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  • Measure Summary
  • NQMC:009282
  • Sep 2010

Disease-specific antibiotic prescribing: percentage of patients aged between 18 and 65 years with pneumonia prescribed antibacterials for systemic use receiving quinolones.

Adriaenssens N, Coenen S. Disease-specific antibiotic prescribing quality indicators report. Antwerp (Belgium): European Surveillance of Antimicrobial Consumption (ESAC); 2010 Sep 10. 55 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in October 2015.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients aged between 18 and 65 years with pneumonia prescribed antibacterials for systemic use receiving quinolones.

This measure gives an estimate of inappropriate antibiotic use for pneumonia.

Rationale

Antibiotic use is increasingly recognized as the major selective pressure driving antimicrobial resistance (Goossens et al., 2005; Malhotra-Kumar et al., 2007). In addition, antibiotic use requires more resources, motivates patients to reconsult and exposes them to the additional risk of side effects, whereas underprescribing might be associated with higher risk of complications of untreated infections (Petersen et al., 2007).

Guidelines recommend antibiotic prescribing for adults (greater than 18 years) but for patients older than 65 years ambulatory treatment is being questioned (Woodhead et al., 2005; Fine et al., 1997). In case antibiotics are prescribed, penicillins with extended spectrum or tetracyclines are recommended as first choice (Woodhead et al., 2005). In case of immunoglobulin E (IgE) mediated allergy to penicillins quinolones can be used.

Currently, resistance against quinolones is low but quinolone use is associated with development of resistance as well. Therefore, quinolones have to be reserved for pneumonia cases with resistance against first or second choice antibiotics.

Evidence for Rationale

Adriaenssens N, Coenen S. Disease-specific antibiotic prescribing quality indicators report. Antwerp (Belgium): European Surveillance of Antimicrobial Consumption (ESAC); 2010 Sep 10. 55 p.

Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997 Jan 23;336(4):243-50. PubMed External Web Site Policy

Goossens H, Ferech M, Vander Stichele R, Elseviers M, ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005 Feb 12-18;365(9459):579-87. PubMed External Web Site Policy

Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. Lancet. 2007 Feb 10;369(9560):482-90. PubMed External Web Site Policy

Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007 Nov 10;335(7627):982. PubMed External Web Site Policy

Woodhead M, Blasi F, Ewig S, Huchon G, Ieven M, Leven M, Ortqvist A, Schaberg T, Torres A, van der Heijden G, Verheij TJ, European Respiratory Society, European Society of Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections. Eur Respir J. 2005 Dec;26(6):1138-80. PubMed External Web Site Policy

Primary Health Components

Antibiotic prescribing; pneumonia; systemic use; quinolones

Denominator Description

Number of patients aged between 18 and 65 years diagnosed with pneumonia prescribed antibacterials for systemic use (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients aged between 18 and 65 years diagnosed with pneumonia prescribed quinolones (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • There is a wealth of information on the prevalence of resistance in human pathogens, and these data show substantial geographical differences in the proportion of resistance to various classes of antibiotics in Europe (Bruinsma et al., 2004; Goossens & Sprenger, 1998). Whereas the rates of resistance remain low in northern European countries, they are reaching alarming levels in southern and central European countries. Studies have shown that differential selection pressure of antibiotic agents may be responsible for some of these observed differences (Bronzwaer et al., 2002; Goossens et al., 2005). Consequently, antimicrobial consumption was to be monitored to accompany analogous surveillance programmes on resistance (Anon, 2002).
  • The largest volumes of antibiotic prescriptions for systemic use are prescribed in primary care, with respiratory tract infections being the most common indication. More detailed analysis of antibiotic use in outpatients again showed considerable differences in overall antibiotic use, the use of the different kinds of antibiotics, and seasonal variation of antibiotic use, suggesting inappropriate antibiotic use in Europe (Adriaenssens et al., "ESAC: outpatient antibiotic," 2011; Adriaenssens et al., "ESAC: outpatient macrolide," 2011; Adriaenssens et al., "ESAC: outpatient quinolone," 2011; Coenen, 2011; Versporten et al., "ESAC: outpatient penicillin," 2011; Versporten et al., "ESAC: outpatient cephalosporin," 2011), as these striking variations cannot be explained by differences in incidence of disease alone or by differences in aetiology or resistance rates between countries.

Evidence for Additional Information Supporting Need for the Measure

Adriaenssens N, Coenen S, Versporten A, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi3-12. PubMed External Web Site Policy

Adriaenssens N, Coenen S, Versporten A, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient macrolide, lincosamide and streptogramin (MLS) use in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi37-45. PubMed External Web Site Policy

Adriaenssens N, Coenen S, Versporten A, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient quinolone use in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi47-56. PubMed External Web Site Policy

Anon. Council recommendation of 15 November 2001 on the prudent use of antimicrobial agents in human medicine. OJEC. 2002;45:13-6.

Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJ, Degener JE, European Antimicrobial Resistance Surveillance System. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis. 2002 Mar;8(3):278-82. PubMed External Web Site Policy

Bruinsma N, Kristinsson KG, Bronzwaer S, Schrijnemakers P, Degener J, Tiemersma E, Hryniewicz W, Monen J, Grundmann H, European Antimicrobial Resistance Surveillance System (EARSS). Trends of penicillin and erythromycin resistance among invasive Streptococcus pneumoniae in Europe. J Antimicrob Chemother. 2004 Dec;54(6):1045-50. PubMed External Web Site Policy

Coenen S, Adriaenssens N, Versporten A, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient use of tetracyclines, sulphonamides and trimethoprim, and other antibacterials in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi57-70. PubMed External Web Site Policy

Coenen S, Ferech M, Haaijer-Ruskamp FM, Butler CC, Vander Stichele RH, Verheij TJ, Monnet DL, Little P, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual Saf Health Care. 2007 Dec;16(6):440-5. [30 references] PubMed External Web Site Policy

Goossens H, Ferech M, Vander Stichele R, Elseviers M, ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005 Feb 12-18;365(9459):579-87. PubMed External Web Site Policy

Goossens H, Sprenger MJ. Community acquired infections and bacterial resistance. BMJ. 1998 Sep 5;317(7159):654-7. PubMed External Web Site Policy

Versporten A, Coenen S, Adriaenssens N, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient cephalosporin use in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi25-35. PubMed External Web Site Policy

Versporten A, Coenen S, Adriaenssens N, Muller A, Minalu G, Faes C, Vankerckhoven V, Aerts M, Hens N, Molenberghs G, Goossens H, ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): outpatient penicillin use in Europe (1997-2009). J Antimicrob Chemother. 2011 Dec;66 Suppl 6:vi13-23. PubMed External Web Site Policy

Extent of Measure Testing

Taking into account the scores from a relevant group of experts – professionals rather than policy makers – from a set of 21 (7x3) proposed guideline based disease specific quality indicators for outpatient antibiotic use in Europe, all seem to be relevant, that is, they have face validity and are potentially applicable.

Evidence for Extent of Measure Testing

Adriaenssens N, Coenen S, Tonkin-Crine S, Verheij TJ, Little P, Goossens H, on behalf of the ESAC Project Group. European Surveillance of Antimicrobial Consumption (ESAC): disease-specific quality indicators for outpatient antibiotic prescribing. BMJ Qual Saf. 2011 Mar 21;20:764-72. [36 references] PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age 18 to 65 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients aged between 18 and 65 years diagnosed with pneumonia prescribed antibacterials for systemic use

Note: Refer to the original measure documentation for International Classification of Primary Care (ICPC-2-R) and International Classification of Diseases, Tenth Revision (ICD-10) codes.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients aged between 18 and 65 years diagnosed with pneumonia prescribed quinolones

Note: Refer to the original measure documentation for International Classification of Primary Care (ICPC-2-R) and International Classification of Diseases, Tenth Revision (ICD-10) codes.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Prescriptive standard

Prescriptive Standard

The acceptable use ranges between 0% and 5%, i.e., taking into account the prevalence of patients aged between 18 and 65 years with immunoglobulin E (IgE) mediated allergy to penicillins (Salkind, Cuddy, & Foxworth, 2001), and patients with known resistance against first and second choice antibiotics.

Evidence for Prescriptive Standard

Adriaenssens N, Coenen S. Disease-specific antibiotic prescribing quality indicators report. Antwerp (Belgium): European Surveillance of Antimicrobial Consumption (ESAC); 2010 Sep 10. 55 p.

Salkind AR, Cuddy PG, Foxworth JW. The rational clinical examination. Is this patient allergic to penicillin? An evidence-based analysis of the likelihood of penicillin allergy. JAMA. 2001 May 16;285(19):2498-505. PubMed External Web Site Policy

Original Title

Indicator 7c: the percentage of patients aged between 18 and 65 years with pneumonia (ICPC-2-R: R81) prescribed antibacterials for systemic use (ATC: J01) receiving quinolones (ATC: J01M) [R81_J01M_%].

Measure Collection Name

Disease-specific Antibiotic Prescribing Quality Indicators

Submitter

European Surveillance of Antimicrobial Consumption Network - Clinical Specialty Collaboration

Developer

European Surveillance of Antimicrobial Consumption Network - Clinical Specialty Collaboration

Funding Source(s)

The European Surveillance of Antimicrobial Consumption (ESAC) project was funded by the European Centre for Disease Prevention and Control (ECDC; Grant Agreement 2007/001).

Composition of the Group that Developed the Measure

Adriaenssens N, Coenen S, Tonkin-Crine S, Verheij TJ, Little P, Goossens H, on behalf of the European Surveillance of Antimicrobial Consumption (ESAC) Project Group

Financial Disclosures/Other Potential Conflicts of Interest

None to declare.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2010 Sep

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in October 2015.

Source(s)

Adriaenssens N, Coenen S. Disease-specific antibiotic prescribing quality indicators report. Antwerp (Belgium): European Surveillance of Antimicrobial Consumption (ESAC); 2010 Sep 10. 55 p.

Measure Availability

Source available from the European Centre of Disease Prevention and Control (ECDC) Web site External Web Site Policy.

For more information, contact the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) at the ECDC at Tomtebodavägen 11a, 171 83 Stockholm, Sweden; Phone: +46 (0)8 586 010 00; Fax: +46 (0)8 586 010 01; Web site: www.ecdc.europa.eu External Web Site Policy; E-mail: ESACNET@ecdc.europa.eu.

NQMC Status

This NQMC summary was completed by ECRI Institute on July 24, 2014. The information was verified by the measure developer on September 7, 2014.

The information was reaffirmed by the measure developer on October 13, 2015.

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