Germán Peñalva1, Rocío Fernández-Urrusuno2, José María Turmo3, Rocío Hernández-Soto2, Ignacio Pajares4, Lucía Carrión5, Inmaculada Vázquez-Cruz6, Blanca Botello7, Beatriz García-Robredo8, Manuel Cámara-Mestres6, Juan Carlos Domínguez-Camacho4, Manuel María Aguilar-Carnerero3, José Antonio Lepe1, Marina de Cueto9, María Carmen Serrano-Martino10, María Carmen Domínguez-Jiménez11, Ana Domínguez-Castaño12, José Miguel Cisneros13. 1. Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain. 2. Primary Health-care District Aljarafe-Sevilla Norte, Mairena del Aljarafe, Seville, Spain. 3. Primary Health-care District Huelva-Costa, Huelva, Spain. 4. Primary Health-care District Sevilla, Seville, Spain. 5. Primary Health-care District Huelva-Costa, Huelva, Spain; Primary Health-care District Huelva-Condado-Campiña, La Palma del Condado, Huelva, Spain. 6. Primary Health-care District Osuna, Seville, Spain. 7. Primary Health-care District Huelva-Condado-Campiña, La Palma del Condado, Huelva, Spain. 8. Promotion of Rational Use of Medicines Department, Andalusian Health Service, Seville, Spain. 9. University Hospital Virgen Macarena, Seville, Spain. 10. Hospital San Juan de Dios del Aljarafe, Bormujos, Seville, Spain. 11. Hospital de la Merced, Osuna, Seville, Spain. 12. University Hospital Complex of Huelva, Huelva, Spain. 13. Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain. Electronic address: jmcisnerosh@gmail.com.
Abstract
BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: Instituto de Salud Carlos III, Spanish Government (PI14/01523).
BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: Instituto de Salud Carlos III, Spanish Government (PI14/01523).
Authors: Elad Ziv-On; Michael D Friger; Lisa Saidel-Odes; Abraham Borer; Orly Shimoni; Anna Nikonov; Lior Nesher Journal: Antibiotics (Basel) Date: 2021-02-10
Authors: Ana Belén Guisado-Gil; Regina Sandra Benavente; Román Villegas-Portero; María Victoria Gil-Navarro; Raquel Valencia; Germán Peñalva; José Miguel Cisneros Journal: Clin Microbiol Infect Date: 2022-01-10 Impact factor: 13.310
Authors: Rocío Fernández-Urrusuno; Carmen Marina Meseguer Barros; Regina Sandra Benavente Cantalejo; Elena Hevia; Carmen Serrano Martino; Aranzazu Irastorza Aldasoro; Juan Limón Mora; Antonio López Navas; Beatriz Pascual de la Pisa Journal: PLoS One Date: 2020-05-15 Impact factor: 3.240