Abstract
This study aimed to clarify the details of outpatient oral antimicrobial use (AMU) at a Japanese community hospital and investigate the influence of the current inpatient-based antimicrobial stewardship (AS) on outpatients. A repeated cross-sectional study was conducted in Komaki City Hospital. Data on patients, physicians, and oral antibiotics were collected in October 2013, 2016, and 2019, and appropriateness of treatment and surgical antimicrobial prophylaxis (SAP) was evaluated. The percentage of patients receiving oral antibiotics increased significantly from 4.7% in 2013 (345/7338) to 5.9% in 2019 (365/6146), and the overall number of antimicrobial prescriptions per 1000 outpatients increased from 51.8 in 2013 to 68.0 in 2019. Prescriptions for third-generation cephalosporins per 1000 outpatients decreased (from 21.4 to 6.3), whereas the number of prescriptions for penicillin (from 3.8 to 15.3), fluoroquinolones (from 7.0 to 13.2), and co-trimoxazole (from 5.0 to 15.8) increased from 2013 to 2019. The appropriate AMU for overall infections significantly increased (from 68.4% in 2013 to 83.7% in 2019). The choice and duration of AMU significantly improved for SAP. However, even in 2019, only 29.3% of patients received antibiotics before surgery. The improved selection of antibiotics on outpatient prescription may be due to the influence of AS—which is focused on inpatients—while prescriptions for fluoroquinolones and prophylactics also increased. The challenges of antimicrobial administration after surgeries were also highlighted.
INTRODUCTION
In recent years, the increase in drug-resistant bacteria and associated infections due to inappropriate antimicrobial use (AMU) has become a major global health issue.1) In 2016, the Japanese government announced the National Action Plan on Antimicrobial Resistance (NAP-AMR).2) This program aims to reduce AMR and inappropriate AMU. A Japanese study on AMU based on prescription sales estimated that the daily AMU per 1000 population was 15.8, based on the defined daily dose (DDD), of which 92.6% was reported to be for oral antibiotics.3) Both reports of AMU based on the sales data and health insurance claims data showed higher prescriptions for oral third-generation cephalosporins (3GCs), fluoroquinolones, and macrolides than other antimicrobial classes.3,4) Thus, reducing outpatients’ AMU, especially for 3GCs, fluoroquinolones, and macrolides, is essential for achieving the goal of NAP-AMR.
The increasing number of annual publications of articles in the field of antimicrobial stewardship (AS) in Japanese hospitals from 2016 might reflect overall AS activities in many Japanese hospitals.5) However, we believe that most AS in Japanese hospitals, including our hospital, is targeted at inpatients. Interventions for outpatients are more challenging than those for inpatients, mostly because of their irregular, sporadic hospital visit. Upon initiation of AS for outpatients, it is important that details of antimicrobial prescriptions, as well as their target for intervention, are clear. However, only reports based on receipt data of outpatients are available and not the details of outpatients themselves.6,7) Therefore, this study aimed to clarify the details of AMU in outpatients in a community hospital in Japan and investigate the influence of the current inpatient-based AS on outpatients.
MATERIALS AND METHODS
Study DesignThis repeated cross-sectional study was conducted at Komaki City Hospital (KCH; bed capacity: from 558 in April 2019 to 520 in May 2019), a tertiary care center in Aichi, Japan. All patients who visited the outpatient department during the weekdays in the second week of October 2013, 2016, and 2019 were included in the study. Information on outpatients (age and gender), prescriptions of antibiotics (indications, clinical diagnosis for treatment, and duration of surgical antimicrobial prophylaxis (SAP)), and physicians’ post-graduate year (PGY) and gender was collected retrospectively from electronic medical records.
The percentage of outpatients who were prescribed antibiotics, percentage of physicians who prescribed antibiotics, and number of antibiotic prescriptions per 1000 outpatients were calculated.
Indications of Antimicrobial PrescriptionsIndications of antimicrobial prescriptions were categorized into the treatment of infections, prophylaxis for outpatient surgeries to prevent surgical site infections, prophylaxis for pneumocystis pneumonia (PCP), prophylaxis for other purposes, and others (e.g., minocycline for skin trouble caused by molecular targeted drugs and clarithromycin for bronchiectasis).
Definition of Appropriateness for Treatment and SAPAssessment of the correct treatment and SAP is shown in Supplementary Table 1. Clinical diagnoses for treatment were retrieved from physicians’ descriptions in electronic medical records. The antimicrobial selection was classified as appropriate, inappropriate, or unevaluable based on The Japanese Association for Infectious Diseases (JAID)/Japanese Society of Chemotherapy (JSC) Guide to Clinical Management of Infectious Diseases, The Sanford Guide to Antimicrobial Therapy 2020, Manual of Antimicrobial Stewardship (2nd Edition), or culture results.8–10) After excluding unevaluable, appropriateness was calculated as appropriate ×100/(appropriate + inappropriate).
The collected data on SAP included the timing of antimicrobial administrations (before and after surgery), antibiotic selection, and SAP duration. Antimicrobial selection was evaluated based on the Japanese Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery (JCPG-APS), profiles of antibiotic activity against methicillin-susceptible Staphylococcus aureus, bioavailability, and preoperative culture results.11)
The appropriateness of antimicrobial selection for treatment and SAP was evaluated independently by two assessors (pharmacists and physicians). Differences in assessment were resolved through discussion.
AS in KCHMembers of the AS team at KCH include physicians, pharmacists, microorganism examination technicians, and nurses. Since 2014, an infectious disease physician from another hospital has joined our AS team every week, making AS more active. The main activities of our AS team were as follows: intervention for patients with positive blood cultures (as necessary), weekly post-prescription review with feedback of anti-methicillin-resistant Staphylococcus aureus agents and anti-pseudomonal agents, and weekday consultation services for patients affected by infectious diseases. Since 2017, our AS team has performed interventions to optimize SAP in accordance with the JCPG-APS, including the elimination of oral antimicrobial prescriptions. As for other activities, our AS team held in-hospital workshops on appropriate AMUs twice a year. However, all activities of our AS team were focused on inpatients rather than outpatients. This is because prompt interventions were sometimes impossible for the AS team to maintain during patients’ sporadic visits.
Statistical Analysis and Ethics StatementThe numbers of antibiotics administered, including total, treatment, prophylaxis, and others, are expressed in terms of “per 1000 patients.” Categorical variables are presented as total numbers and percentages, and trends in categorical variables were evaluated using the Cochran-Armitage trend test. Multi-categorical variables (e.g., SAP duration) are expressed as total numbers and percentages and were evaluated using the Jonckheere-Terpstra trend test. All statistical tests were two-sided, and statistical significance was set at p < 0.05. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). It is a modified version of R commander designed to add statistical functions frequently used in biostatistics.12)
This study adhered to the Japanese ethical guidelines for epidemiological studies, and all the study protocols were approved by the Institutional Review Board of KCH (Approval No. 201038). Written informed consent was waived owing to the retrospective nature of this study.
RESULTS
Table 1 presents the background data of outpatients, physicians, and antimicrobial prescriptions. The number of outpatients during the study periods was 7338 in 2013, 7085 in 2016, and 6146 in 2019. The number of antimicrobial prescriptions was 380 in 2013, 437 in 2016, and 418 in 2019.
Table 1. Background Data of Outpatients, Physicians and Antimicrobial Prescriptions
| 2013 | 2016 | 2019 | P for trend |
|---|
| Total number |
| Patients | 7338 | 7085 | 6146 | N/A |
| Physicians | 197 | 205 | 213 | N/A |
| Antimicrobial prescriptions | 380 | 437 | 418 | N/A |
| Patients with antibiotics % (N) |
| Overall | 4.7 (345/7338) | 5.7 (402/7085) | 5.9 (365/6146) | 0.001 |
| Age categories |
| 0–5 | 5.5 (13/237) | 5.1 (12/235) | 2.7 (5/182) | 0.198 |
| 6–17 | 3.5 (8/226) | 7.3 (16/218) | 3.5 (5/142) | 0.777 |
| 18–44 | 6.0 (75/1255) | 6.9 (70/1014) | 7.0 (62/891) | 0.339 |
| 45–64 | 4.0 (76/1922) | 4.9 (83/1677) | 5.1 (77/1520) | 0.111 |
| 65–79 | 4.8 (144/3018) | 5.3 (163/3066) | 6.6 (166/2531) | 0.004 |
| 80– | 4.3 (29/680) | 6.6 (58/875) | 5.7 (50/880) | 0.282 |
| Gender |
| Male | 4.9 (187/3802) | 5.6 (212/3772) | 5.8 (178/3078) | 0.106 |
| Female | 4.5 (158/3536) | 5.7 (190/3313) | 6.1 (187/3068) | 0.003 |
| Physicians who prescribed antibiotics % (N) |
| Overall | 38.6 (76/197) | 45.4 (93/205) | 42.7 (91/213) | 0.410 |
| PGY categories |
| PGY 1–2 | 35.7 (10/28) | 29.2 (7/24) | 18.2 (4/22) | 0.176 |
| PGY 3–5 | 45.7 (16/35) | 51.4 (18/35) | 58.3 (21/36) | 0.287 |
| PGY 6–10 | 36.0 (18/50) | 46.3 (19/41) | 45.2 (19/42) | 0.355 |
| PGY 11–20 | 32.4 (12/37) | 48.2 (27/56) | 43.8 (28/64) | 0.356 |
| PGY 21– | 42.6 (20/47) | 44.9 (22/49) | 38.8 (19/49) | 0.703 |
| Gender |
| Male | 37.3 (57/153) | 43.5 (67/154) | 40.0 (64/160) | 0.630 |
| Female | 43.2 (19/44) | 51.0 (26/51) | 50.9 (27/53) | 0.461 |
Abbreviations: PGY; post graduate year, N/A; not applicable.
A significant upward trend was noted in the percentage of patients who were prescribed antibiotics from 4.7 to 5.9% (P = .001), in patients in the age group 65–79 years (P = .004), and in female patients (P = .003). However, no significant trends were observed in prescribing physicians’ PGY and gender.
Figure 1 shows the number of antimicrobial prescriptions per 1000 patients according to antimicrobial categories. The overall number of antimicrobial prescriptions per 1000 outpatients was 51.8 in 2013 and 68.0 in 2019. The number of prescriptions for 3GCs decreased from 21.4 to 6.3, whereas the number of prescriptions for penicillins, first or second-generation cephalosporins (1/2GCs), fluoroquinolones, and co-trimoxazole increased from 3.8 to 15.3, 0.5 to 6.0, 7.0 to 13.2, and 5.0 to 15.8, respectively.
The number of antibiotic prescriptions per 1000 patients is shown in Table 2. The total number of antimicrobial prescriptions for treatment was 27.4 in 2013, 30.2 in 2016, and 28.0 in 2019. Compared with that noted in 2013, the number of 3GCs and macrolides decreased in 2019 from 7.8 to 2.6 and 4.6 to 2.0, respectively. However, the number of penicillins, 1/2GCs, and fluoroquinolones in 2019 increased from 3.0 to 9.9, 0.3 to 1.8, and 5.2 to 6.7, respectively. The total number of antimicrobial prescriptions for SAP was 15.1 in 2013, 17.5 in 2016, and 18.9 in 2019. Similar to prescriptions for treatment, the number of penicillins, 1/2GCs, and fluoroquinolones increased from 2013 to 2019, whereas 3GCs showed a drastic decrease (from 12.9 in 2013 to 3.6 in 2019). Regarding PCP prophylaxis, co-trimoxazole showed a 3.7-fold increase (from 4.1 in 2013 to 15.0 in 2019).
Table 2. Number of Antimicrobial Prescriptions by Categories
| 2013 | 2016 | 2019 |
|---|
| Treatment of infections, N per 1000 patients |
| Overall | 27.4 | 30.2 | 28.0 |
| Penicillins | 3.0 | 5.6 | 9.9 |
| 1st/2nd generation Cephalosporins | 0.3 | 0.3 | 1.8 |
| 3rd generation Cephalosporins | 7.8 | 8.0 | 2.6 |
| Fluoroquinolones | 5.2 | 7.1 | 6.7 |
| Macrolides | 4.6 | 3.0 | 2.0 |
| Co-trimoxazole | 0.4 | 0.6 | 0.5 |
| Tetracyclines | 1.6 | 1.3 | 0.7 |
| Anti-tuberculosis | 3.8 | 3.8 | 3.4 |
| Others | 0.7 | 0.6 | 0.5 |
| Prophylaxis for outpatient surgeries, N per 1000 patients |
| Overall | 15.1 | 17.5 | 18.9 |
| Penicillins | 0.5 | 0.6 | 5.2 |
| 1st/2nd generation Cephalosporins | 0 | 0.1 | 3.9 |
| 3rd generation Cephalosporins | 12.9 | 15.0 | 3.6 |
| Fluoroquinolones | 1.4 | 1.1 | 6.2 |
| Others | 0.3 | 0.7 | 0 |
| Prophylaxis for PCP, N per 1000 patients |
| Overall (Co-trimoxazole) | 4.1 | 10.0 | 15.0 |
| Prophylaxis for others, N per 1000 patients |
| Overall | 2.3 | 1.4 | 1.1 |
| Others, N per 1000 patients |
| Overall | 2.9 | 2.5 | 5.0 |
Abbreviations: PCP; pneumocystis pneumonia.
Table 3 shows the appropriateness of treatments according to patients, physicians, and clinical diagnoses. There was a significant increase in the appropriateness of overall therapy from 68.4% (130/190) in 2013 to 83.7% (123/147) in 2019 (P = .002). No significant trend was observed in appropriateness by patients’ age; however, antimicrobial prescriptions for male patients tended to be properly prescribed antibiotics during the study period. There was a significant increasing trend in the appropriateness of prescriptions by PGY 3–5, PGY 6–10, and male physicians (P = .006, P = .047, and P < .001, respectively). No significant trend was noted in the other physicians’ groups; however, no group showed a decrease in appropriateness in 2019 compared with that in 2013. The appropriateness for urinary tract infections remained very high since 2013, and the appropriateness for respiratory tract infections and skin and soft tissue infections showed a significant upward trend (p = .011 and p = .002, respectively). The only significant decrease of appropriateness of prescription was observed for genital infections (p = .044). A total of three cases of prescription was considered inappropriate: 3GCs for balanoposthitis and prostatitis and minocycline for syphilis without allergy to penicillins. Among respiratory tract infections, there was a total of 13 antimicrobial prescriptions (6 cases in 2013, 5 in 2016, and 2 in 2019) for common colds. There were four cases of antimicrobial prescriptions for acute diarrhea over 3 years (3 cases in 2013 and 1 in 2016).
Table 3. Appropriateness of Treatment
| 2013 | 2016 | 2019 | p for trend |
|---|
| Total, % (N)* | 68.4 (130/60/11) | 74.2 (144/50/20) | 83.7 (123/24/25) | 0.002 |
| Patients’ backgrounds, % (N)* |
| Age categories |
| 0–5 | 20.0 (2/8/0) | 50.0 (3/3/3) | N/A (0/0/1) | N/A |
| 6–17 | 33.3 (1/2/1) | 69.2 (9/4/1) | 0 (0/1/2) | 0.853 |
| 18–44 | 63.6 (28/16/6) | 75.0 (27/9/4) | 73.9 (17/6/7) | 0.311 |
| 45–64 | 71.4 (30/12/1) | 68.3 (28/13/4) | 85.3 (29/5/7) | 0.192 |
| 65–79 | 75.7 (56/18/2) | 73.2 (52/19/6) | 85.7 (66/11/1) | 0.131 |
| 80– | 76.5 (13/4/1) | 92.6 (25/2/2) | 91.7 (11/1/7) | 0.179 |
| Gender |
| Male | 55.8 (48/38/6) | 71.6 (73/29/7) | 83.1 (59/12/11) | <0.001 |
| Female | 78.8 (82/22/5) | 77.2 (71/21/13) | 84.2 (64/12/14) | 0.417 |
| Physicians’ backgrounds, % (N)* |
| PGY categories |
| PGY 1–2 | 78.6 (11/3/2) | 88.9 (8/1/0) | 100 (3/0/3) | 0.302 |
| PGY 3–5 | 61.9 (13/8/5) | 66.7 (24/12/2) | 93.5 (29/2/12) | 0.006 |
| PGY 6–10 | 73.7 (42/15/1) | 91.8 (56/5/3) | 86.7 (26/4/3) | 0.047 |
| PGY 11–20 | 71.4 (30/12/0) | 53.8 (28/24/15) | 79.1 (34/9/5) | 0.442 |
| PGY 21– | 60.7 (34/22/3) | 77.8 (28/8/0) | 77.5 (31/9/2) | 0.062 |
| Gender |
| Male | 68.1 (92/43/9) | 73.3 (99/36/11) | 88.1 (96/13/16) | <0.001 |
| Female | 69.1 (38/17/2) | 76.3 (45/14/9) | 71.1 (27/11/9) | 0.760 |
| Categories of infections, % (N)* |
| Respiratory infections | 84.3 (59/11/0) | 90.3 (65/7/0) | 97.0 (65/2/0) | 0.011 |
| Urinary tract infections | 97.6 (41/1/0) | 100 (46/0/1) | 95.7 (22/1/0) | 0.743 |
| Skin and soft tissue infections | 26.9 (7/19/2) | 27.3 (6/16/4) | 69.2 (18/8/1) | 0.002 |
| ENT infections | 68.8 (11/5/2) | 69.6 (16/7/7) | 66.7 (6/3/8) | 0.934 |
| Dental infections | 16.7 (2/10/0) | 8.3 (1/11/0) | 55.6 (5/4/0) | 0.056 |
| Intraabdominal infections | 100 (1/0/2) | 80.0 (4/1/2) | 100 (3/0/6) | 0.708 |
| Genital infections | 100 (4/0/0) | 83.3 (5/1/0) | 33.3 (1/2/2) | 0.044 |
| Bone and joint infections | 33.3 (3/6/1) | 50.0 (1/1/1) | 50.0 (1/1/0) | 0.597 |
| Intestinal infections | 40.0 (2/3/0) | 0 (0/1/0) | 100 (2/0/0) | 0.216 |
| Unknown infections | 0 (0/5/4) | 0 (0/5/5) | 0 (0/3/8) | N/A |
*N = (appropriate/inappropriate/unevaluable), Appropriateness = “appropriate” * 100/(“appropriate” + ”inappropriate”) Abbreviations: PGY; post graduate year, ENT; ear, nose and throat, N/A; not applicable.
Regarding SAP, the timing of antibiotic administration showed no significant trend during the study period (Table 4). In 2019, only 29.3% (34/116) of the cases received antibiotic administration before surgery. A significant upward trend was observed in the number of appropriately selected antibiotics (p < .001), whereas a significant decrease was observed in SAP duration (p < .001).
Table 4. Appropriateness of Surgical Antimicrobial Prophylaxis for Outpatients
| 2013 (n = 111) | 2016 (n = 124) | 2019 (n = 116) | p for trend |
|---|
| Timing of antimicrobial administration, N (%) |
| Before surgery | 23 (20.7) | 34 (27.4) | 34 (29.3) | 0.142 |
| Selection of antibiotics, N (%) |
| Appropriate selection | 11 (9.9) | 13 (10.5) | 93 (80.2) | <0.001 |
| Durations of antibiotics, N (%) |
| 1 d | 12 (10.8) | 5 (4.0) | 37 (31.9) | <0.001 |
| 2 d | 8 (7.2) | 4 (3.2) | 35 (30.2) |
| Over 3 d | 91 (82.0) | 115 (92.7) | 44 (37.9) |
DISCUSSION
To the best of our knowledge, this is the first comprehensive, case-based study of outpatient AMU at a Japanese community hospital. This study highlighted the trends in patients, prescribers, AMU by antimicrobial categories, indications, appropriateness of treatment, and SAP. This study gives true insight into AMU in a Japanese community hospital.
Oral 3GCs, 1/2GCs, and penicillins showed a similar trend in the treatment of infections and in SAP. However, prescriptions of fluoroquinolones for SAP increased compared to the treatment of infections. As a result, compared to that noted in 2013, the number of prescriptions per 1000 patients for all oral cephalosporins in 2019 decreased from 21.9 to 12.3 (▼43.8%), generally achieving the target (▼50%) of the NAP-AMR.2) In contrast, the number of prescriptions per 1,000 patients for fluoroquinolone increased from 7.0 to 13.2 (▲88.6%). This is believed to be due to the substitution of fluoroquinolones for 3GCs in the treatment of urinary tract infections and SAP.
Although the amount of fluoroquinolones has increased, the appropriate rate of antimicrobial selection has also increased. However, at a Japanese hospital, the prescriptions of fluoroquinolones for both prophylaxis and treatment in the outpatient setting were significantly reduced in 2019 compared to those in 2013.13) According to antimicrobial sales volume data, fluoroquinolone sales decreased from 2.87 in 2013 to 2.35 (DDD/1000 inhabitants/d) in 2019.14) Given these reports, a case-by-case analysis of the necessity of fluoroquinolones is necessary, despite being recommended in the JAID/JSC guide or other guides. Among the infections with a relatively high number of prescriptions, the appropriateness for skin and soft tissue infections, otorhinolaryngological infections, and dental infections was lower than average. The appropriateness of prescription for genital infections decreased significantly, although the number of these infections was rare (15 cases in the study periods). This survey shows that the AS team needs to promote the target of these infections in the future.
According to the 2016 Tennessee IQVIA Xponent data, physicians born in the 1960 s prescribed the highest number of antibiotics.15) A report of antimicrobial prescriptions in the emergency room at a community hospital in Japan described that physicians with PGY of ≥8 prescribed antibiotics more inappropriately than younger doctors.16) In contrast, in our study, the percentage of prescriptions was lower among physicians with PGY ≥11 throughout 2013–2019 than among younger physicians with PGY 3–5, and the number of cases of appropriate AMU increased over 2013 among all physician categories. The higher rate of antimicrobial prescriptions by junior doctors compared to senior doctors may be due to their greater exposure to acute illnesses of new outpatients or handover patients from the emergency room. The increase in the appropriateness of AMU among all physician categories may be due to the influence of inpatient-associated AS on outpatient prescription. In addition, the concept of NAP-AMR may have been disseminated to general practitioners.
In 2018, the Ministry of Health, Labor, and Welfare (MHLW) established financial support for AS in hospital inpatients and children in outpatient department to promote appropriate AMU.17) Since 2020, the number of antimicrobial prescriptions for acute diarrhea and acute upper respiratory infections should be reported when billing the AS fee.18) As for two infectious diseases, MHLW published Manual of Antimicrobial Stewardship in 2017 and 2019.10,19) In this repeated one-week surveys, only a few prescriptions for these infections were observed. However, we could not judge that the results were derived from the proper managements for these infections or the small number of patients with these infections. These results may show us that these diseases might not be the main target of AS in a community hospital in Japan.
The increasing number of co-trimoxazole prescriptions for PCP prophylaxis has contributed to an overall increase in antimicrobial prescriptions. According to antimicrobial sales volume data, co-trimoxazole sales increased from 0.25 in 2013 to 0.39 (DDD/1000 inhabitants/d) in 2019.14) According to point prevalence surveys in hospitalized patients, co-trimoxazole might be more commonly prescribed for inpatients in Japan than in Europe or the United States.20–23) However, the prevalence of outpatients with co-trimoxazole in a Japanese hospital has not been reported. Doses of PCP prophylaxis were less than those of treatment. Thus, antimicrobial sales volume data may underestimate the real prevalence of PCP prophylaxis. Co-trimoxazole exhibits good bioavailability and tissue penetration, and it can be used for urinary tract infections or skin and soft tissue infections in outpatient settings.8) Considering the increase in prescriptions of co-trimoxazole, we need to monitor susceptibilities of co-trimoxazole, even in outpatient settings.
The appropriate selection of antibiotics for SAP increased significantly, and the duration of prescribed prophylactic course decreased. The AS team at KCH has been promoting the optimization of perioperative antimicrobials in hospital patients. In Japan, oral antibiotics were frequently prescribed as SAP for inpatients.24) In KCH, 3GCs were frequently prescribed following intravenous antibiotics. After discussion with surgical departments, the AS team at KCH managed to change SAPs according to the JCPG-APS, thus changing clinical pathways with oral antibiotics. This activity contributed to appropriate selections and shortage of durations of SAP. However, the appropriate timing of administration has not been increased significantly. The antibiotic effect, when prescribed after surgery, is expected to be quite limited compared with the generally recommended administration before surgery.25,26) There are few reports on prescriptions during outpatient surgeries and procedures, except for those in dentistry.27) Therefore, it is necessary to investigate the current status of antimicrobial prescriptions for SAP in outpatient settings in Japan and make efforts to optimize these prescriptions.
This study has several limitations. First, only patients with antimicrobial prescriptions were included in this study; therefore, overall changes in patients’ backgrounds during the study periods could not be ascertained. Second, the trends in patients without antimicrobial prescriptions are unknown. Thus, the number of infectious diseases without antimicrobials and outpatient surgeries without antimicrobials could not be counted. Third, we evaluated the appropriateness of treatment based on clinical diagnosis; however, the validity of physicians’ diagnoses of outpatients was not evaluated in this study. Fourth, this study did not evaluate appropriateness of treatment durations. The duration of antimicrobial prescriptions in the emergency room was usually one to two days, and physicians often encouraged patients to visit their primary care physician. Thus, these cases could not be evaluated. To simplify the study, we evaluated only appropriateness of antimicrobial selection for outpatients. Fifth, the necessity of antimicrobial agents for outpatient surgeries not listed in the JCPG-APS was not determined. The antimicrobials for those surgeries may be unnecessary prescriptions. Sixth, most of the younger physicians appeared only once in the three surveys, whereas 11 senior physicians appeared three times in the PGY ≥11 group. Hence, we can consider the prescriptions of younger physicians to be reflective of their overall trend at the time of the survey. However, we suspect that the prescriptions of senior physicians may have reflected the trends of specific senior physicians. Finally, this study was conducted at a single hospital and did not reflect the overall trend in Japan.
This study showed the current status of outpatient oral AMU and the influence of AS on outpatients, which is mainly aimed at inpatients. Although appropriateness of antimicrobial selection was generally increased, fluoroquinolones and prescriptions for prophylaxis also increased. The challenges of antimicrobial administration mostly after outpatient surgeries were also highlighted. Future surveys of outpatient antimicrobial administration in multicenter settings should be conducted to clarify the challenges of outpatient AMU in Japan.
Acknowledgments
This research was supported by Grant-in-Aid for Young Scientists—Grant Number 20K18880.
Conflict of Interest
The authors declare no conflict of interest.
Supplementary Materials
This article contains supplementary materials.
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