Editorial
Quality of antimicrobial prescriptions: A multifaceted, multidisciplinary approach
Calidad de la prescripción de los antimicrobianos. Abordaje polifacético y multidisciplinar
a Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva. Grupo de Investigación en Enfermedades Infecciosas, Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla/CSIC/Hospital Universitario Hospital Virgen del Rocío, Sevilla, Spain
b Unidad Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Jiménez-Mejías, M.V. Gil-Navarro" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M.E." "apellidos" => "Jiménez-Mejías" "email" => array:1 [ 0 => "mej-mejias@telefonica.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.V." "apellidos" => "Gil-Navarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva. Grupo de Investigación en Enfermedades Infecciosas, Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla/CSIC/Hospital Universitario Hospital Virgen del Rocío, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Calidad de la prescripción de los antimicrobianos. Abordaje polifacético y multidisciplinar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The rise of antimicrobial resistance is a worldwide problem. The European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) consider it a problem of global priority and one of the top ten threats to public health. Infections caused by multidrug-resistant bacteria (B-MDR) cause more than 33,000 deaths/year in Europe, although it is predicted that they will cause 390,000 deaths (41,345 in Spain) by 2050 (more deaths than those caused by cancer).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Spain has the third highest B-MDR infection rate in Europe.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In addition, the treatment of B-MDR costs approximately 1.5 billion additional Euros per year in Europe (150 million per year in Spain).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The inappropriate and excessive use of antibiotics has a decisive influence on the emergence of B-MDR. In Spain, use is very high: 26.1 defined daily doses (DDD) per 1000 inhabitants in 2018. Although it has decreased 6.8% in recent years (28 DDD in 2015 to 26.1 in 2018), it is one of the highest rates in Europe and is far from the European mean (20.1 DDD).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In Spain, DDDs are higher than in other rich and developed countries such as Germany, the United Kingdom, Sweden, or Norway.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are differences in antibiotic use among the Autonomous Communities (CC.AA. for its initials in Spanish) in Spain. Multiple factors influence these differences: rural or urban setting, socioeconomic status, greater use of private healthcare, population aging, and the implementation of antibiotic optimization programs (PROA, for its initials in Spanish) such as the Comprehensive Program for the Prevention and Control of Healthcare-Related Infections and Appropriate Antibiotics Use in Andalusia (PIRASOA, for its initials in Spanish) or the Coordinating Center for Nosocomial Infection Surveillance of Catalonia (VINCAT, for its initials in Spanish). Other factors are independent, such as seasonality, sex, etc.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The greatest use of antibiotics (93%) is among outpatients (prescriptions from the Spanish National Health Service (NHS), mutual insurance companies, and private healthcare providers). Hospitals are only responsible for the remaining 7% of use. In 2019, according to data from the National Plan against Antibiotic Resistance (PRAN, for its initials in Spanish),<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> use ranged from 19.3 DDD in the Balearic Islands to 27.3 DDD in Extremadura. These differences are also notable in prescriptions from the NHS (11.32 DDD in the Balearic Islands to 19.94 DDD in Extremadura), prescriptions from mutual insurance companies (0.27 DDD in Basque Country to 1.61 in Extremadura), and prescriptions from private healthcare providers (3.72 DDD in Navarre to 9 DDD in Catalonia). In La Rioja, antibiotic use in 2019 was 25.03 DDD: 17.9 DDD in prescriptions from the NHS, 0.95 from mutual insurance companies, and 6.17 from private healthcare providers.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">If we want to improve antimicrobial use and prescribing quality, we must act on the public healthcare sector through a strategy that encompasses all scopes. Between 2015 and 2018, the use of antibiotics obtained through NHS prescriptions decreased 7.4% (from 26.31 DDD in 2015 to 24.3 DDD in 2018; about three million packs): a) prescriptions from the NHS and mutual insurance companies decreased from 18.1 DDD to 16.7 DDD (1.4 DDD, 7.7%); b) prescriptions from private healthcare providers decreased from 8.2 to 7.6 DDD (0.6 DDD, 7.3%).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This reduction coincided with the implementation of the first PRAN (2014–2018), which all autonomous communities participated in. One of the objectives of the 2019–2021 PRAM is to come closer to the mean use in Europe: 20 DDD.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This antimicrobial use is underestimated. In Spain, antibiotics are only dispensed with a medical prescription, but 20% of pharmacies “recognize” doing so without a medical prescription. This is in addition to those which do so “without recognizing it.” Furthermore, the registers from private healthcare providers and dentists are calculated using information provided by just 27.5% of pharmacies. Another source for acquiring antibiotics is the internet. In light of this, it is necessary to implement legislative measures to achieve greater control over pharmacies and online sales as well as interventions to reduce unnecessary use and increase prescribing quality.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The PROAs are being implemented as a strategy to improve the use of antimicrobials by:<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> a) reducing antibiotic use;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> b) increasing treatment compliance; c) shortening treatment duration; d) decreasing the percentage of inappropriate treatments (from 36.5% in 2014 to 26.9% in 2017);<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> e) reducing the incidence of infection and colonization by B-MDR, such as extended-spectrum beta-lactamase-producing <span class="elsevierStyleItalic">Escherichia coli</span> (BLEE)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> or <span class="elsevierStyleItalic">Clostridioides difficile</span>;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> f) decreasing the mortality of candidemias or bacteremias due to B-MDR;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and g) reducing spending on antibiotics (23,142,349 Euros in primary care in the five years PIRASOA has been in place in Andalusia).</p><p id="par0040" class="elsevierStylePara elsevierViewall">When a PROA is implemented, an initial evaluation is necessary in order to establish strategies and measurable indicators as well as periodic evaluations to determine its effectiveness. The indicators must be shared and homogeneous among the different PROAs. In the 2012 PROA document, the first directives were established and included antimicrobial and microbiologic use indicators and morbidity and mortality. In 2017, the PRAN included new indicators (5 ESAC and 4 non-ESAC) as well as qualitative indicators in primary care in the seven most prevalent infections in the general population.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this issue, Rojas García y Antoñanzas<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> present an analysis of the quality of antibiotics prescribing in La Rioja. They use the prescribing quality indicators of the ESAC.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Other authors have defined other prescribing quality indicators.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The 2019–2021 PRAN included qualitative and quantitative indicators of antibiotic use in primary care (some from ESAC and others that were new).<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As the PRAN indicates, it is very important to conduct local studies that identify problems and, following their analysis, search for local solutions. But we cannot forget that this is part of a larger problem and it is necessary to implement general measures.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The focus on improving antimicrobial prescribing is a multifaceted issue that must be approached in a gradual<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and multidisciplinary manner with the creation of treatment guidelines; education, diffusion, and implementation of the guidelines; and the monitoring of results and feedback on them, etc.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">First, when a PROA is implemented in the community and in a hospital, we need high-quality antimicrobial treatment guidelines that help make therapeutic decisions. These are the reference used to analyze prescribing quality. With National Antimicrobial Treatment Guidelines for the main infections and recommendations based on evidence and their resistance patterns, we could improve care, reduce the variability in clinical practice and treatment, and ensure homogeneous information.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The CC.AA. in Spain could develop their own guidelines, although they must be adapted to the national recommendations. Treatment guidelines must be created by a multidisciplinary team in which the prescribers themselves participate. It must be a dynamic process with frequent revisions and updates (every year or two years) that adapt to changes in microbial sensitivity and new treatment recommendations. This favors its implementation, acceptance, and integration into daily practice. In our country, there are currently various antimicrobial treatment guidelines available online which can be accessed for free from anywhere, be it a rural or urban setting.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Another fundamental pillar of the PROAs is training on all levels (physicians, pharmacists, dentists, veterinarians, nurses, etc.). The prescribers are those ultimately responsible for antibiotic use. The method shown to be the most effective is comprehensive training in clinical practice provided by peers in addition to periodic clinical advising sessions.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Peer advising involves the professionalism of the consultant and not top-down management; it involves education rather than imposition or coercion; it is inclusive and participative, all within a multidisciplinary team with shared leadership rather than individual command. The role of the consultant (pharmacist, infectious disease specialist, primary care physician, microbiologist) is based on their scientific expertise and leadership and leads to acceptance of treatment advice with the conviction that it is the best option for the patient and society.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Training can be done through courses, conferences, periodic reports, etc. Education must be included in undergraduate and graduate studies (in all clinical specialties) with specific units on resistance and the appropriate use of antibiotics.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Sources of commercial information negatively influence antimicrobial prescribing quality.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Measurements that only seek to reduce pharmaceutical spending<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> as well as restrictive measurements (prior authorization, treatment substitution and/or suspension) have not been shown to be effective in the long-term, as they are perceived as a limitation on the prescriber’s freedom.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">An interesting piece of data provided by Rojas García et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> is that prescriptions from the NHS (18.55 DDD) were of “high” quality, according to ESAC standards. However, prescriptions among patients who belong to mutual insurance companies (21.79 DDD) were of “low” quality. This should lead to intensifying measures to implement the PROAs among mutual insurance company physicians (and private practice physicians and dentists).</p><p id="par0090" class="elsevierStylePara elsevierViewall">In Andalusia, within the PIRASOA framework, collaboration agreements are signed between the professional colleges of physicians, pharmacists, and most recently dentists as well. These agreements establish measures such as the periodic diffusion of the PIRASOA objectives among members, collaboration on healthcare prevention and education campaigns aimed at the general population, and support for research and innovation.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ease of dosing, drugs with fewer side effects, and shorter courses of treatment facilitate proper compliance with antimicrobial treatment. In recent years, various clinical trials have demonstrated the effectiveness of shorter courses of treatment in some more common, uncomplicated, community-acquired infections (pyelonephritis, cystitis, cellulitis, acute bronchitis, community-acquired pneumonia, or ENT infections). Therefore, smaller packages should be prescribed. Significantly decreasing use could also be achieved by using packages adapted to the duration of treatment.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In addition to the evaluation of prescribing quality, it is essential to report local, autonomous community, and national information back to the prescribers. This allows for implementing agreed-upon corrective measures if necessary while at the same time making them participants in the programs.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Lastly, patient empowerment is fundamental. This includes shared doctor-patient decision-making (especially when there is no indication for antibiotic treatment); education on the proper use of antibiotics; and campaigns to raise awareness and educate the public on the prudent use of antibiotics, especially among the most demanding groups (older adults, those with a low socioeconomic status). A more rational use of antibiotics would have a positive impact and, fundamentally, would prevent self-medication.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Among the novel measures to improve antimicrobial prescribing, computer systems have been developed for decision-making regarding prescribing. Some of them are specifically for primary care, such as <span class="elsevierStyleItalic">Antibioclic.</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The use of antibiotics in veterinary medicine is another important point. Data on use are obtained from laboratories which have voluntarily joined the REDUCE program.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The data are incomplete; they do not include all laboratories nor purchases made at retailers or online. According to the REDUCE program, antibiotic sales for veterinary use decreased 32.4% (from 418.8 mg/PCU in 2014 to 283.1 mg/PCU in 2017). Their use has been reduced 71% in aviculture and colistin use among swine has been reduced 97.18%. Even still, Spain is one of the countries with the highest veterinary antibiotic use.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Avoiding the use of critically important antimicrobials is of particular relevance. They must be reserved for treating potentially lethal infections in humans. Veterinarians must periodically declare all antibiotics they have prescribed for animals and farms within the framework of PRAN actions.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion, the implementation of PROA programs in hospitals and primary care and the creation of the REDUCE program for veterinary medicine have improved antimicrobial prescribing quality. It is essential to encourage healthcare providers to adhere to the PRAN and to conduct training courses. There must be a close relationship and integration among hospital care, primary care, and long-term care facilities. Institutional support and involvement from the Autonomous Communities and the Ministry of Health, Consumption, and Social Welfare as well as other government agencies is fundamental.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez-Mejías ME, Gil-Navarro MV. Calidad de la prescripción de los antimicrobianos. Abordaje polifacético y multidisciplinar. 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