Changes in resistance among coliform bacteraemia associated with a primary care antimicrobial stewardship intervention: A population-based interrupted time series study

Abstract

Background Primary care antimicrobial stewardship interventions can improve antimicrobial prescribing, but there is less evidence that they reduce rates of resistant infection. This study examined changes in broad-spectrum antimicrobial prescribing in the community and resistance in people admitted to hospital with community-associated coliform bacteraemia associated with a primary care stewardship intervention. Methods and findings Segmented regression analysis of data on all patients registered with a general practitioner in the National Health Service (NHS) Tayside region in the east of Scotland, UK, from 1 January 2005 to 31 December 2015 was performed, examining associations between a primary care antimicrobial stewardship intervention in 2009 and primary care prescribing of fluoroquinolones, cephalosporins, and co-amoxiclav and resistance to the same three antimicrobials/classes among community-associated coliform bacteraemia. Prescribing outcomes were the rate per 1,000 population prescribed each antimicrobial/class per quarter. Resistance outcomes were proportion of community-associated (first 2 days of hospital admission) coliform ( Escherichia coli , Proteus spp ., or Klebsiella spp .) bacteraemia among adult (18+ years) patients resistant to each antimicrobial/class. 11.4% of 3,442,205 oral antimicrobial prescriptions dispensed in primary care over the study period were for targeted antimicrobials. There were large, statistically significant reductions in prescribing at 1 year postintervention that were larger by 3 years postintervention when the relative reduction was −68.8% (95% CI −76.3 to −62.1) and the absolute reduction −6.3 (−7.6 to −5.2) people exposed per 1,000 population per quarter for fluoroquinolones; relative −74.0% (−80.3 to −67.9) and absolute reduction −6.1 (−7.2 to −5.2) for cephalosporins; and relative −62.3% (−66.9 to −58.1) and absolute reduction −6.8 (−7.7 to −6.0) for co-amoxiclav, all compared to their prior trends. There were 2,143 eligible bacteraemia episodes involving 2,004 patients over the study period (mean age 73.7 [SD 14.8] years; 51.4% women). There was no increase in community-associated coliform bacteraemia admissions associated with reduced community broad-spectrum antimicrobial use. Resistance to targeted antimicrobials reduced by 3.5 years postintervention compared to prior trends, but this was not statistically significant for co-amoxiclav. Relative and absolute changes were −34.7% (95% CI −52.3 to −10.6) and −63.5 (−131.8 to −12.8) resistant bacteraemia per 1,000 bacteraemia per quarter for fluoroquinolones; −48.3% (−62.7 to −32.3) and −153.1 (−255.7 to −77.0) for cephalosporins; and −17.8% (−47.1 to 20.8) and −63.6 (−206.4 to 42.4) for co-amoxiclav, respectively. Overall, there was reversal of a previously rising rate of fluoroquinolone resistance and flattening of previously rising rates of cephalosporin and co-amoxiclav resistance....

Pelargonium sidoides root extract for the treatment of acute cough due to lower respiratory tract infection in adults: a feasibility double-blind, placebo-controlled randomised trial

“…Reducing antibiotic resistance is a national and international priority, and the UK aims to reduce antibiotic use in humans in the community by 25% by 2024, from the 2013 baseline [ 1 ]. National levels of antibiotic resistance correlate with rates of antibiotic prescriptions [ 2 ] and reducing primary care consumption is associated with reduced resistance [ 3 ]. At an individual level, risk of antibiotic-resistant infection is over twice as high if an antibiotic has been taken in the past year [ 4 ] and this increases the risk of clinical treatment failure [ 5 ].…”

Antimicrobial Resistance: Physicians' and Pharmacists' Perspective

“…12,13 Antimicrobial stewardship program implementation in primary care settings can reduce broad-spectrum antimicrobial use. 14 As studies keep identifying potentially inappropriate antimicrobials prescribed with duration of treatment outside of guideline-based range, 15 more collaboration among physicians and community pharmacists and greater involvement of community pharmacists in antimicrobial stewardship programs should be encouraged. This study included community pharmacists, family medicine other physicians.…”

Practice-Level Association between Antibiotic Prescribing and Resistance: An Observational Study in Primary Care

“…Three other studies on the association between antibiotic use and AMR in primary care show conflicting results [ 7 , 8 , 13 ]. In line with our findings, Butler et al showed a statistically significant reduction in ampicillin and trimethoprim resistance per 1000 registered patients for practices that significantly reduced antibiotic dispensing over several years [ 7 ].…”

“…No data on numbers of tests, or resistance percentages with numbers of cultures as denominators were given. Hernandez-Santiago et al found less community-associated resistant coliform bacteraemia among adult patients as a result of antibiotic stewardship interventions [ 8 ]. Hay et al used individual patient data to investigate the relationship between prescribed antibiotics and the development of AMR using urine isolates of asymptomatic adults.…”

“…To our knowledge, there is only limited evidence linking antibiotic use and AMR in the primary care setting. A study in Wales demonstrated that reductions in antibiotic prescribing over several years resulted in decreased antibiotic resistant coliform urinary tract infections [ 7 ], and a study in Scotland showed that large reductions in community broad-spectrum antibiotic use resulted in modest changes in resistance among coliform bacteraemia [ 8 ].…”