Ria Benko

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

BackgroundExcessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.MethodsGPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.ResultsA total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.ConclusionA multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.

Drug Utilization Research: Methods and Applications

Drug Utilization Research (DUR) is an eclectic scientific discipline, integrating descriptive and analytical methods for the quantification, understanding and evaluation of the processes of prescribing, dispensing and consumption of medicines and for the testing of interventions to enhance the quality of these processes. The discipline is closely related and linked mainly to the broader field of pharmacoepidemiology, but also to health outcomes research, pharmacovigilance and health economics.

Treatment of acute cystitis in Hungary: comparison with national guidelines and with disease-specific quality indicators

Abstract Background: The aim of this study was to compare Hungarian antibiotic use in acute cystitis with the internationally developed disease-specific quality indicators and with the national guidelines. Methods: The aggregated national-level data on systemic antibiotic use was purchased from the National Health Fund Administration. The study period was January–June 2007. Antibiotic use in acute cystitis was evaluated by means of the defined daily dose (DDD) methodology. Quality indicators of antibiotic prescribing proposed by the European Surveillance of Antimicrobial Consumption (ESAC) team were the usage rate of recommended antibacterials and the usage rate of quinolones. Adherence to the available national guidelines was determined. Results: For acute cystitis, 1.06 DDD per 1000 inhabitant-days antibiotic use was recorded. The ESAC recommended antibiotic use in cystitis (23.3%) was well below the recommended range (80–100%). The consumption of fluoroquinolones was 56.2%, which exceeded the recommended range (0–5%) more than 10 times. The adherence rate to the Hungarian guidelines ranged between 59.3% and 74.2%. Conclusions: As both investigated disease-specific quality indicators were well outside the acceptable ranges, some inappropriateness of antibiotic use in cystitis seems to be present. Adherence rates to the different national guidelines were also moderate, but due to the general recommendation of quinolones, values should be interpreted with caution. New transparent guidelines – issued by the Hungarian Society of Family Physicians – should be introduced in Hungary, recommending quinolones only for second-line therapy.

Quantitative disparities in outpatient antibiotic exposure in a Hungarian county

OBJECTIVES Although antibiotic utilization data expressed in defined daily doses (DDDs)/1000 inhabitants/day are often available for a given period and area, the actual antibiotic exposure of the population is rarely explored. We aimed to identify the real antibiotic exposure of the inhabitants of one Hungarian county. METHODS The patient-level dispensing data for 2005 for Csongrád County were retrieved from the database of the Hungarian National Health Fund Administration. The number of antibiotic users was quantified, and differences in antibiotic use (quantity and frequency) were explored. Disparities were revealed by Lorenz curves. A new form of Lorenz curve was also introduced. The DDD values for 2005 were used. RESULTS In 2005, a total of 486 115 antibiotic prescriptions were redeemed, and 3 329 385 DDDs were dispensed to 213 748 different patients; 50.3% of the inhabitants of Csongrád County (total population 424 615) took antibiotics. The average consumption of 1-, 2-, 3-, 4- and 5-time users was 7.5, 14.6, 21.0, 26.9 and 32.2 DDDs per user, respectively. Lorenz curves (including the new form of Lorenz curve) demonstrated the existence of disparities in antibiotic use. One percent of the users with the heaviest consumption were responsible for 6.9% of the total use and redeemed antibiotic prescriptions nine times or more during 2005. CONCLUSIONS Disparities in antibiotic use were detected: half of the inhabitants were exposed to antibiotics, and among antibiotic users, the quantity of antibiotics that they redeemed displayed great variance, mainly due to differences in the prescribing frequency. Special attention should be paid to those with frequent antibiotic use (five times or more annually).

An 8-Year Evaluation of Antibiotic Consumption and Antibiotic Resistance Among Streptococcus pneumoniae from In- and Out-Patients in Szeged, Hungary

Abstract At the beginning of the 1990s, the prevalence of penicillin resistance of Streptococcus pneumoniae strains in Hungary was found to be extremely high (up to 58% non-susceptible) in some studies, while in other publications the percentage of penicillin highly resistant strains was 0-2%. To see whether this was due to differences in methodology or the composition of the patient population studied, a retrospective evaluation was carried out of the penicillin, amoxicillin, ceftriaxone and macrolide resistance of all S. pneumoniae strains isolated from in- and outpatients in our laboratory between 1998 and 2005. Of the 2670 S. pneumoniae isolates only 5.58% was found to exhibit high-level resistance to penicillin, while resistance to amoxicillin, ceftriaxone and erythromycin was 2.62%, 1.12% and 42.06%, respectively. During this period 6 (3.8%) of 155 S. pneumoniae strains isolated from invasive samples displayed high-level resistance to penicillin. Earlier surveillance data on penicillin resistance of S. pneumoniae may have been biased by the age groups affected by the infection, by whether the strain was isolated from an out-patient or an in-patient, and by whether the isolates were obtained from invasive samples. Our 8-year study using the NCCLS/CLSI methodology consequently revealed a low prevalence of high-level resistance to penicillin in S. pneumoniae strains obtained both from adults and children.

Treatment of Community-Acquired Pneumonia in Adults: Analysis of the National Dispensing Database

Crude national ambulatory antibiotic dispensing data (2007–2011) of adult patients (aged between 20 and below 65 years) with CAP were obtained and expressed as DDD per 1000 inhabitants and per day (DID). European quality indicators of antibiotic prescribing were calculated and adherence rate to the national CAP guideline was assessed. Antibiotic use for CAP in adults ranged between 0.27 and 0.30 DID in various years. The most frequently used antibacterials were levofloxacin, co‐amoxiclav and clarithromycin. Antibiotic use in CAP was compliant with the European recommendations in 6.4% in 2007, which decreased to 4.9% by 2011, in contrast to the optimal compliant range of 80–100%. The consumption of fluoroquinolones mounted up to ~40% in both genders, which exceeded the recommended range (0–5%) substantially. National guideline also favoured the use of macrolides in the empiric therapy of CAP in otherwise healthy adults; hence, guideline‐concordant antibiotic use ranged between 24.0–32.3%. Agents that were contra‐indicated in the empiric therapy of CAP were also used in 6.5–9.0% in various years. These data reflect some worrisome figures and trends in the outpatient antibiotic treatment of adults with CAP. Clarified and updated national guidelines focusing on outpatients and incentives/regulations to increase guideline concordance are warranted.

Hungarian Hospital Antibiotic Consumption at the Regional Level, 1996–2005

Background:Regional variations in antibiotic consumption in outpatients have been reported previously, but nothing is as yet known about the regional distribution of antibiotic consumption in the hospital sector in Hungary. This study was designed to explore regional variations and investigate determinants of antibiotic consumption in hospital care in Hungary.Materials and Methods:Regional distribution-based antibiotic sales data were obtained for a 10-year period (1996–2005) for the 20 Hungarian counties. Systemic antibacterial use (Anatomical Therapeutic Chemical code: J01) was expressed as the number of defined daily doses (DDD) per 100 patient-days. The multiple linear regression model was applied to investigate the determinants of regional differences in hospital antibiotic consumption. Independent variables related to health care access, utilization of hospital resources, doctors’ workload, type of hospital care provided, and patient’s characteristics and infections were considered as possible determinants, and data on these variables were obtained for 2 years (2004, 2005). We also tested the association between hospital and ambulatory care antibiotic consumption in Hungarian regions using the Pearson correlation test.Results:For each year during the 1996–2005 study period, there were large and stable variations in total hospital antibiotic consumption (e.g., min–max1996: 16.0–28.2; min–max2005: 15.2–32.2 DDD per 100 patient-days) depending on the region. In the two developed models (Model 1 and Model 2), the number of reported infections accounted for 53% of the observed regional variations in hospital antibiotic consumption (Model 1), and the number of reported infections together with the case-mix index were responsible for 61% (Model 2) . Total antibiotic consumption in hospitals showed a positive correlation (R = 0.71, p = 0.002) with total antibiotic consumption in ambulatory care.Conclusion:The case-mix index and the number of reported infections explained some of the observed regional variations. However, the moderate value of the models in explaining these regional variations suggest that determinants which could not be explored in this preliminary study may also contribute to regional differences. Future studies should aim at collecting data for each individual hospital as well as data on possible determinants for hospital antibiotic consumption.

Legal framework of antimicrobial stewardship in hospitals (LEASH): a European Society of Clinical Microbiology and Infectious Diseases (ESCMID) cross-sectional international survey

Antimicrobial stewardship (AMS) is the cornerstone activity in the combat against antimicrobial resistance. In order to ensure sustainable deployment and development of AMS, a strategic and regulatory framework needs to be provided by national healthcare authorities. Experts from 32 European countries, Israel and Turkey were invited to participate in a cross-sectional internet-based survey from October 2016 to May 2017 on the legal framework and mandatory components (structures, activities) of AMS in hospitals, i.e. components required by legislation or regulations. We collected data from 25 countries and two regions (in countries with federal health administration). Laws regulating AMS existed in seven countries and one region. Other health ministry regulations were applicable in 13 countries and one region. National strategies and/or action plans approved by ministries of health were in place in 13 countries and one region. Conversely, five countries and one region had no regulation of AMS in hospitals. Funding for AMS in hospitals was provided in five countries and one region. Eight countries and one region reported mandatory AMS structures and activities complying with the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) structure, policy and practice indicators. In 10/27 cases, however, the mandatory AMS activities were not being fully carried out. The survey showed heterogeneous legal frameworks for AMS in hospitals, and in many countries it was even lacking. The situation may be critical in countries with poor control of antimicrobial use and resistance. Recent international initiatives calling on policy-makers to address the threat of antimicrobial resistance could yield improvement.

2SPD-005 Mapping the use of reserve group antibiotics in hospitals

Background All antibiotics were categorised into access, watch and reserve groups in the latest List of Essential Medicines by the WHO.1 Antibiotics belonging to the reserve group should be protected and kept as a last resort when all others fail to give therapeutic effect. Purpose To map the consumption of reserve class antibiotics during the past 5 years. Material and methods The study was done on reserve group antibiotics which were selected based on the WHO definition. National data, regarding distribution to hospitals, were collected from wholesales statistics for the period between 2012 and 2016. Additionally, regional consumption data for 2016 were collected. Antibiotic use was analysed according to the Anatomical Therapeutic Chemical – Defined Daily Dose method (version 2017) and expressed in DDD per 100 patient-days. Results During the study period an increase in the national use of reserve antibiotics from 0.13 to 0.26 DDD per 100 patient-days could be observed. This corresponds to a relative increase from 0.57% to 1.13% in the total use of antibiotics in the hospital. A noticeable increase in the use of colistine (from 0.09 to 0.19 DDD per 100 patient-days) and tigecycline (from 0.01 to 0.03 DDD per 100 patient-days) accounts for a great part of this upward trend. A huge variation in the regional use of reserve group antibiotics were also detected (mean: 0.26; min: 0.02; max: 1.08 DDD per 100 patient-days). Three out of four counties providing tertiary care were among the top consumers of these antibiotics. Conclusion Though the collected data is a crude measure, it shows a trend in the increase (roughly doubled) in the absolute and relative use of reserve antibiotics nationally. This trend could be explained by several factors, as an increase in antibiotic resistance and increased access of these drugs. The detected large regional variations require further research. Since these antibiotics belong to the last-line treatment options, tight monitoring is essential, to maintain their therapeutic value. Reference and/or Acknowledgements 1. WHO Model List of Essential Medicines, 20th List, World Health Organisation, 2017. No conflict of interest

PS-104 Initiative for improving medicines safety in surgical inpatients

Background Audits of the drug prescribing process in hospitals can help to identify problematic fields in relation to drug treatment. This can increase patient safety by preventing potential medicines errors. Purpose To quantify the frequency of drug-related problems (DRPs) and assess consequent interventions in hospitalised patients. Material and methods The study took place in the vascular and general surgery ward over a 6-week period in 2014. Medicines recorded on patient charts were reviewed by a pharmacy resident in order to identify DRPs. DRPs of chronic medicines and those newly prescribed during the stay in hospital were assessed. Interventions were also recorded. The number of chronic medicines (i.e. including polypharmacy status: taking ≥6 medicines) in relation to DRPs were analysed (SPSS, T-test). Results Medicines of 171 patients (vascular surgery: 105, general surgery: 66) were assessed. Overall 123 DRPs were identified from 89 patients. Majority (68%, 84 cases) of DRPs were related to newly prescribed medicines while the rest (32%, 39 cases) were related to chronic medicines. In case of chronic medicines the most frequent type of error (71%) was inaccuracy of product strength or recording of dosing regimen. In newly prescribed drugs the lack of daily update on patient charts was the most frequent DRP (60%). The most frequent types of intervention were clarification of dosage/dosing regimen (60 cases) and clarification of the necessity for daily dosing (50 cases). Association was found between the number of medicines and DRPs: firstly, patients with polypharmacy had significantly higher chances of DRPs (OR: 2.45, 95% CI: 1.14–5.26; p = 0.020), secondly, in the vascular surgical ward, the average number of chronic medicines per patient was significantly higher when DRPs were found (7.1 ± 4.5 vs. 8.9 ± 3.5, p = 0.03). Conclusion We identified drug-related problems (DRPs) in every second patient. Pharmacists are able to detect and solve DRPs and prevent potential medicines errors. Reference PCNE Classification of DRP V 6.2 No conflict of interest.