BACKGROUND: Millions of people die every year as a result of antimicrobial resistance worldwide. An inappropriate prescription of antimicrobials (e.g., overuse, inadequate use, or a choice that diverges from established guidelines) can lead to a heightened risk of antimicrobial resistance. This study aimed to determine the rate and appropriateness of antimicrobial prescriptions for respiratory tract infections.
METHODS: This review was conducted in accordance with the PRISMA guidelines. Web of Science, PubMed, ProQuest Health and Medicine, and Scopus were searched between October 1, 2023, and December 15, 2023, with no time constraints. Studies were independently screened by the first author and the co-authors. We included original studies reporting antimicrobial prescription patterns and appropriateness for respiratory tract infections. The quality of included studies\' was assessed via the Joanna Briggs Institute\'s Critical Appraisal Checklists for Cross-Sectional Studies. The assessment of publication bias was conducted using a funnel plot and Egger\'s regression test. A random effect model was employed to estimate the pooled antibiotic prescribing and inappropriate rates. Subgroup analysis was conducted by country, study period, data source, and age group.
RESULTS: Of the total 1220 identified studies, 36 studies were included in the review. The antimicrobial prescribing rate ranged from 25% (95% CI 0.24-0.26) to 90% (95% CI 0.89-0.91). The pooled antimicrobial prescription rate was 66% (95% CI 0.57 to 0.73). Subgroup analysis by region revealed that the antimicrobial prescription rate was highest in Africa (79%, 95% CI 0.48-0.94) and lowest in Europe (47%, 95% CI 0.32-0.62). Amoxicillin and amoxicillin-clavulanate antimicrobials from the Access group, along with azithromycin and erythromycin from the Watch group, were the most frequently used antimicrobial agents. This study revealed that the major reasons for antimicrobial prescription were acute bronchitis, pharyngitis, sinusitis, and the common cold. The pooled inappropriate antimicrobial prescription rate was 45% (95% CI 0.38-0.52). Twenty-eight of the included studies reported that prescribing antimicrobials without proper indications was the main cause of inappropriate antimicrobial prescriptions. Additionally, subgroup analysis by region showed a higher inappropriate antimicrobial prescription rate in Asia at 49% (95% CI 0.38-0.60). The result of the funnel plot and Egger\'s tests revealed no substantial publication bias (Egger\'s test: p = 0.268).
CONCLUSIONS: The prescribing rate and inappropriate use of antimicrobials remain high and vary among countries. Further studies should be conducted to generate information about factors contributing to unnecessary antimicrobial prescriptions in outpatients.
BACKGROUND: Systematic review registration: CRD42023468353.

BACKGROUND: Inappropriate prescribing (IP) is common in hospitalised older adults with frailty. However, it is not known whether the presence of frailty confers an increased risk of mortality and readmissions from IP nor whether rectifying IP reduces this risk. This review was conducted to determine whether IP increases the risk of adverse outcomes in hospitalised middle-aged and older adults with frailty.
METHODS: A systematic review was conducted on IP in hospitalised middle-aged (45-64 years) and older adults (≥ 65 years) with frailty. This review considered multiple types of IP including potentially inappropriate medicines, prescribing omissions and drug interactions. Both observational and interventional studies were included. The outcomes were mortality and hospital readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, World of Science, SCOPUS and the Cochrane Library. The search was updated to 12 July 2024. Meta-analysis was performed to pool risk estimates using the random effects model.
RESULTS: A total of 569 studies were identified and seven met the inclusion criteria, all focused on the older population. One of the five observational studies found an association between IP and emergency department visits and readmissions at specific time points. Three of the observational studies were amenable to meta-analysis which showed no significant association between IP and hospital readmissions (OR 1.08, 95% CI 0.90-1.31). Meta-analysis of the subgroup assessing Beers criteria medicines demonstrated that there was a 27% increase in the risk of hospital readmissions (OR 1.27, 95% CI 1.03-1.57) with this type of IP. In meta-analysis of the two interventional studies, there was a 37% reduced risk of mortality (OR 0.63, 95% CI 0.40-1.00) with interventions that reduced IP compared to usual care but no difference in hospital readmissions (OR 0.83, 95% CI 0.19-3.67).
CONCLUSIONS: Interventions to reduce IP were associated with reduced risk of mortality, but not readmissions, compared to usual care in older adults with frailty. The use of Beers criteria medicines was associated with hospital readmissions in this group. However, there was limited evidence of an association between IP more broadly and mortality or hospital readmissions. Further high-quality studies are needed to confirm these findings.

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OBJECTIVE: To systematically review and synthesise evidence on the effectiveness and implementation barriers/facilitators of pharmacist-led interventions to promote medicines optimisation and reduce overprescribing in UK primary care.
METHODS: Systematic review.
METHODS: UK primary care.
METHODS: We searched MEDLINE, Embase, CINAHL PsycINFO and The Cochrane Library for UK-based studies published between January 2013 and February 2023. Targeted searches for grey literature were conducted in May 2023. Quantitative and qualitative studies (including conference abstracts and grey literature) that addressed a relevant intervention and reported a primary outcome related to changes in prescribing were eligible for inclusion. Quality of included studies was assessed using the Multiple Methods Appraisal Tool. We performed a narrative synthesis, grouping studies by publication status, setting and type of data reported (effectiveness or implementation).
RESULTS: We included 14 peer-reviewed journal articles and 11 conference abstracts, together with 4 case study reports. The journal articles reported 10 different interventions, 5 delivered in general practice, 4 in care homes and 1 in community pharmacy. The quality of evidence was higher in general practice than in care home settings. It was consistently reported that the intervention improved outcomes related to prescribing, although the limited number of studies and wide range of outcomes reported made it difficult to estimate the size of any effect. Implementation was strongly influenced by relationships between pharmacists and other health and care professionals, especially general practitioners. Implementation in care homes appeared to be more complex than in general practice because of differences in systems and \'culture\' between health and social care.
CONCLUSIONS: Pharmacist-led interventions have been reported to reduce overprescribing in primary care settings in the UK but a shortage of high-quality evidence means that more rigorous studies using high-quality designs are needed. More research is also needed in community pharmacy settings; to assess intervention effects on patient outcomes other than prescribing and to investigate how reducing overprescribing can impact health inequalities.
UNASSIGNED: CRD42023396366.

BACKGROUND: Potentially inappropriate prescribing (PIP) refers to the prescription of medications that carry a higher risk of adverse outcomes, such as drug interactions, falls, and cognitive impairment. PIP is of particular concern in older adults, and is associated with increased morbidity, mortality, and healthcare costs. Socioeconomic deprivation has been identified as a potential risk factor for PIP. However, the extent of this relationship remains unclear. This review aimed to synthesize the current literature on the association between PIP and socioeconomic status (SES) in older adults.
METHODS: A literature search was conducted using the databases Medline, Embase and CINAHL. A search strategy was developed to capture papers examining three key concepts: PIP, socioeconomic deprivation and older/elderly populations. Peer-reviewed quantitative research published between 1/1/2000 and 31/12/2022 was eligible for inclusion.
RESULTS: Twenty articles from 3,966 hits met the inclusion criteria. The sample size of included studies ranged from 668 to 16.5million individuals, with the majority from Europe (n = 8) and North America (n = 8). Most defined older patients as being 65 or over (n = 12) and used income (n = 7) or subsidy eligibility (n = 5) to assess SES. In all, twelve studies reported a statistically significant association between socioeconomic deprivation and an increased likelihood of experiencing PIP. Several of these reported some association after adjusting for number of drugs taken, or the presence of polypharmacy. The underlying reasons for the association are unclear, although one study found that the association between deprivation and higher PIP prevalence could not be explained by poorer access to healthcare facilities or practitioners.
CONCLUSIONS: The findings suggest some association between an older person\'s SES and their likelihood of being exposed to PIP. SES appears to be one of several factors that act independently and in concert to influence an older person\'s likelihood of experiencing PIP. This review highlights that prioritising older people living in socioeconomically-deprived circumstances may be an efficient strategy when carrying out medication reviews.

OBJECTIVE: Multimorbidity and polypharmacy in older adults converts the detection and adequacy of potentially inappropriate drug prescriptions (PIDP) in a healthcare priority. The objectives of this study are to describe the clinical decisions taken after the identification of PIDP by clinical pharmacists, using STOPP/START criteria, and to evaluate the degree of accomplishment of these decisions.
METHODS: Multicenter, prospective, non-comparative cohort study in patients aged 65 and older, hospitalized because of an exacerbation of their chronic conditions. Each possible PIDP was manually identified by the clinical pharmacist at admission and an initial decision was taken by a multidisciplinary clinical committee. At discharge, criteria were re-applied and final decisions recorded.
RESULTS: From all patients (n = 674), 493 (73.1%) presented at least one STOPP criteria at admission, significantly reduced up to 258 (38.3%) at discharge. A similar trend was observed for START criteria (36.7% vs. 15.7%). Regarding the top 10 most prevalent STOPP criteria, the clinical committee initially agreed to withdraw 257 (34.2%) prescriptions and to modify 93 (12.4%) prescriptions. However, the evaluation of final clinical decisions revealed that 503 (67.0%) of those STOPP criteria were ultimately amended. For the top 10 START criteria associated PIDP, the committee decided to initiate 149 (51.7%) prescriptions, while a total of 198 (68.8%) were finally introduced at discharge.
CONCLUSIONS: The clinical committee, through a pharmacotherapy review, succeeded in identifying and reducing the degree of prescription inadequacy, for both STOPP and START criteria, in older patients with high degree of multimorbidity and polypharmacy.
BACKGROUND: NCT02830425.

BACKGROUND: Proton Pump Inhibitors (PPI) are frequently prescribed. Long-term use is associated with side-effects and patients often lack a valid indication. Inappropriate PPI prescribing thus needs to be addressed. This review aims to scope 1) what determinants are studied as reasons for PPI prescribing, 2) what strategies are used for changing PPI (de)prescribing, and 3) whether important determinants are addressed in these interventions.
METHODS: We searched eight databases for papers on determinants of physician PPI prescribing. Studies were included if they were conducted in a Western country and focused on oral PPIs for an adult population. By following the Behaviour Change Wheel, we extracted information regarding PPI prescribing behavior, behavioral determinants and intervention strategies.
RESULTS: We included 74 papers. Most focused on the determinants knowledge and beliefs about consequences. The latter was consistently related to PPI prescribing. Results for knowledge were mixed. Most interventions used education or enablement (e.g., algorithms, quality check improvements, involvement of pharmacists) as strategies. Enablement consistently improved PPI prescribing, while results for education were mixed.
CONCLUSIONS: There is an overemphasis on reflective processes in studies on PPI prescribing. Future research should comprehensively identify behavioral determinants, focusing on reflective and impulsive processes, such that interventions can address the most important determinants.

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

BACKGROUND: Polypharmacy is common among individuals with multimorbidity, often leading to inappropriate medication use and is associated with an increased risk of frailty, hospitalisation and mortality. Structured medication reviews (SMRs) have emerged as a promising method for optimising medication use. However, research examining their efficacy is limited. This review aims to evaluate the impact of SMRs on improving outcomes for adults with multimorbidity and polypharmacy in primary care settings. Additionally, this review seeks to identify prevailing patterns and trends in the mode of delivery of SMRs.
METHODS: A systematic review will be conducted using Ovid MEDLINE, Ovid EMBASE, Web of Science and CINAHL (1997-present). Primary outcomes will include medication-related measures such as dose, frequency and dosage form. Secondary outcomes under investigation will include physical, mental, functional and health service outcomes, as reported. Two independent reviewers will conduct the screening and data extraction, resolving disagreements through discussion. Once eligible studies are identified, the extracted data will be summarised in tabular format. The risk of bias in the articles will be assessed using either the Cochrane Risk of Bias 2 tool or the Newcastle-Ottawa scale, depending on the design of the studies retrieved. Subgroup analysis will be performed using demographic variables and modes of delivery where the data supports. If appropriate, a meta-analysis of the data extracted will be conducted to determine the impact of the SMRs on reported outcomes. If a meta-analysis is not possible due to heterogeneity, a narrative synthesis approach will be adopted.
BACKGROUND: This proposed review is exempt from ethical approval as it aims to collate and summarise peer-reviewed, published evidence. This protocol and the subsequent review will be disseminated in peer-reviewed journals, conferences and patient-led lay summaries.
UNASSIGNED: CRD42023454965.

BACKGROUND: Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention.
OBJECTIVE: To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions.
METHODS: We performed a scoping review as defined by the Joanna Briggs Institute.
METHODS: The focus was on primary care settings.
METHODS: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024.
METHODS: We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded.
UNASSIGNED: We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions.
RESULTS: In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention.
CONCLUSIONS: Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.