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----- Original Message ----- From: Sent by NCBI To: ibra@zadar.net Sent: Friday, June 30, 2006 3:05 PM Subject: pubmed Search Results This message contains search results from the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM). Do not reply directly to this message. Sender's message: Sent on Friday, 2006 Jun 30 GMT Select 20 document(s) Entrez pubmed Results Items 1 - 20 of 20 1: J Clin Pharm Ther. 2006 Apr;31(2):179-85. Related Articles, Books, LinkOut Developing and implementing a model for changing physicians' prescribing habits-- the role of clinical pharmacy in leading the change. Schwartzberg E, Rubinovich S, Hassin D, Haspel J, Ben-Moshe A, Oren M, Shani S. Department of Pharmacy, Hillel Yaffe Medical Centre, Hadera, Israel. eyal@hy.health.gov.il BACKGROUND AND OBJECTIVE: Budgetary constraints led the Israeli Hillel Yaffe Medical Center management to implement policies for reducing expenditure while maintaining the quality of care. For this purpose, the pharmacy services management developed and implemented a three-tier intervention feedback model for changing physicians' prescribing habits, and achieving cost-effective changes in antibiotic utilization. METHODS: A prospective drug utilization evaluation was conducted to profile antibiotic utilization. The results established a base from which a three-tier feedback, evidence-based intervention model was built. This model corresponds to the following three hierarchical levels: Level 1 activities involved management actions that influenced all levels of staff and concentrated mainly on the creation of guidelines. Level 2 activities involved the reorganization of the restricted antibiotics prescription authorization system, through the co-operation of the clinical pharmacy unit and the hospital infection control specialist. Level 3 focussed on clinical pharmacist activities on the wards. The model was implemented and assessed in the hospital from June 2002 until December 2004. RESULTS AND DISCUSSION: Implementation of the model resulted in a cumulative decrease of 6,473 i.v. antibiotics daily defined doses (DDDs) and a parallel increase in total oral antibiotic DDDs (Table 1). These changes were especially notable with high-bioavailability antibiotics and co-amoxiclav, where over 2.5 years there was a reduction of 2,472 and 4,752 i.v. DDDs, respectively (P < 0.000). The successful implementation of the model resulted in a reduction of 375,000 NIS ( approximately 66,190 euro) in pharmacy antibiotic costs, equivalent to 10 i.v. DDDs or 570 NIS ( approximately 102 euro) saved per clinical pharmacist working day. CONCLUSIONS: Our study demonstrates the successful implementation of a three-tier model for changing physicians' antibiotic prescribing. PMID: 16635053 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 2: Emerg Infect Dis. 2006 Feb;12(2):211-6. Related Articles, Books, LinkOut Systematic review of antimicrobial drug prescribing in hospitals. Davey P, Brown E, Fenelon L, Finch R, Gould I, Holmes A, Ramsay C, Taylor E, Wiffen P, Wilcox M. University of Dundee Medical School, Dundee, United Kingdom. p.g.davey@chs.dundee.ac.uk Prudent prescribing of antimicrobial drugs to hospital inpatients may reduce incidences of antimicrobial drug resistance and healthcare-associated infection. We reviewed the literature from January 1980 to November 2003 to identify rigorous evaluations of interventions to improve hospital prescribing of antimicrobial drugs. We identified 66 studies with interpretable data, of which 16 reported 20 microbiologic outcomes: gram-negative resistant bacteria, 10 studies; Clostridium difficile-associated diarrhea, 5 studies; vancomycin-resistant enterococci, 3 studies; and methicillin-resistant Staphylococcus aureus, 2 studies. Four studies provided strong evidence that the intervention changed microbial outcomes with low risk for alternative explanations, 8 studies provided less convincing evidence, and 4 studies provided no evidence. The strongest and most consistent evidence was for C. difficile-associated diarrhea, but we were able to analyze only the immediate impact of interventions because of nonstandardized durations of follow-up. The ability to compare results of studies could be substantially improved by standardizing methods and reporting. Publication Types: a.. Review PMID: 16494744 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 3: Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003543. Related Articles, Books, LinkOut Interventions to improve antibiotic prescribing practices for hospital inpatients. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, Holmes A, Ramsay C, Taylor E, Wilcox M, Wiffen P. Ninewells Hospital and Medical School, MEMO, Department of Clinical Pharmacology, Dundee, Scotland, UK DD1 9SY. p.g.davey@chs.dundee.ac.uk BACKGROUND: Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing. OBJECTIVES: To estimate the effectiveness of professional interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens or CDAD and their impact on clinical outcome. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles SELECTION CRITERIA: We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of antibiotic prescribing to hospital inpatients. Interventions included any professional or structural interventions as defined by EPOC. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data and assessed quality. MAIN RESULTS: Sixty six studies were included and 51 (77%) showed a significant improvement in at least one outcome. Six interventions only aimed to increase treatment, 57 interventions aimed to decrease treatment and three interventions aimed to both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 61 studies) or the duration of treatment (10 studies); 12 studies had more than one target. Of the six interventions that aimed to increase treatment, five reported a significant improvement in drug outcomes and one a significant improvement in clinical outcome. Of the 60 interventions that aimed to decrease treatment 47 reported drug outcomes of which 38 (81%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and duration of follow up it was only possible to perform meta-regression on a few studies. AUTHORS' CONCLUSIONS: The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections. Publication Types: a.. Meta-Analysis b.. Review PMID: 16235326 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 4: J Obstet Gynaecol Res. 2005 Jun;31(3):202-9. Related Articles, Books, LinkOut Evidence on antibiotic prophylaxis for cesarean section alone is not sufficient to change the practices of doctors in a teaching hospital. Liabsuetrakul T, Islam M. Department of Obstetric s and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand. ltippawa@hotmail.com AIMS: To assess the pattern of prophylactic antibiotic use in cesarean sections, identify factors associated with single-dose prescriptions as evidence-based best practice, and evaluate the changes in use of single-dose compared with multiple-dose regimens and the variation of use between doctors after dissemination of evidence. METHODS: An analytical descriptive study was conducted. The medical records of 432 women undergoing cesarean section from April to September 2001 after dissemination of evidence in a teaching hospital in Southern Thailand were reviewed. Use of single-dose prophylactic antibiotic was the main outcome measure. Patterns of prophylactic antibiotics, and factors associated with pregnant women and doctors, were analyzed and compared with baseline data among 463 women undergoing cesarean section in 1998. Multivariate logistic regression with random effects was used for analysis. RESULTS: After the dissemination of evidence, the rate of single-dose prescriptions increased from 14.2 to 22.4% (P < 0.01), single-dose prescriptions decreased for patients who had experienced longer durations of ruptured membranes, and the timing of the administration of antibiotics improved, but multiple-dose and duration of postoperative prescriptions increased. The variation in prescribing antibiotics between doctors was significant (P < 0.001). CONCLUSIONS: Knowledge of evidence alone does not improve practices uniformly. Consequently, other interventions are necessary to improve practices. PMID: 15916655 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 5: Pharmacotherapy. 2005 Feb;25(2):289-98. Related Articles, Books, LinkOut Controlled trials to improve antibiotic utilization: a systematic review of experience, 1984-2004. Parrino TA. West Palm Beach Veterans Affairs Medical Center, West Palm Beach, Florida 33410, USA. thomas.parrino@med.va.gov STUDY OBJECTIVES: To review the effectiveness of interventions designed to improve antibiotic prescribing patterns in clinical practice and to draw inferences about the most practical methods for optimizing antibiotic utilization in hospital and ambulatory settings. METHODS: A literature search using online databases for the years 1975-2004 identified controlled trials of strategies for improving antibiotic utilization. Due to variation in study settings and design, quantitative meta-analysis was not feasible. Therefore, a qualitative literature review was conducted. RESULTS: Forty-one controlled trials met the search criteria. Interventions consisted of education, peer review and feedback, physician participation, rewards and penalties, administrative methods, and combined approaches. Social marketing directed at patients and prescribers was effective in varying contexts, as was implementation of practice guidelines. Authorization systems with structured order entry, formulary restriction, and mandatory consultation were also effective. Peer review and feedback were more effective when combined with dissemination of relevant information or social marketing than when used alone. CONCLUSIONS: Several practices were effective in improving antibiotic utilization: social marketing, practice guidelines, authorization systems, and peer review and feedback. Online systems providing clinical information, structured order entry, and decision support may be the most promising approach. Further studies, including economic analyses, are needed to confirm or refute this hypothesis. Publication Types: a.. Review PMID: 15767243 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 6: Eur J Clin Microbiol Infect Dis. 2005 Jan;24(1):6-11. Related Articles, Books, LinkOut Optimizing fluoroquinolone utilization in a public hospital: a prospective study of educational intervention. Lacombe K, Cariou S, Tilleul P, Offenstadt G, Meynard JL. Infectious and Tropical Diseases Department, Saint-Antoine Hospital AP-HP, 184 rue du Faubourg Saint-Antoine, 75012 Paris, France. Fluoroquinolone (FQ) utilization should be optimized, with the aim of controlling both multidrug-resistant bacteria and costs. In the present study, the appropriateness of FQ prescriptions for urinary tract infections (UTIs) before and after an educational intervention was examined prospectively. FQ-prescribing physicians received oral and written guidelines between the two phases of the study. All patients admitted to Saint-Antoine University Hospital (Paris) and treated with FQs for UTIs during the study period were included. The main outcome measures of the appropriateness of FQ prescriptions were based on the principles of Antibiotic Utilization Review. The study involved 127 patients. The main prescribing errors before the intervention were wrong routes of administration and failure to take into account antibiotic susceptibility results. The rate of erroneous prescriptions fell by 74.4% after intervention. About 71% of the improvement can be attributed to the intervention (71.4%; 95% confidence interval, 39.3-86.8). The intervention had an overall positive impact on FQ prescription quality. The decrease in inappropriate prescriptions was due mainly to the use of antibiotic susceptibility results (23% vs. 11.5%, P<0.05) and better consideration of indications (18.9% vs. 3.8%; P<0.05). Future educational interventions will cover other indications and will take into account costs and local antimicrobial susceptibility patterns. PMID: 15599786 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 7: Arch Pediatr Adolesc Med. 2004 Oct;158(10):977-81. Related Articles, Books, LinkOut Effect of a standardized pharyngitis treatment protocol on use of antibiotics in a pediatric emergency department. Diaz MC, Symons N, Ramundo ML, Christopher NC. Department of Pediatrics, Northeastern Ohio Universities College of Medicine, and Pediatric Emergency Services, Children's Hospital Medical Center of Akron, Akron, Ohio, USA. mcdiaz@NEMOURS.org BACKGROUND: Pharyngitis is a common complaint in pediatric patients. If clinical parameters are used alone, bacterial pathogens will be wrongly implicated in many cases. A nonstandardized approach to the treatment of children with pharyngitis in an emergency department setting may lead to inappropriate empirical therapy, contribute to increased bacterial resistance, and result in adverse events related to the treatment provided. OBJECTIVE: To implement evidence-based guidelines for the diagnosis and treatment of children with pharyngitis in an emergency department setting and thereby influence practices of prescribing antibiotics. DESIGN AND METHODS: An evidence-based guideline for the evaluation and treatment of patients with pharyngitis was developed and implemented in our emergency department. Preintervention and postintervention patient cohorts were identified by a search of the emergency department's clinical repository. A medical record review was performed using a standardized data abstraction form (history and examination data, diagnostic testing, and therapy provided). Treatment decisions were judged as appropriate if the diagnosis of pharyngitis caused by group A beta-hemolytic streptococci was based on confirmatory microbiological testing rather than on the history and physical examination findings alone. RESULTS: We included 443 patients for study (219 preintervention and 224 postintervention). In the preintervention group, 97 (44%) of 214 received appropriate treatment. In the postintervention group, 204 (91%) of 224 received appropriate treatment. CONCLUSION: An evidence-based clinical guideline can influence and improve practices of prescribing antibiotics by pediatric emergency physicians in a teaching hospital setting. PMID: 15466686 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 8: Med J Aust. 2004 May 3;180(9):455-8. Related Articles, Books, LinkOut Impact of an electronic antibiotic advice and approval system on antibiotic prescribing in an Australian teaching hospital. Grayson ML, Melvani S, Kirsa SW, Cheung S, Korman AM, Garrett MK, Thomson WA. Austin Health, Studley Road, Heidelberg, VIC 3084, Australia. Lindsay.Grayson@austin.org.au The impact of a computer-based infectious diseases electronic antibiotic advice and approval system ("IDEA(3)S") was assessed as an alternative to a labour-intensive, phone-based approval system. IDEA(3)S-based approvals replaced 48% of all approvals for the most frequently requested antimicrobial agents (ceftriaxone/cefotaxime, vancomycin) and were associated with stable overall rates of antimicrobial use. Antibiotic prescribing for community-acquired pneumonia was 76% concordant with IDEA(3)S recommendations, and clinical acceptance of IDEA(3)S was excellent. Successful implementation required a coordinated, evidence-based approach between clinicians, pharmacists and hospital administration, together with ongoing staff education and feedback of results. IDEA(3)S is a useful new adjunct to routine clinician consultation to support appropriate antibiotic prescribing for a number of common indications in hospitals. PMID: 15115423 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 9: J Antimicrob Chemother. 2003 Nov;52(5):764-71. Epub 2003 Oct 16. Related Articles, Cited in PMC, Books, LinkOut Room for improvement: a systematic review of the quality of evaluations of interventions to improve hospital antibiotic prescribing. Ramsay C, Brown E, Hartman G, Davey P. Health Services Research Unit, University of Aberdeen, Aberdeen, UK. INTRODUCTION: In 1999, the British Society for Antimicrobial Chemotherapy (BSAC) and Hospital Infection Society (HIS) convened a working party on optimization of antibiotic prescribing in hospitals. This study was undertaken in order to evaluate the current evidence base on the effectiveness of interventions to change antibiotic prescribing to hospital inpatients. METHODS: We have systematically reviewed the literature from 1980 to identify interventions that alone, or in combination, are effective in improving antibiotic prescribing to hospital inpatients. The protocol was peer reviewed and has been published by the Effective Practice and Organization of Care (EPOC) Group of the Cochrane Collaboration (www.update-software.com/cochrane/). RESULTS: We identified 306 papers, of which 91 (30%) met the minimum inclusion criteria for a Cochrane EPOC review. The reasons for exclusion were uncontrolled before and after design (141/306; 46%) and inadequate interrupted time series (74/306; 24%) with fewer than three observations before and after the intervention. Most of the rejected interrupted time series (ITS) studies had only one or two data points before the intervention with many (up to 15) after it. Only 15 (40%) of the 38 included ITS studies had a statistical analysis and 11 of these used inappropriate statistical tests (e.g. t-test of pre- and post-intervention mean data) rather than analysis of time trends. Regression analysis of the proportion of included studies by year of publication did show a significant positive correlation (R2 = 0.7886). Nonetheless, of 47 papers published since 2000, only 19 (40%) met the minimum eligibility criteria. CONCLUSIONS: The majority of evaluations used fundamentally flawed methodology. There is limited evidence of improvement over time. These problems could be resolved if researchers and referees of protocols or manuscripts implemented the EPOC methodology. Publication Types: a.. Review PMID: 14563901 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 10: Arch Intern Med. 2003 Jun 23;163(12):1409-16. Related Articles, Cited in PMC, Books, LinkOut Comment in: a.. ACP J Club. 2004 Mar-Apr;140(2):52. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Kaushal R, Shojania KG, Bates DW. Division of General Internal Medicine, Brigham and Women's Hospital, Partners HealthCare System, Boston, Mass, USA. rkaushal@partners.org BACKGROUND: Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. METHODS: We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. RESULTS: Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. CONCLUSIONS: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems. Publication Types: a.. Review PMID: 12824090 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 11: Cent Afr J Med. 2001 Jun;47(6):150-5. Related Articles, Books, LinkOut Antibiotic use in infants hospitalised with HIV-related pneumonia in Harare, Zimbabwe. Chitsike I. Department of Paediatrics and Child Health Medical School, University of Zimbabwe, PO Box A 178, Avondale, Harare, Zimbabwe. ichitsike@healthnet.zw OBJECTIVE: To describe the clinical features of infants admitted with HIV-related pneumonia and to describe antibiotic use in relation to recommended treatment guidelines. DESIGN: Case series. SETTING: Paediatric medical wards of two University Teaching Hospitals, Parirenyatwa and Harare Central Hospitals. SUBJECTS: 100 infants aged one to 12 months admitted with HIV-related pneumonia. MAIN OUTCOME MEASURES: Mortality and antibiotic use in the two hospitals. METHODS: Records of 100 infants admitted for 48 hours or more with features of HIV-related pneumonia were analysed for clinical features and antibiotic use. RESULTS: 77% of patients were in the first six months of life with a peak age of two months and a median of four months (Q1 = 2, Q3 = 6). The median age of children admitted to Parirenyatwa hospital was 5.5 months (Q1 = 3, Q3 = 7) and in Harare hospital it was three months (Q1 = 2, Q3 = 6). The difference was statistically significant, p = 0.035. Fifty four percent of cases received penicillin, aminoglycoside and cotrimoxazole and overall only 30% of prescriptions complied with Essential Drug List of Zimbabwe (EDLIZ) recommendations for treatment of severe pneumonia in children with HIV infection. The overall mortality was 27.0%. The mortality in Harare Central Hospital was 40.4% and 15.7% in Parirenyatwa. The difference was statistically significant p = 0.005. CONCLUSION: The difficulties in establishing the cause of the pneumonia in infants with HIV infection was a contributory factor to lack of adherence to standard treatment guidelines. In countries with a high prevalence of HIV infection and with limited resources, a clinical case definition for Pneumocystis carinii pneumonia (PCP) is required as a measure to provide treatment for infants with HIV related pneumonia which is evidence based. This approach will also promote rational antibiotic prescribing and will contain cost. Publication Types: a.. Multicenter Study PMID: 12201021 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 12: Curr Opin Infect Dis. 2002 Aug;15(4):395-400. Related Articles, Books, LinkOut Antibiotic policies and control of resistance. Gould IM. Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK. i.m.gould@abdn.ac.uk PURPOSE OF THE REVIEW: The current worldwide pandemic of antibiotic resistance shows no signs of abating. It is clear that it is driven mainly by heavy and often inappropriate antibiotic use. Although control measures are widely practised, it is important that we assess their efficacy critically in order to concentrate expensive control efforts where they will be most effective. The past year has seen much activity in this area, with evidence-based assessments of the literature according to strict guidelines, as well as progress in basic science studies of mechanisms of resistance, and their causes and relations to pathogenicity and adaptability. RECENT FINDINGS: The present review summarizes current developments in the causes of antibiotic resistance, the classification of antibiotic stewardship and control measures, the evidence base for their efficacy, current problems in hospital practice, the adaptability of bacteria, the content of antibiotic policies and anticipated activities. SUMMARY: The conclusions from the published literature are that much of it that pertains to changing prescribing practices does not stand up to modern evidence-based analysis concepts. Nevertheless, we can learn from experience in changing other areas of medical practice. We must be pragmatic and must not expect to change the world, but rather take it step by step, recognizing barriers and measuring outcomes and quality indicators. Studies into the molecular basis of resistance confirm the superb genetic adaptability of micro-organisms. They will always be several steps ahead of us. Nevertheless, we are learning how to modify our prescribing habits to minimize resistance, not only by using antibiotics less frequently but also by altering dosing schedules in various ways. Publication Types: a.. Review PMID: 12130936 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 13: Br J Gen Pract. 2002 Mar;52(476):187-90, 193. Related Articles, Compound via MeSH, Substance via MeSH, Cited Articles, Free in PMC, Cited in PMC, Books, LinkOut Comment in: a.. Br J Gen Pract. 2002 May;52(478):412. Antibiotic prescribing and admissions with major suppurative complications of respiratory tract infections: a data linkage study. Little P, Watson L, Morgan S, Williamson I. Community Clinical Sciences (Primary Medical Care Group), University of Southampton, Aldermoor Health Centre, Aldermoor Close. psl3@soton.ac.uk BACKGROUND: Systematic reviews of antibiotic treatment of common acute respiratory tract infections (RTIs) suggest modest symptomatic benefit, but provide limited evidence that prescribing prevents complications. AIM: To assess the relationship between penicillin prescribing (the most commonly used group of antibiotics for RTIs) and hospital admission with complications. DESIGN OF STUDY: Data linkage study. SETTING: Ninety-six health authorities of England for the year 1997-1998. METHOD: Hospital admissions related to RTIs were linked with prescribing analysis and cost (PACT) data. RESULTS: There was close correlation between items of penicillin use and total antibiotic use (r = 0.96). After controlling for SMR, age, sex, and Townsend score, a one-unit increase in penicillin use (items dispensed per capita) was associated with a reduction in annual incidence per 10,000 of admissions for quinsy (-3.55 admissions, 95% confidence interval [CI] = -6.85 to -0.26), and mastoiditis (square root of incidence of admissions = -1.05, 95% CI = -1.82 to -0.27). This does not represent lower referral thresholds among higher prescribers as higher prescribing was associated with more admissions for tonsillectomy and overall admissions. Increasing prescribing by 2000 items of penicillin for a practice of 10,000 patients could possibly prevent one admission for either mastoiditis or quinsy. CONCLUSION: Higher antibiotic prescribing is associated with significantly fewer admissions with major complications. However, the overall size of the effect is modest and it is difficult to advocate an overall increase in prescribing to prevent complications. Future research should concentrate on finding better methods of targeting antibiotics to individuals at risk of poor outcome. PMID: 12030660 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 14: Ned Tijdschr Geneeskd. 2001 Sep 15;145(37):1773-7. Related Articles, Books, LinkOut ['Evidence-based' perioperative antibiotic prophylaxis policy in Belgian hospitals after a change in the reimbursement system] [Article in Dutch] Goossens H, Peetermans W, Sion JP, Bossens M. Universitair Ziekenhuis Antwerpen, Laboratorium voor Microbiologie, Wilrijkstraat 10, 2650 Edegem, Belgie. herman.goossens@uza.uia.ac.be The costs of antibiotics in Belgian hospitals are nearly fully reimbursed by the health insurance. Such a situation is not conductive to rational drug use. A new reimbursement system for perioperatively-administered antibiotics in Belgian hospitals was implemented in May 1997 by Royal Decree. A reimbursement code for antibiotic use was linked to the reimbursement of surgical interventions. This code represents a reimbursement which covers 75% of the cost of perioperative prophylaxis based on optimal indication, dose, and duration as recommended by international and Belgian consensus guidelines. The actual antibiotic prescribed during the 72-hour perioperative period (the day before, during and after surgery) is reimbursed at only 25% of its full cost. Thus, if the perioperative prophylactic antibiotic regimen complies with the evidence-based guidelines, the costs of antibiotic prescribing will be fully reimbursed by the health insurance (75% of the standard +25% of the actual costs). The new reimbursement system does not apply to antibiotics which are prescribed for treatment of intercurrent infections; these antibiotics continue to be fully reimbursed. Annual expenditures for antibiotics, for both antibiotic treatment and prophylaxis, nationwide and per hospital, have shown marked improvements in perioperative antibiotic use after the decree was implemented. Surgeons' adherence to the evidence-based standard of prophylactic antibiotic use has improved over time. In conclusion, rapid implementation of the perioperative antibiotic prophylaxis policy was achieved through changes in the reimbursement of antibiotics for surgery patients. Publication Types: a.. Review PMID: 11582638 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 15: Int J Technol Assess Health Care. 2001 Spring;17(2):171-80. Related Articles, Compound via MeSH, Substance via MeSH, Books, LinkOut A randomized trial to measure the optimal role of the pharmacist in promoting evidence-based antibiotic use in acute care hospitals. Dranitsaris G, Spizzirri D, Pitre M, McGeer A. Mt. Sinai Hospital. BACKGROUND: There is a considerable gap between randomized clinical trials and implementing the results into practice. This is particularly relevant in the use of broad-spectrum antibiotics in hospitals. Hospital pharmacists can be effective vehicles for bridging this gap and promoting evidence-based medicine. To determine the most effective way of using the pharmacist in this role, a prospective cefotaxime intervention study was conducted with randomization incorporated into the design as well as patient-related therapeutic outcomes. METHODS: A total of 323 patients who were prescribed cefotaxime were randomized into an intervention or nonintervention group where only the former was challenged by pharmacists for inappropriate cefotaxime usage relative to hospital guidelines. The primary outcome was the appropriateness of cefotaxime prescribing between groups. Logistic regression analysis was then used to identify factors that were associated with successful clinical response. RESULTS: Overall, 94% of orders in the intervention group met cefotaxime dosage criteria compared with 86% in the control group (p = .018). However, there was no impact with respect to promoting cefotaxime use for an appropriate indication (81% vs. 80%; p = .67). There was a trend for improved clinical outcomes in patients who received cefotaxime within hospital guidelines (OR = 1.73; p = .31). CONCLUSIONS: The pharmacist as a vehicle for promoting the appropriate use of broad-spectrum antibiotics in the acute care hospital setting can improve the dosing of such agents. However, several barriers to optimizing the impact of the pharmacist were implied by the data. Removing these barriers could increase the pharmacists' utility as an agent for improved patient care. Publication Types: a.. Clinical Trial b.. Multicenter Study c.. Randomized Controlled Trial PMID: 11446129 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 16: Cochrane Database Syst Rev. 2000;(2):CD000336. Related Articles, Books, LinkOut Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes. Bero LA, Mays NB, Barjesteh K, Bond C. Institute for Health Policy Studies, University of California, San Francisco, Laurel Heights, Suite 265, 3333 California Street, Box 0936, San Francisco, California 94118, USA. bero@medicine.ucsf.edu BACKGROUND: In recent years pharmacists' roles have expanded from simply packaging and dispensing medications to working with other health care professionals and the public. OBJECTIVES: To assess the effects of expanding outpatient pharmacists' roles on health services utilisation, the costs of health services, and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, International Pharmaceutical Abstracts and reference lists of articles up to December 1995. We also searched the published abstracts of three meetings and hand searched five journals and two bibliographies. SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of interventions comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus no intervention; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; and 4. Pharmacist services targeted at health professionals versus no intervention. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Fourteen studies were included involving more than 1991 patients. In the one study identified for comparison 1 the relative changes in professional outcome measures ranged from a 24% increase in clinic visits to a 16% decrease in hospital admissions. Relative differences in patient outcome measures were not statistically significant. Seven studies were identified for comparison 2. Four measured process of care and demonstrated decreases in health services utilisation from -67% for hospital admissions to -564% for total ambulatory care visits, as well as decreases in the numbers and costs of drugs compared to control patients. Five measured patient outcomes and consistently reported improvements in the targeted patient condition. In the one study identified for comparison 3 the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate antibiotic prescribing. All six studies identified for comparison 4 demonstrated that the pharmacist intervention produced the intended effect on physician prescribing practices. These studies did not measure patient outcomes. REVIEWER'S CONCLUSIONS: The limited number of studies analysed support the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined nature of the interventions tested, and the lack of studies including cost assessments and patient outcome data indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions. Publication Types: a.. Review PMID: 10796529 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 17: JAMA. 1996 Jan 17;275(3):234-40. Related Articles, Cited in PMC, Books, LinkOut Comment in: a.. JAMA. 1996 May 22-29;275(20):1544. Strategies to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals. A challenge to hospital leadership. Goldmann DA, Weinstein RA, Wenzel RP, Tablan OC, Duma RJ, Gaynes RP, Schlosser J, Martone WJ. Department of Medicine, Children's Hospital, Boston, Mass 02115, USA. OBJECTIVE--To provide hospital leaders with strategic goals or actions likely to have a significant impact on antimicrobial resistance, outline outcome and process measures for evaluating progress toward each goal, describe potential barriers to success, and suggest countermeasures and novel improvement strategies. PARTICIPANTS--A multidisciplinary group of experts was drawn from the following areas: hospital epidemiology and infection control, infectious diseases (including graduate training programs), clinical practice (including nursing, surgery, internal medicine, and pediatrics), pharmacy, administration, quality improvement, appropriateness evaluation, behavior modification, practice guideline development, medical informatics, and outcomes research. Representatives from appropriate federal agencies, the Joint Commission on Accreditation of Healthcare Organizations, and the pharmaceutical industry also participated. EVIDENCE--Published literature, guidelines, expert opinion, and practical experience regarding efforts to improve antibiotic utilization and prevent and control the emergence and dissemination of antimicrobial-resistant microorganisms in hospitals. CONSENSUS PROCESS--Participants were divided into two quality improvement teams: one focusing on improving antimicrobial usage and the other on preventing and controlling transmission of resistant microorganisms. The teams modeled the process a hospital might use to develop and implement a strategic plan to combat antimicrobial resistance. CONCLUSIONS--Ten strategic goals and related process and outcome measures were agreed on. The five strategic goals to optimize antimicrobial use were as follows: optimizing antimicrobial prophylaxis for operative procedures; optimizing choice and duration of empiric therapy; improving antimicrobial prescribing by educational and administrative means; monitoring and providing feedback regarding antibiotic resistance; and defining and implementing health care delivery system guidelines for important types of antimicrobial use. The five strategic goals to detect, report, and prevent transmission of antimicrobial resistant organisms were as follows: to develop a system to recognize and report trends in antimicrobial resistance within the institution; develop a system to rapidly detect and report resistant microorganisms in individual patients and ensure a rapid response by caregivers; increase adherence to basic infection control policies and procedures; incorporate the detection, prevention, and control of antimicrobial resistance into institutional strategic goals and provide the required resources; and develop a plan for identifying, transferring, discharging, and readmitting patients colonized with specific antimicrobial-resistant pathogens. Publication Types: a.. Consensus Development Conference b.. Review PMID: 8604178 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 18: Hosp Pharm. 1992 Mar;27(3):213-6. Related Articles, Books, LinkOut Impact of a pharmacist/physician cooperative target drug monitoring program on prophylactic antibiotic prescribing in obstetrics and gynecology. Michael KA, Henderson PL, Newman RB, Blackwelder EN, Caldwell RD. U niversity of Virginia Health Sciences Center, Charlottesville. The pharmacist's role in promoting rational, cost-effective use of drugs has been described in the literature. In a target drug monitoring program (TDMP), a single agent or group of agents becomes targeted for review. Antibiotics have been the primary focus of TDMP because of their therapeutic impact and cost considerations. The objectives of this project were to assess the prophylactic antibiotic prescribing habits of OB/GYN physicians and to evaluate the impact of a pharmacist/physician cooperative TDMP on prophylactic antibiotic prescribing and cost. The study was conducted in three phases: 1) a retrospective chart review of 150 patients, 2) an in-service education session, and 3) a concurrent chart review of 107 patients. Patient selection, timing of preoperative dose, and use of single dose prophylaxis were according to criteria in greater than 90% of patients both before and after the in-service training. Compliance with recommended regimens increased from 45 to 73% after the in-service training. A cost savings was not realized because the physicians wished to use a regimen with anti-anaerobic coverage (i.e., cefotetan) rather than a less expensive agent. However, the cost of selection of resistant organisms must be considered when discouraging the use of multiple broad spectrum agents. Active involvement of the medical staff in a pharmacy-based TDMP produces a cooperative atmosphere in which to educate clinicians and promote rational prescribing habits. PMID: 10116721 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 19: Med J Aust. 1991 May 6;154(9):587-92. Related Articles, Books, LinkOut Measuring and modifying hospital drug use. Eckert GM, Ioannides-Demos LL, McLean AJ. St George Hospital, Kogarah, NSW. OBJECTIVE: Various methods are available to quantitate medicinal drug use in hospitals. These represent a hierarchy of clinical specificity, complexity and cost of acquisition. Similarly, various strategies and methods are available to modify prescribing patterns. The objectives of this study are to illustrate these processes of measurement of drug use and modification of prescribing patterns using specific examples derived from practice at three major Australian teaching hospitals over 15 years. DESIGN, SETTING, MAIN OUTCOME MEASURES: Methods to measure and modify drug usage in the three hospitals are outlined and 12 examples are presented by specific drug or drug category. Each example includes details of the methods used to detect inappropriate drug use (pharmacy purchases, pharmacy issues, prescription analysis, clinical record review, performance and outcome assessment), the intervention strategies used (re-educative, persuasive, facilitative, power), the methods employed to alter drug prescribing and the relative effectiveness and cost-efficiency of the interventions. RESULTS: Readily available, relatively cheap quantitative methods provide significant information and an efficient basis for planning definitive studies, and substantial modification of prescription patterns is possible through the strategic use of limited manpower and resources. Publication Types: a.. Clinical Trial b.. Randomized Controlled Trial PMID: 1905384 [PubMed - indexed for MEDLINE] -------------------------------------------------------------------------------- 20: Am J Infect Control. 1990 Dec;18(6):399-404. Related Articles, Books, LinkOut Antibiotic sensitivity and the prescribing information sheet: assisting the prescribing physician. Snyder LL, Clyne KE, Wagner JC. St. Elizabeth Community Health Center, Lincoln, NE 68510. The concept conceived 5 years ago is now a reality. Physicians have information readily available for empiric prescribing from the home, office, or hospital. The other two hospitals in the city have implemented the systems. The reaction of physicians has been extremely favorable. In fact, two new publications for the outpatient/community and for the pediatric populations are now under way at the suggestion of physicians. Plans are in place to assess physician satisfaction and use of the information sheet within the coming year. Presently, too little time has passed to evaluate whether changes in prescribing have actually occurred. In fact, it may never be possible to identify how many instances of inadvisable prescribing are prevented with good initial information. However, for the relatively low cost involved, this has been an exciting new opportunity for education, as well as a method to promote cost-effective and appropriate antibiotic therapy. Publication Types: a.. Guideline PMID: 2285178 [PubMed - indexed for MEDLINE] --------------------------------------------------------------------------------