Improving appropriateness of antibiotic prescribing for lower respiratory tract infections. The physician's decision

Stud­ies suggest that increasing appropriate use of antimicrobials leads to a reduced pressure on the development of antimicrobial resistance. In this thesis we evaluated several different strategies with the aim to improve the quality of antibiotic prescribing for community-acquired pneumonia (CAP). First, we evalu­ated the effect of rapid point-of-care (POC) C-reactive (CRP) protein measurement on the number of antibiotic prescriptions for patients presenting with lower respiratory tract infection (LRTI) in primary care. Through a systematic review we found that evidence suggesting that POC CRP measurement reduces the number of antimicrobial prescriptions is limited in quality and extent. Moreover, our prospective cohort study showed that POC CRP measurement did not decrease the overall number of prescriptions and the test was used off indication (i.e. not for LRTI) in 30% of cases. Secondly, we retrospectively studied all rapid urinary antigen tests for S. pneumoniae (PUAT) and Legionella spp. (LUAT) in CAP patients performed between 2005 and 2012 to evaluate its use and treatment consequences. We found that current PUAT application is inefficient and may be improved by more selective test use (i.e. CAP patients only) and by providing patients with targeted treat­ment in case of a positive test result. In addition, timely LUAT use in accordance with current guidelines allowed early detection and treatment of CAP caused by Legionella spp. at considerable expense. Lastly, we performed two prospective clinical studies to evaluate the level of adher­ence to a timely switch to oral antibiotics in hospitalized CAP patients and reasons for non-adherence. Subsequently an implementation strategy tailored to the aforementioned reasons was applied. We implemented a novel protocol through education, reminders and active involvement of nursing staff at a total cost of €5.798,-. As a result, the duration of intravenous antibiotic treatment decreased by one day at the cost of €26,-per day.