Presence of bacteriuria caused by trimethoprim resistant bacteria in patients prescribed antibiotics: Multilevel model with practice and individual patient data
To look for evidence of a relation between antibiotic resistance and prescribing by general practitioners by analysis of prescribing at both practice and individual patient level. Repeated cross-sectional study in 1995 and 1996. 28 general practices in the Ninewells Hospital laboratory catchment area, Tayside, Scotland. SUBJECTS REVIEWED: 8833 patients registered with the 28 practices who submitted urine samples for analysis. Resistance to trimethoprim in bacteria isolated from urine samples at practice and individual level simultaneously in a multilevel model. Practices showed considerable variation in both the prevalence of trimethoprim resistance (26-50% of bacteria isolated) and trimethoprim prescribing (67-357 prescriptions per 100 practice patients). Although variation in prescribing showed no association with resistance at the practice level after adjustment for other factors (P = 0.101), in the multilevel model resistance to trimethoprim was significantly associated with age, sex, and individual-level exposure to trimethoprim (P < 0.001) or to other antibiotics (P = 0.002). The association with trimethoprim resistance was strongest for people recently exposed to trimethoprim, and there was no association for people with trimethoprim exposure more than six months before the date of the urine sample. Analysis of practice level data obscured important associations between antibiotic prescribing and resistance. The results support efforts to reduce unnecessary prescribing of antibiotics in the community and show the added value of individual patient data for research on the outcomes of prescribing.
[Show abstract] [Hide abstract] ABSTRACT: Antibiotics are essential agents that have greatly reduced human mortality due to infectious diseases. Their use, and sometimes overuse, have increased over the past several decades in humans, veterinary medicine and agriculture. However, the emergence of resistant pathogens is becoming an increasing problem that could result in the re-emergence of infectious diseases. Antibiotic prescription in human medicine plays a key role in this phenomenon. Under selection pressure, resistance can emerge in the commensal flora of treated individuals and disseminate to others. However, even if the effects of antimicrobial use on resistance is intuitively accepted, scientific rationales are required to convince physicians, legislators and public opinion to adopt appropriate behaviours and policies. With this review, we aim to provide an overview of different epidemiological study designs that are used to study the relationship between antibiotic use and the emergence and spread of resistance, as well as highlight their main strengths and weaknesses.0Comments 14Citations
- "For instance, Harbarth et al. demonstrate this in a study reporting a significant association between antibiotic exposure and resistance at the individual level but not at the group level . Similarly, Donnan et al. studied the association between trimethoprim resistance in urinary bacteria and antibiotic exposure and found no association at the practice level, whereas individual exposure to antibiotics was significantly associated with trimethoprim resistance in the multi-level model . The main feature of cluster-randomised trials is the same as that of a randomised trial, except that investigators control the intervention by assigning it randomly to groups of patients rather than individuals104105106 . "
[Show abstract] [Hide abstract] ABSTRACT: Liver function tests (LFTs) are routinely performed in primary care, and are often the gateway to further invasive and/or expensive investigations. Little is known of the consequences in people with an initial abnormal liver function (ALF) test in primary care and with no obvious liver disease. Further investigations may be dangerous for the patient and expensive for Health Services. The aims of this study are to determine the natural history of abnormalities in LFTs before overt liver disease presents in the population and identify those who require minimal further investigations with the potential for reduction in NHS costs. A population-based retrospective cohort study will follow up all those who have had an incident liver function test (LFT) in primary care to subsequent liver disease or mortality over a period of 15 years (approx. 2.3 million tests in 99,000 people). The study is set in Primary Care in the region of Tayside, Scotland (pop approx. 429,000) between 1989 and 2003. The target population consists of patients with no recorded clinical signs or symptoms of liver disease and registered with a GP. The health technologies being assessed are LFTs, viral and auto-antibody tests, ultrasound, CT, MRI and liver biopsy. The study will utilise the Epidemiology of Liver Disease In Tayside (ELDIT) database to determine the outcomes of liver disease. These are based on hospital admission data (Scottish Morbidity Record 1), dispensed medication records, death certificates, and examination of medical records from Tayside hospitals. A sample of patients (n = 150) with recent initial ALF tests or invitation to biopsy will complete questionnaires to obtain quality of life data and anxiety measures. Cost-effectiveness and cost utility Markov model analyses will be performed from health service and patient perspectives using standard NHS costs. The findings will also be used to develop a computerised clinical decision support tool. The results of this study will be widely disseminated to primary care, as well as G.I. hospital specialists through publications and presentations at local and national meetings and the project website. This will facilitate optimal decision-making both for the benefit of the patient and the National Health Service.0Comments 6Citations
- "@BULLET Prescribing database: The Health Informatics Centre (HIC) has person-specific dispensing information for the whole of Tayside , @BULLET Hospitalisation, Scottish Morbidity Records (SMR1 – general admissions, SMR4 – alcohol related psychiatric admissions and SMR6 – cancer admissions), @BULLET Death registry from the General Registry Office, @BULLET Carstairs categories for social deprivation based on the decennial census , @BULLET Endoscopy, @BULLET Regional biochemistry, @BULLET Pathology, @BULLET Virology, and @BULLET Immunology databases. Diagnostic algorithms for liver diseases have been created and this database has already been used to assess the epidemiology and economic burden of viral hepatitis  and other liver diseases. "
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