & Technology</topic><topic>Studies</topic><topic>Sustainability</topic><topic>Time series</topic><topic>Trometamol</topic><topic>Urinary tract diseases</topic><topic>Urinary tract infections</topic><topic>Urine</topic><topic>Urogenital system</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Peñalva, Germán</creatorcontrib><creatorcontrib>Fernández-Urrusuno, Rocío</creatorcontrib><creatorcontrib>Turmo, José María</creatorcontrib><creatorcontrib>Hernández-Soto, Rocío</creatorcontrib><creatorcontrib>Pajares, Ignacio</creatorcontrib><creatorcontrib>Carrión, Lucía</creatorcontrib><creatorcontrib>Vázquez-Cruz, Inmaculada</creatorcontrib><creatorcontrib>Botello, Blanca</creatorcontrib><creatorcontrib>García-Robredo, Beatriz</creatorcontrib><creatorcontrib>Cámara-Mestres, Manuel</creatorcontrib><creatorcontrib>Domínguez-Camacho, Juan Carlos</creatorcontrib><creatorcontrib>Aguilar-Carnerero, Manuel María</creatorcontrib><creatorcontrib>Lepe, José Antonio</creatorcontrib><creatorcontrib>de Cueto, Marina</creatorcontrib><creatorcontrib>Serrano-Martino, María Carmen</creatorcontrib><creatorcontrib>Domínguez-Jiménez, María Carmen</creatorcontrib><creatorcontrib>Domínguez-Castaño, Ana</creatorcontrib><creatorcontrib>Cisneros, José Miguel</creatorcontrib><creatorcontrib>Alcántara, Juan deDios</creatorcontrib><creatorcontrib>Álvarez-Marín, Rocío</creatorcontrib><creatorcontrib>Cos-Vega, Ana</creatorcontrib><creatorcontrib>Delgado-Cuesta, Juan</creatorcontrib><creatorcontrib>Fajardo, José María</creatorcontrib><creatorcontrib>Garrucho-Moreno, Joaquín</creatorcontrib><creatorcontrib>Hevia, Elena</creatorcontrib><creatorcontrib>Irastorza, Aránzazu</creatorcontrib><creatorcontrib>Mestraitúa-Vázquez, Ainhoa</creatorcontrib><creatorcontrib>Molina, Jose</creatorcontrib><creatorcontrib>Montero, Emilio</creatorcontrib><creatorcontrib>Palma-Aguilar, José Luis</creatorcontrib><creatorcontrib>Remesal, Tomás</creatorcontrib><creatorcontrib>Retamar, Pilar</creatorcontrib><creatorcontrib>Taboada-Prieto, Salomé</creatorcontrib><creatorcontrib>Toral, Javier</creatorcontrib><creatorcontrib>Torres-Moreno, Joaquín</creatorcontrib><creatorcontrib>PIRASOA-FIS team</creatorcontrib><creatorcontrib>PIRASOA-FIS Team</creatorcontrib><collection>Web of Science - Science Citation Index Expanded - 2020</collection><collection>Web of Science Core Collection</collection><collection>Science Citation Index Expanded</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Pharma and Biotech Premium PRO</collection><collection>ProQuest Central (Corporate)</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Nursing & Allied Health Database</collection><collection>Virology and AIDS Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Lancet Titles</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Nursing & Allied Health Premium</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>MEDLINE - Academic</collection><jtitle>The Lancet infectious diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Peñalva, Germán</au><au>Fernández-Urrusuno, Rocío</au><au>Turmo, José María</au><au>Hernández-Soto, Rocío</au><au>Pajares, Ignacio</au><au>Carrión, Lucía</au><au>Vázquez-Cruz, Inmaculada</au><au>Botello, Blanca</au><au>García-Robredo, Beatriz</au><au>Cámara-Mestres, Manuel</au><au>Domínguez-Camacho, Juan Carlos</au><au>Aguilar-Carnerero, Manuel María</au><au>Lepe, José Antonio</au><au>de Cueto, Marina</au><au>Serrano-Martino, María Carmen</au><au>Domínguez-Jiménez, María Carmen</au><au>Domínguez-Castaño, Ana</au><au>Cisneros, José Miguel</au><au>Alcántara, Juan deDios</au><au>Álvarez-Marín, Rocío</au><au>Cos-Vega, Ana</au><au>Delgado-Cuesta, Juan</au><au>Fajardo, José María</au><au>Garrucho-Moreno, Joaquín</au><au>Hevia, Elena</au><au>Irastorza, Aránzazu</au><au>Mestraitúa-Vázquez, Ainhoa</au><au>Molina, Jose</au><au>Montero, Emilio</au><au>Palma-Aguilar, José Luis</au><au>Remesal, Tomás</au><au>Retamar, Pilar</au><au>Taboada-Prieto, Salomé</au><au>Toral, Javier</au><au>Torres-Moreno, Joaquín</au><aucorp>PIRASOA-FIS team</aucorp><aucorp>PIRASOA-FIS Team</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis</atitle><jtitle>The Lancet infectious diseases</jtitle><stitle>LANCET INFECT DIS</stitle><addtitle>Lancet Infect Dis</addtitle><date>2020-02</date><risdate>2020</risdate><volume>20</volume><issue>2</issue><spage>199</spage><epage>207</epage><pages>199-207</pages><issn>1473-3099</issn><eissn>1474-4457</eissn><abstract>There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use.
We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.
The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012–13 and an intervention period of 2014–17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect −15·9%, 95% CI −23·9 to −8·0) and cephalosporins (−22·6%, −35·9 to −9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by −0·028 cases per 1000 inhabitants (95% CI −0·034 to −0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of −65·6% (−68·2 to −63·0) 4 years later.
Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care.
Instituto de Salud Carlos III, Spanish Government (PI14/01523).</abstract><cop>OXFORD</cop><pub>Elsevier Ltd</pub><pmid>31767423</pmid><doi>10.1016/S1473-3099(19)30573-0</doi><tpages>9</tpages><orcidid>https://orcid.org/0000-0002-7101-2514</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1473-3099 |
| ispartof | The Lancet infectious diseases, 2020-02, Vol.20 (2), p.199-207 |
| issn | 1473-3099 1474-4457 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_2318727138 |
| source | Web of Science - Science Citation Index Expanded - 2020<img src="https://exlibris-pub.s3.amazonaws.com/fromwos-v2.jpg" />; Access via ScienceDirect (Elsevier); ProQuest Central UK/Ireland |
| subjects | Ambulatory care Amoxicillin Antibiotics Antiinfectives and antibacterials Antimicrobial agents Cephalosporins Ciprofloxacin Drug resistance E coli Ecological effects Ecological monitoring Education Epidemiology Escherichia coli Fosfomycin Health care Health care facilities Health services Hospitals Infectious Diseases Inhabitants Intervention Interviews Laboratories Life Sciences & Biomedicine Pharmacists Pharmacy Physicians Prescriptions Primary care Questionnaires Reduction Regional government Science & Technology Studies Sustainability Time series Trometamol Urinary tract diseases Urinary tract infections Urine Urogenital system |
| title | Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis |
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