Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
BMJ 2024; 385 doi: https://doi.org/10.1136/bmj-2024-079329 (Published 05 June 2024) Cite this as: BMJ 2024;385:e079329Linked Editorial
Antimicrobial stewardship
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Dear Editor
Ageing predisposes to increased risk of infections which make these populations vulnerable to high risk of various chronic co-morbidities, organ dysfunction and mortality. (1,2) Increased frequency of infections has led to an increasing proportion of geriatric patient admission to hospitals, and antibiotics therapy has long been recognized as a cornerstone in the treatment of infections.( 3,4) Although the interest of antibiotics is well known, antibiotics prescription is associated with side effect, especially in patients with multiples comorbidities. One way to reduce the incidence of side effects is to respect antibiotics prescriptions guidelines.
Antibiotics are among the most prescribed drugs in the world (5). Since the 2000s, there has been an increase of more than 20% of antibiotics prescriptions in elderly patients. Antibiotics have undeniable benefit effects, but have also side effects that could represent a serious threat to public health (6). Good quality of antibiotics prescription, defined by an adapted use of an antibacterial agent during an infection (molecule, dose and duration) and by the adherence of prescription guidelines, is associated with less side-effect.(7,8)
Various antibiotic stewardship programs have been running all over the world however minimal efforts have been made to integrate “The Beers criteria, called the American Geriatrics Society AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” with commonly adopted practices.(9) These 2023 criteria, prepared under the stewardship of the American Geriatrics Society, provide an explicit list of potentially inappropriate medications including antibiotics that should be avoided by older adults in most circumstances. The World Health Organization (WHO) identified inappropriate polypharmacy reduction as a major public health goal in the Third Global Patient Safety Challenge: Medication Without Harm (10). Hence the physicians need to be updated about such guidelines through periodic training programs and awareness workshops from time to time to be abreast with most recent guidelines to avoid inappropriate medication. Further, more strict antibiotic policy and antibiotic treatment guidelines are needed to be framed that enhance rational prescribing practices in geriatrics along with use of guidelines like AGS Beer criteria/STOPP/START guidelines for better outcome.
1. van Duin D. Diagnostic challenges and opportunities in older adults with infectious diseases. Clinical infectious diseases. 2012 Apr 1;54(7):973-8.
2. Henig O, Kaye KS. Bacterial pneumonia in older adults. Infectious Disease Clinics. 2017 Dec 1;31(4):689-713.
3. Gleckman RA. Antibiotic concerns in the elderly. A clinician's perspective. Infectious disease clinics of North America. 1995 Sep 1;9(3):575-90.
4. Bernier A, Delarocque-Astagneau E, Ligier C, Vibet MA, Guillemot D, Watier L. Outpatient antibiotic use in France between 2000 and 2010: after the nationwide campaign, it is time to focus on the elderly. Antimicrobial agents and chemotherapy. 2014 Jan;58(1):71-7.
5. Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, Laxminarayan R. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. The Lancet infectious diseases. 2014 Aug 1;14(8):742-50.
6. Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Klugman K, Davies S. Access to effective antimicrobials: a worldwide challenge. The Lancet. 2016 Jan 9;387(10014):168-75.
7. Gavazzi G, Krause KH. Ageing and infection. The Lancet infectious diseases. 2002 Nov 1;2(11):659-66.
8. Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, Anderson GM, Bell CM. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA internal medicine. 2015 Aug 1;175(8):1331-9.
9. Samuel MJ. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J. Am. Geriatr. Soc. 2023; 71:2052-81.
10. . de Godoi Rezende Costa Molino C, Chocano-Bedoya PO, Sadlon A et al (2022) Prevalence of polypharmacy in community-dwelling older adults from seven centres in five European countries: a cross-sectional study of DO-HEALTH. BMJ Open 12(4):e051881.
11.Bansal, P, Bansal, R, Bansal C, Ushav, Gupta V. (2024). American Geriatrics Society 2023 updated AGS Beers Criteria may be used as a supplementary tool for augmenting deprescribing in older adults with polypharmacy.
https://doi.org/10.1136/bmj-2023-074892
Competing interests: No competing interests
Re: Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial
Dear Editor
Globally, antimicrobial resistance (AMR) poses a major threat to human health. In the U.S., more people die annually from methicillin-resistant Staphylococcus aureus (MRSA) than from several other diseases combined, including emphysema, HIV/AIDS, Parkinson's disease, and murder (1). Antibiotics, which were once considered miraculous, are now less effective due to various factors contributing to antibiotic resistance (2). In Canada, 92% of antibiotic prescriptions are issued for ambulatory settings, indicating a significant proportion of improper antibiotic use (3). So, this study (BMJ 2024;385: e079329) provides valuable insights into the effectiveness of antibiotic audit and feedback in reducing antibiotic prescriptions.
The study explores methods to decrease excessive antibiotic prescriptions in primary care using evidence-based strategies. Drawing on data from over 5000 physicians, the research employs a pragmatic trial design for real-world application. The comprehensive analysis assesses various aspects of antibiotic prescribing practices and utilizes a factorial randomized control design to evaluate the impact of multiple feedback components. This study also highlights the effectiveness of postal feedback in reducing antibiotic prescriptions, underlining its potential for scalable quality improvement in routine primary care settings.
However, I would like to address some of the limitations of this study here also.
First and foremost, Primary healthcare practitioners received mailed letters, but a study found out that sending emails and letters from prominent communicators, such Chief Medical Officers, and clinician-focused letters, can considerably lower the prescribing of antibiotics at a cheap cost and on a national scale (4).Older individuals face complex health scenarios due to comorbidities, drug interactions, and polypharmacy, necessitating careful attention to avoid treatment errors. Although recognizing and addressing polypharmacy is important, practical challenges exist. While providing feedback to doctors via mail is a potential approach, it may not be adequate for addressing individual complex cases. An analysis of the feedback system is crucial to enhance patient safety.
Additionally, peer-comparison feedback, point-of-care diagnostics, and communication skills training have strong supporting data in combating antibiotic resistance. Implementing multiple approaches targeting the general population and prescribers is key to maximizing the impact of community antimicrobial stewardship programs, thereby optimizing antibiotic use and slowing the emergence of antibiotic resistance (5).
1Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety [Internet]. 2014 Oct 16;5(6):229–41. Available from: https://doi.org/10.1177/2042098614554919
2 Mir S, Brett D, De La BA, Martha K. Antibiotics overuse and bacterial resistance. Annals of Microbiology and Research [Internet]. 2019 Oct 26;3(1). Available from: https://doi.org/10.36959/958/573
3 Schwartz KL, Langford BJ, Daneman N, Chen B, Brown KA, McIsaac W, et al. Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data. CMAJ Open [Internet]. 2020 Apr 1;8(2):E360–9. Available from: https://doi.org/10.9778/cmajo.20190175
4 Hallsworth M, Chadborn T, Sallis A, Sanders M, Berry D, Greaves F, et al. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. Lancet [Internet]. 2016 Apr 1;387(10029):1743–52. Available from: https://doi.org/10.1016/s0140-6736(16)00215-4
5 Schwartz KL, Achonu C, Brown KA, Langford B, Daneman N, Johnstone J, et al. Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study. CMAJ Open [Internet]. 2018 Oct 1;6(4):E445–52. Available from: https://doi.org/10.9778/cmajo.20180017
Competing interests: No competing interests