IMPORTANCE Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance.OBJECTIVE To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing. DESIGN, SETTING, AND PARTICIPANTSIn this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada.INTERVENTIONS Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis. MAIN OUTCOMES AND MEASURESThe primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis. RESULTSOf the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months. CONCLUSIONS AND RELEVANCEIn this randomized clinic...

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The proposed categorization scheme provides a simple and logical way to organize the different cases of EV that have been described in the literature. This system organizes EV by its cause, allowing for a better understanding of the disease and helps differentiate EV from other causes of generalized verrucosis.

BACKGROUND Antimicrobial stewardship programs have been established in hospitals, but less studied in long‐term care facilities (LTCFs), a setting with unique challenges related to patient populations and available resources. This systematic review sought to provide a comprehensive assessment of antimicrobial stewardship interventions implemented in LTCFs, using meta‐analysis to examine their impact on overall antimicrobial use. METHODS Electronic searches of MEDLINE, Embase, and CINAHL (1990 to July 2018) identified any antimicrobial stewardship interventions in LTCFs, with no restriction on patient population, study design, or outcomes. Intervention components were categorized using the Cochrane Effective Practice and Organization of Care taxonomy on implementation strategies. Random‐effects meta‐analysis used ratio of means to facilitate pooling of different metrics of antimicrobial use. RESULTS Eighteen studies (one randomized controlled trial [RCT], four cluster RCTs, four controlled pre/post studies, and nine uncontrolled pre/post studies) met inclusion, using 13 different antimicrobial stewardship intervention strategies; 15 studies used multifaceted (maximum, seven; median, four) interventions. The three most commonly implemented strategies were educational materials, educational meetings, and guideline implementation. Intervention labor intensity and resource requirements varied considerably among interventions. Meta‐analysis of 11 studies demonstrated that antimicrobial stewardship strategies were associated with a 14% reduction in overall antimicrobial use (95% confidence interval = −8% to −20%; P < .0001), with similar results by study design but high heterogeneity (I2 = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I2 = 0%) for the cluster RCT and controlled pre/post study subgroups. Funnel plot analysis suggested publication bias, with a lack of publication of smaller studies showing increased antibiotic use. CONCLUSION Antimicrobial stewardship strategies implemented in long‐term care vary considerably in design and resource intensity, but collectively suggest potential to reduce antimicrobial use in this challenging setting. J Am Geriatr Soc 67:392–399, 2019.

ising rates of antimicrobial resistance are an emerging public health crisis. 1,2 Antibiotic use is associated with antimicrobial resistance at both the patient and population level. 3-5 The largest modifiable driver of resistance is antibiotic use. In addition, antibiotics have important adverse effects, including up to a 30% risk of allergic reactions and gastrointestinal symptoms, including diarrhea associated with Clostridium difficile. 6-9 Existing evidence suggests there is a considerable amount of inappropriate antibiotic use in ambulatory settings, where 92% of antibiotics are prescribed in Canada. 10 In the United States, it is estimated that 30%-50% of antibiotics prescribed outside of hospitals are unnecessary. 11,12 In the United Kingdom, overprescribing of antibiotics for respiratory infections is common, particularly for acute bronchitis, sinusitis and acute otitis media in children. 13,14 Furthermore, an Ontario study identified that 46% of older adults with a presumed viral respiratory infection filled an antibiotic prescription. 15 However, the degree of unnecessary antibiotic use in Canadian primary care settings is not well defined. The US National Action Plan for Combatting Antibioticresistant Bacteria has set a goal to reduce inappropriate antibiotic prescribing by 50% by 2020. 16 The UK's 5-year plan is to reduce overall human antibiotic use by 15% by 2024. 17 Canada has yet to articulate a similar plan to reduce overall antibiotic use in humans, partly because, to date, reasonable targets