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: Benzodiazepines are frequently prescribed to treat anxiety and insomnia, but long-term use has been associated with the development of dependence, tolerance, and cognitive decline, especially among older adults. This study aimed to investigate the pattern of consumption and factors associated with inappropriate prescribing of benzodiazepines in primary health care.
METHODS: This is a cross-sectional analytical study, using dispensing records of diazepam, clonazepam, and nitrazepam from public pharmacies in a Brazilian municipality between 2018 and 2022. Metrics for benzodiazepine consumption were DDD (Defined Daily Dose) and DDD/1000PD (per 1000 population per day). Long-term/prolonged benzodiazepine use was defined as consuming at least 90 DDD and at least 2 dispensations per year. To ascertain associations between long-term use and predictor variables, a multivariate logistic regression model was utilized.
RESULTS: A total of 40402 participants were included, with an average age of 55 years (SD = 0.30), 38.5% were older aged. Diazepam and nitrazepam exceeded the daily dose recommended. There was a reduction in diazepam consumption during the study period, as calculated by DDD/1.000PD, while the consumption of other benzodiazepines remained stable. However, a significant increase in diazepam consumption is noted when considering the last decade. Prolonged use was observed in 29.1% of participants, with a significant prevalence among the older people (34.8% of them were long-term users) and advancing age was identified as a risk factor for long-term use. Higher PDDs were also associated with long-term use and aging. Participants who used different benzodiazepines during the period had a higher risk of prolonged use.
CONCLUSIONS: These results provide insights into the prevalence of problematic utilization of benzodiazepines in primary health care. Authorities and health care providers must take steps to encourage gradual cessation of prolonged benzodiazepine prescriptions and the embrace of suitable strategies for addressing anxiety and insomnia within primary health care settings.

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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Despite reliable evidence of adverse drug effects, the substantially increased prescription rates of proton pump inhibitors (PPIs) remain at a high level. This study analyzed the appropriateness of PPI prescriptions among residents of nursing homes in three regions of Germany. Baseline data of a cluster-randomized controlled trial were used to determine the prevalence of PPI prescriptions, the validity of indications, and the adequacy of the prescribed dosages according to 1. their drug approvals and 2. valid recommendation guidelines. Regression analyses were conducted to assess associated factors. A total of 437 residents in 37 nursing homes were included (mean age 83 ± 9.2 years, 72% women). The PPI prescription prevalence was 44% (n = 193). In 52/193 (27%) there was no adequate indication, and in 54 (39%) of 138 indicated PPI prescriptions it was overdosed. Yet, in only less than one-third (28%) of \"adequate\" prescriptions, the indication was according to the PPI approvals, whereas the majority (72%) were off-label indications in line with valid guideline recommendations. Non-indicated PPI prescription was associated with the total number of prescribed drugs (OR 1.32; 95% CI 1.18-1.62; p = 0.013). There were no associations with age, level of care dependency, cognitive impairment, prescription of psychotropic drugs, number of chronic diseases, number of physicians\' consultations, or study region. To conclude, in 55%, the high prescription prevalence among residents was either not indicated or overdosed. In total, only 20% (39/193) of cases of PPI use complied with the approved indications. There is a need for quality control of 1. PPI administration in German nursing homes, and 2. of guideline recommendations expanding the off-label PPI use by 72% within the indication scale, predominantly from wide prescription for low-dose ASA.

BACKGROUND: Older adults requiring care often have multiple morbidities that lead to polypharmacy, including the use of potentially inappropriate medications (PIMs), leading to increased medical costs and adverse drug effects. We conducted a cross-sectional study to clarify the actual state of drug prescriptions and the background of polypharmacy and PIMs.
METHODS: Using long-term care (LTC) and medical insurance claims data in the Ibaraki Prefecture from April 2018 to March 2019, we included individuals aged ≥ 65 who used LTC services. The number of drugs prescribed for ≥ 14 days and the number of PIMs were counted. A generalized linear model was used to analyze the association between the backgrounds of individuals and the number of drugs; logistic regression analysis was used for the presence of PIMs. PIMs were defined by STOPP-J and Beers Criteria.
RESULTS: Herein, 67,531 older adults who received LTC services were included. The median number of total prescribed medications and PIMs was 7(IQR 5-9) and 1(IQR 0-1), respectively. The main PIMs were loop diuretics/aldosterone antagonists (STOPP-J), long-term use of proton pump inhibitors (Beers Criteria), benzodiazepines/similar hypnotics (STOPP-J and Beers Criteria), and nonsteroidal anti-inflammatory drugs (STOPP-J and Beers Criteria). Multivariate analysis revealed that the number of medications and presence of PIMs were significantly higher in patients with comorbidities and in those visiting multiple medical institutions. However, patients requiring care level ≥1, nursing home residents, users of short-stay service, and senior daycare were negatively associated with polypharmacy and PIMs.
CONCLUSIONS: Polypharmacy and PIMs are frequently observed in older adults who require LTC. This was prominent among individuals with comorbidities and at multiple consulting institutions. Utilization of nursing care facilities may contribute to reducing polypharmacy and PIMs.

BACKGROUND: Misuse and overuse of antibiotics comprise leading causes of antimicrobial resistance. The study aims to assess the pattern of antibiotic prescription among primary healthcare general practitioners in the South Batinah Governorate of Oman.
METHODS: A cross-sectional study of 600 antibiotic prescriptions issued in the South Batinah Governorate in 2019 was conducted to verify the triggering diagnoses and determine the appropriateness of the prescribed antibiotic. Logistic regression analysis was used to determine the association between predictors and inappropriate use.
RESULTS: Respiratory infections accounted for 62% of antibiotic prescriptions, of which 92.2% were inappropriately prescribed. Extended-spectrum antibiotics were inappropriately prescribed in 33.3% of cystitis cases, while 14.3% of gastroenteritis received incorrect spectrum of antibiotics. Amoxicillin represented 46.2% of antibiotic prescriptions, of which 84.4% were unnecessarily prescribed. Lower inappropriate antibiotic prescribing rate was linked to patients ≥ 18 years (OR = 0.46, 95% CI: [0.26, 0.82]), those who underwent laboratory tests (OR = 0.22, 95% CI: [0.12, 0.39]), and consultations at health centers (OR = 0.44, 95% CI: [0.24, 0.79]). Arabic-speaking physicians were more likely to prescribe antibiotics inappropriately.
CONCLUSIONS: Inappropriate antibiotic prescription was frequently observed in mild respiratory infections and associated with specific patient and physician characteristics. Appropriateness of antibiotic prescriptions issued can be improved through enhanced testing capacities as well as implementation of physician and community awareness campaigns.

BACKGROUND: Managing medication use in older orthopedic patients is imperative to extend their healthy life expectancy in an aging society. However, the actual situation regarding polypharmacy, the intake of potentially inappropriate medications (PIMs), and fall risk-increasing drugs (FRIDs) among older orthopedic patients is not well characterized. This study aimed to investigate the medication-based profiles of older orthopedic patients to highlight the critical points of concern.
METHODS: We retrospectively reviewed the clinical data of consecutive patients aged ≥ 65 years who underwent orthopedic surgery at two acute care hospitals between April 2020 and March 2021. The cutoff number of prescribed drugs for polypharmacy was set at 6. According to the specified guidelines, 19 categories of drugs were identified as PIMs, and 10 categories were classified as FRIDs.
RESULTS: A total of 995 older patients with orthopedic surgery were assessed, of which 57.4% were diagnosed with polypharmacy, 66.0% were receiving PIMs, and 41.7% were receiving FRIDs. The prevalence of FRID intake did not significantly differ among patients with degenerative spinal disease (n = 316), degenerative disease of extremities (n = 331), and fractures (n = 272). Compared with patients with degenerative disease of the extremities, the multivariable-adjusted prevalence ratios (PRs) of polypharmacy and PIM intake were significantly higher in patients with degenerative spinal disease (1.26 [confidence intervals (CI): 1.11-1.44] and 1.12 [CI: 1.00-1.25]), respectively. Use of antiemetic drugs (adjusted PR, 13.36; 95% CI: 3.14-56.81) and nonsteroidal anti-inflammatory drugs (adjusted PR, 1.37; 95% CI: 1.05-1.78) was significantly higher in patients with degenerative spinal disease. Among patients with degenerative spinal disease, the prevalence of antiemetic drug intake was 8.7% in lumbar spinal patients and 0% in cervical spinal patients.
CONCLUSIONS: More than half of the orthopedic patients in this study were affected by polypharmacy, and approximately two-thirds were prescribed some form of PIMs. Patients with degenerative spinal disease showed a significantly higher prevalence of polypharmacy and PIM use compared with other orthopedic diseases. Particular attention should be paid to the high frequency of antiemetic drugs and nonsteroidal anti-inflammatory drugs intake among patients with degenerative lumbar spine conditions.

OBJECTIVE: Despite evidence that most upper respiratory infections (URIs) are due to viruses, antibiotics are frequently prescribed for this indication in the outpatient setting. Antibiotic stewardship strategies are needed to reduce adverse patient outcomes and staggering healthcare costs due to resistant infections that ensue from inappropriate prescriptions.
OBJECTIVE: To determine if individual provider scorecards detailing antibiotic prescribing rates paired with educational resources reduce inappropriate antibiotic use for URIs in the outpatient primary care setting.
METHODS: This quality improvement project investigated the number of URI-coded office visits in the primary care setting over three consecutive influenza seasons, which resulted in an antibiotic prescription in Cooper University Healthcare\'s 14 primary care offices. We compared provider\'s individual prescribing patterns to their peers\' average and created a scorecard that was shared with each provider over a series of intervention phases. Data were collected from a preintervention period (November 2017-February 2018), and two postintervention phases, phase I (November 2018-February 2019) and phase II (November 2019-February 2020).
METHODS: A personalised, digital scorecard containing antibiotic-prescribing data for URI-coded visits from the prior influenza season was emailed to each primary care provider. Prior to the subsequent influenza season, prescribers received their updated prescribing rates as well as peer-to-peer comparisons. In both phases, the scorecard was attached to an email with antimicrobial stewardship educational materials.
METHODS: The primary outcome was a reduction in the number of inappropriate antibiotic prescriptions for URI-related diagnoses. The diagnoses were organised into five broad coding categories, including bronchitis, sinusitis, sore throat excluding strep, influenza and tonsillitis excluding strep.

BACKGROUND: More than 263,000 individuals died due to prescription opioid misuse between 1999 and 2020. Between 2013 and 2015 alone, pharmaceutical companies spent over $39 million to market opioids to over 67,000 prescribers. However, there is still limited information about differences in provider responses to promotions for medications. In this study we investigated and evaluated strategies used by opioid manufacturers to encourage overprescribing, specifically focusing on oncology.
METHODS: We conducted a retrospective review of opioid industry documents released in litigation between 1999 and 2021. We began with a preliminary search for business plans in a subset of collections that identified key terms and phrases. These search terms were then used to narrow the investigation, which ultimately focused on Insys Therapeutics, and how they targeted oncology providers as well as patients with cancer pain.
RESULTS: We found that, overall, Insys sought to market to institutions with fewer resources, to less experienced and high-volume providers, and directly to cancer patients, with the goal of encouraging increased opioid prescribing and use.
CONCLUSIONS: Our research revealed gaps in provider training that may make some providers more susceptible to pharmaceutical marketing. Developing and promoting continuing education courses for providers that are free from conflicts of interest, particularly at smaller institutions, may be one step towards reducing opioid overprescribing and its associated harms.