Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

BACKGROUND

Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

METHODS

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30-61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

RESULTS

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

CONCLUSIONS

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Towards an international consensus on safety netting advice for acutely ill children presenting to ambulatory care: a modified e-Delphi procedure

OBJECTIVE

Develop a consensus on the content and form of safety netting advice (SNA) for parents of acutely ill children.

DESIGN

Four-round modified e-Delphi using online questionnaires and feedback among clinical and research experts.

SETTING

Ambulatory care in high-income countries.

PARTICIPANTS

Forty-one experts from 13 countries: 3 emergency physicians, 15 general practitioners, 4 nurses and 19 paediatricians.

RESULTS

The experts defined the content of SNA as advice on the normal, expected disease course of the provisional diagnosis, diagnostic uncertainty, alarm signs that indicate the need for medical help and information on where and how to find such help. Regarding the form of the SNA, the experts agree that a reliable source should give SNA verbally with paper or digital written or video/image resources at every appropriate healthcare encounter in a short and simple empowering fashion, specific to the child's situation and seek confirmatory feedback from parents.

CONCLUSIONS

SNA needs to contain advice on the expected disease course, alarm signs and where and how to find help. It should be given verbally with written resources by a reliable healthcare professional or digital platform. Short, simple and specific, SNA needs to empower the parent whose understanding of the advice should be checked. The effectiveness of SNA resources coproduced by parents and experts should be assessed in different settings and those providing SNA require up-to-date and reliable training.

Evaluation of parents' attitudes and practices related to antibiotic use for their children in Kosovo: a cross-sectional survey

BACKGROUND

Self-medication and lack of patient adherence contribute to antibiotic misuse. This article describes parents' attitudes and practices regarding use of antibiotics by their children in Kosovo.

METHODS

A cross-sectional survey was conducted during data collection. We surveyed a total of 453 parents of children aged 0-15 years, who had experiences with using antibiotics for their children. Correlation tests and regression analysis were used to explore the relationship between variables.

RESULTS

Our findings showed that 42.2% of parents strongly agreed or agreed with the use of antibiotics as a means to cure a cold or flu in their child more quickly. In addition, 29.8% were not aware of antibiotic side effects. Non-compliance with antibiotic treatment was 35.8%, and 28.9% of surveyed parents suggested that they had pressured their pediatricians to prescribe antibiotics for their children. A total of 10.15% of parents had no information on antibiotic resistance, and 34.38% of parents responded that they did not believe that self-medication with antibiotics could lead to resistance. Regression analysis results indicated that gender and age group have a significant influence on the parents' decision that an antibiotic should be used in children with high fever (p < 0.001).

CONCLUSIONS

Our findings suggest that antibiotic management by parents in Kosovo is not satisfactory, and more attention should be given to their knowledge of the side effects of antibiotics, bacterial resistance and reduction in the self-medication. Health education, adequate measures and interventions are needed to overcome this situation and ensure rational use of antibiotics in Kosovo.

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China

Objectives

This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs).

Methods

A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute.

Results

In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001).

Conclusion

Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

General Practitioners’, Pharmacists’ and Parents’ Views on Antibiotic Use and Resistance in Malta: An Exploratory Qualitative Study

Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement.

Acute respiratory infections in an adult refugee population: an observational study

The presence of acute infectious respiratory diseases (ARD) is one of the main reasons why recently arrived refugees seek medical help. This paper investigates the incidence rates of acute respiratory diseases in an adult refugee population as well as associated sociodemographic factors and drug treatments. We conducted a retrospective observational study of deidentified medical records. The data were collected between 2015 and 2019 in the health care centers of two large German initial reception centers for refugees. Multivariable analyses controlling for sociodemographics were carried out using generalized estimating equations. Out of 10,431 eligible residents, 6965 medical encounters of 2840 adult patients were recorded over 30 months. Of all the adult patients, 34.4% sought medical help for a respiratory symptom or diagnosis at least once. Older patients and patients from Sub-Saharan Africa sought help less often. The occurrence of ARD showed a typical distribution over the course of the year. Facility occupancy was not associated with ARD occurrence. Acute respiratory symptoms are a leading cause for adult refugee patients to seek medical care. The doctor contact rates due to ARD were consistently two to three times higher among refugees than among German residents.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

OBJECTIVE

While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

SETTINGS

English primary care.

INTERVENTIONS

AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.

METHODS

We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

RESULTS

We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

CONCLUSIONS

Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry

Antibiotic stewardship aims to tackle the global problem of drug-resistant infections by promoting the responsible use of antibiotics. Most antibiotics are prescribed in primary care and widespread overprescribing has been reported, including 80% in dentistry. This review aimed to identify outcomes measured in studies evaluating antibiotic stewardship across primary healthcare. An umbrella review was undertaken across medicine and a systematic review in dentistry. Systematic searches of Ovid Medline, Ovid Embase and Web of Science were undertaken. Two authors independently selected and quality assessed the included studies (using Critical Appraisal Skills Programme for the umbrella review and Quality Assessment Tool for Studies with Diverse Designs for the systematic review). Metrics used to evaluate antibiotic stewardship programmes and interventions were extracted and categorized. Comparisons between medical and dental settings were made. Searches identified 2355 medical and 2704 dental studies. After screening and quality assessment, ten and five studies, respectively, were included. Three outcomes were identified across both medical and dental studies: All focused on antibiotic usage. Four more outcomes were found only in medical studies: these measured patient outcomes, such as adverse effects. To evaluate antibiotic stewardship programmes and interventions across primary healthcare settings, measures of antibiotic use and patient outcomes are recommended.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Role of Blueberry Anthocyanin Extract in the Expression of SIRT1 and NF-κB in Rat Lens Epithelial Cells in Experimentally Induced DM

PURPOSE

To investigate the mechanism of the protective effects of blueberry anthocyanin extract (BAE) against oxidative stress and the roles of SIRT1 and NF-κB in the pathogenesis of diabetic cataracts.

METHODS

Male SD rats were randomly divided into a control group (group A) and an experimental group. The rats in the experimental group were intraperitoneally injected with streptozotocin (STZ) (60 mg/kg). Rats with blood glucose levels ≥16.7 mmol/L were considered to have DM. The rats in the experimental group were subdivided into group B (distilled water by oral gavage: 10 ml/kg/day), group C (5% blueberry anthocyanin extract by oral gavage: 10 ml/kg/day), and group D (15% blueberry anthocyanin extract by oral gavage: 10 ml/kg/day), with 15 rats in each group. At the end of 8 weeks, some biochemical parameters, including the expression of SIRT1 and NF-κB by qRT-PCR and western blotting and the activity of SOD and GSH, were measured in lens epithelial cells (LECs).

RESULTS

The lenses of the rats in the control group appeared transparent during the entire 8-week period. Four weeks following STZ injection, cataracts gradually progressed in the experimental rats. SIRT1 expression was upregulated in groups B, C and D compared to the control group. However, the expression of NF-κB decreased in the experimental groups with increasing doses of BAE (p < .05). Our study also showed that the activity of the SOD enzyme and GSH in the LECs of the rats in the experimental group increased with higher doses of BAE.

CONCLUSIONS

The results indicated that BAE significantly delayed the progression of diabetic cataracts in rats. These effects may be due to the dose-dependent antioxidant activity of BAE, which is mediated by enhanced SOD and GSH activities, SIRT1 expression and reduced NF-κB expression. Abbreviations: SD rat: Sprague-Dawley rat; BAE: Blueberry anthocyanin extract; LECs: Lens epithelial cells; SOD: Superoxide dismutase; GSH: Glutathione; DM: Diabetes mellitus; SIRT1: Silent information regulator protein-1; STZ: Streptozotocin; PBS: Phosphate-buffered saline.

Inhibitory Effect of Lygodium Root on the Cytochrome P450 3A Enzyme in vitro and in vivo

Purpose

The aim of the present study was to investigate the interactions of the main components of Lygodium root (ie, p-coumaric acid, acacetin, apigenin, buddleoside and Diosmetin-7-O-β-D-glucopyranoside) with cytochrome P450 3A enzyme activity both in vitro and in vivo.

Methods

In vitro inhibition of drugs was assessed by incubating rat liver microsomes (RLMs) with a typical P450 3A enzyme substrate, midazolam, to determine their 50% inhibitory concentration (IC50) values. For the in vivo study, healthy male Sprague Dawley rats were consecutively administered acacetin or apigenin for 7 days at the dosage of 5 mg/kg after being randomly divided into 3 groups: Group A (control group), Group B (acacetin group) and Group C (apigenin group).

Results

Among the five main components of Lygodium root, only acacetin and apigenin showed inhibitory effects on the cytochrome P450 3A enzyme in vitro. The IC50 values of acacetin and apigenin were 58.46 μM and 8.20 μM, respectively. Additionally, the in vivo analysis results revealed that acacetin and apigenin could systemically inhibit midazolam metabolism in rats. The T_max, AUC_(0-t) and C_max of midazolam in group B and group C were significantly increased (P<0.05), accompanied by a significant decrease in V_z/F and CL_z/F (P<0.05).

Conclusion

Acacetin and apigenin could inhibit the activity of the cytochrome P450 3A enzyme in vitro and in vivo, indicating that herbal drug interactions might occur when taking Lygodium root and midazolam synchronously.

Systematic review of patient-oriented interventions to reduce unnecessary use of antibiotics for upper respiratory tract infections

BACKGROUND

Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) even though most URTIs do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem globally. As physicians' prescribing behaviour is influenced by patients' expectations, there may be some opportunities to reduce antibiotic prescribing using patient-oriented interventions. We aimed to identify these interventions and to understand which ones are more effective in reducing unnecessary use of antibiotics for URTIs.

METHODS

We conducted a systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL, and the Web of Science. We included English language randomized controlled trials (RCTs), quasi-RCTs, controlled before and after studies, and interrupted time series (ITS) studies. Two authors screened the abstract/titles and full texts, extracted data, and assessed study risk of bias. Where pooling was appropriate, a meta-analysis was performed by using a random-effects model. Where pooling of the data was not possible, a narrative synthesis of results was conducted.

RESULTS

We included 13 studies (one ITS, one cluster RCTs, and eleven RCTs). All interventions could be classified into two major categories: delayed prescriptions (seven studies) and patient/public information and education interventions (six studies). Our meta-analysis of delayed prescription studies observed significant reductions in the use of antibiotics for URTIs (OR = 0.09, CI 0.03 to 0.23; six studies). A subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects. The studies in the patient/public information and education group varied according to their methods of delivery. Since only one or two studies were included for each method, we could not make a definite conclusion on their effectiveness. In general, booklets or pamphlets demonstrated promising effects on antibiotic prescription, if discussed by a practitioner.

CONCLUSIONS

Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic prescription for URTIs. Further research is needed to investigate the costs and feasibility of implementing these interventions as part of routine clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016048007.

The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial

Objective

The aim of this study was to test whether the implementation of an enhanced recovery after surgery (ERAS) protocol for patients undergoing elective cesarean delivery has a positive impact on the postoperative status of the patients in terms of pain management, hospital stay, hospitalization costs, and adverse reactions.

Methods

Patients who underwent elective cesarean delivery were randomized into two groups – ERAS group and control group – and the groups were managed with the ERAS protocol and traditional protocol, respectively.

Results

Compared to the control group, the ERAS group had significantly fewer patients with intraoperative nausea, pain of visual analog scale (VAS) scores, and VAS grade >3 during rest in the first 24 h and during motion in the first 24 and 48 h after surgery. There were no intergroup differences in the requirement of extra analgesics, the incidence of vomiting, shivering, hypotension, postoperative nausea, and pruritus. None of the patients in either group had postoperative vomiting. Patient satisfaction rated as per the VAS was significantly higher in the ERAS group than in the control group. The total length of stay, postoperative length of stay, and the cost of anesthesia in both groups were comparable. Further, the average daily hospitalization cost was significantly lower in the ERAS group than in the control group.

Conclusion

The ERAS protocol shows promise and appears to be worthwhile for widespread implementation among patients undergoing elective cesarean delivery; it was found to be beneficial in reducing the postoperative pain, incidence of intraoperative nausea, and average cost of hospitalization and also improved patient satisfaction.

The viral prescription pad - a mixed methods study to determine the need for and utility of an educational tool for antimicrobial stewardship in primary health care

Background

In order to combat rising rates of antimicrobial resistant infections, it is vital that antimicrobial stewardship become embedded in primary health care (PHC). Despite the high use of antimicrobials in PHC settings, there is a lack of data regarding the integration of antimicrobial stewardship programs (ASP) in non-hospital settings. Our research aimed to determine which antimicrobial stewardship interventions are optimal to introduce into PHC clinics beginning to engage with an ASP, as well as how to optimize those interventions. This work became focused specifically around management of viral upper respiratory tract infections (URTIs), as these infections are one of the main sources of inappropriate antibiotic use.

Methods

This mixed methods study of sequential explanatory design was developed through three research projects over 3 years in Regina, Saskatchewan, Canada. First, a survey of PHC providers was performed to determine their perceived needs from a PHC-based ASP. From this work, a “viral prescription pad” was developed to provide a tool to help PHC providers engage in patient education regarding appropriate antimicrobial use, specifically for URTIs. Next, interviews were performed with family physicians to discuss their perceived utility of this tool. Finally, we performed a public survey to determine preferences for the medium by which information is received regarding symptom management for viral URTIs.

Results

The majority of PHC providers responding to the initial survey indicated they were improperly equipped with tools to aid in promoting conversations with patients and providing education about the appropriate use of antimicrobials. Following dissemination of the viral prescription pad and semi-structured interviews with family physicians, the viral prescription pad was deemed to be a useful educational tool. However, about half of the physicians interviewed indicated they did not actually provide a viral prescription to patients when providing advice on symptom management for viral URTIs. When asked about their preferences, 76% of respondents to the public survey indicated they would prefer to receive written or a combination of verbal and written information in this circumstance.

Conclusions

PHC providers indicated a need for educational tools to promote conversations with patients and provide education about the appropriate use of antimicrobials. Viral prescription pads were regarded by family physicians and patients as useful tools in facilitating discussion on the appropriate use of antimicrobials. PHC providers should exercise caution in opting out of providing written forms of information, as many respondents to the general public survey indicated their preference in receiving both verbal and written information.

Effectiveness of Sex Education Interventions in Adolescents: An Overview

The objective of this overview was to identify and evaluate the effectiveness of sex education interventions aimed at reducing sexual risk behaviors in adolescents. A search was conducted of systematic reviews in English, Spanish and Portuguese from 1946 until July 2018 in the following databases: MEDLINE (Ovid), EMBASE, Scopus, PsyArticles, Cochrane Central Register of Controlled Trials, LILACS and additional resources. The extraction and analysis of data was synthesized in a narrative mode describing intervention, population, and key outcomes such as decreased risky sexual behavior, decreases in sexually transmitted infections, and adolescent pregnancy. There were 2289 potentially relevant studies, of which 31 systematic reviews related to adolescent interventions were included. It was demonstrated that interventions involve parents and the community as participants, are based on audiovisual media and school workshops, and their emphasis is on information and training in school. Different reviews framed in methods of psychosocial intervention based on community groups and the home as a fundamental axis were reported. Finally, a large amount of scientific evidence related to the subject was identified. New directions are presented for interventions in sexual education for adolescents based on the combination of actions and techniques, the implementation of digital technology, and socio-cultural and contextual adaptations.

Shanghai Parents' Perception And Attitude Towards The Use Of Antibiotics On Children: A Cross-Sectional Study

Background

Parents play an important role in the management of their children’s illnesses, including in decisions concerning how and whether to use antibiotics. This study aims to assess the knowledge and attitude towards antibiotics usage among young parents from different areas in Shanghai and to identify contributing factors of antibiotics usage that are comprehensible for parents.

Methods

A cross-sectional study was conducted at vaccination clinics of three community health centers from April to June 2017. Primary guardians who took children for vaccination under the national expanded immunization program were invited to participate.

Results

Of the 1368 young parents interviewed, 78.4% of them have taken their children for medical treatment, and 68.9% of their children have taken antibiotics. Parents with education level of senior high school (OR=1.850, 95% CI: 1.214–2.818), or university/college, or above (OR=3.950, 95% CI: 2.604–5.991), and parents with high-income (OR=1.360, 95% CI: 1.013–1.827) have better comprehension of antibiotics. It is found that parents who deny the existence of antibiotic abuse in China (OR=1.857, 95% CI: 1.100–3.135), who have lower income (OR=1.536, 95% CI: 1.074–2.197) and who have antibiotics prescribed by doctors (OR=1.473, 95% CI: 1.048–2.070) are associated with those incorrect practices.

Conclusion

Lack of knowledge and poor perception of antibiotics usage are found among young parents in Shanghai. Intervention should be conducted to publicize the rational use of antibiotics, reduce the rate of inappropriate behaviors and limit the sale of antibiotics.

Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives

Background

Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance.

Methods

We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed.

Results

Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it.

Conclusions

GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public’s perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients’ expectations.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0917-8) contains supplementary material, which is available to authorized users.

Protocol for a comparison study of 1-day (single dose) versus 2-day prophylactic antibiotic administration in Holmium Laser enucleation of the prostate (HoLEP): a randomized controlled trial

Background: The best method of antimicrobial prophylaxis administration for surgical site infection (SSI) in transurethral holmium laser resection and enucleation of the prostate (HoLEP)/bipolar transurethral enucleation (TUEB) remains controversial. The purpose of this study is to compare one-day and two-day cefazolin in a randomized 2 nd-phase study to help establish a protocol with a 95% confidence interval (CI) for SSI prevention. Methods: Patients undergoing HoLEP/TUEB for benign prostate hyperplasia without preoperative pyuria will be enrolled and randomized to receive prophylactic antibiotic administration for HoLEP/TUEB in two groups, 1-day (single dose) cefazolin and 2-day cefazolin. The primary endpoint is the occurrence rate of postoperative urinary tract infection or urogenital infection within 30 days after HoLEP/TUEB with a statistical 95% CI in comparison between those groups. Secondary outcomes include the kind of infectious disease and evidence of diagnosis, day of diagnosis of infectious disease, performance of urine or blood culture, detection of bacteria, treatments, duration of treatments, AEs other than surgical site infection, and drug-induced AEs. Discussion: The results of this study will provide evidence for defining the optimal duration of cefazolin prophylactic antibiotic administration for SSI. Trial registration: This study was registered in the University Hospital Medical Information Network-Clinical Trial Registry ( UMIN000027955) based on recommendations from the International Committee of Medical Journal Editors (ICMJE) on July 1 st 2017.

Protocol for a comparison study of 1-day versus 2-day prophylactic antibiotic administration in Holmium Laser enucleation of the prostate (HoLEP): a randomized controlled trial

Background: The best method of antimicrobial prophylaxis administration for surgical site infection (SSI) in transurethral holmium laser resection and enucleation of the prostate (HoLEP)/bipolar transurethral enucleation (TUEB) remains controversial. The purpose of this study is to compare one-day and two-day cefazolin in a randomized 2 nd-phase study to help establish a protocol with a 95% confidence interval (CI) for SSI prevention. Methods: Patients undergoing HoLEP/TUEB for benign prostate hyperplasia without preoperative pyuria will be enrolled and randomized to receive prophylactic antibiotic administration for HoLEP/TUEB in two groups, 1-day cefazolin and 2-day cefazolin. The primary endpoint is the occurrence rate of postoperative urinary tract infection or urogenital infection within 30 days after HoLEP/TUEB with a statistical 95% CI in comparison between those groups. Secondary outcomes include the kind of infectious disease and evidence of diagnosis, day of diagnosis of infectious disease, performance of urine or blood culture, detection of bacteria, treatments, duration of treatments, AEs other than surgical site infection, and drug-induced AEs. Discussion: The results of this study will provide evidence for defining the optimal duration of cefazolin prophylactic antibiotic administration for SSI. Trial registration: This study was registered in the University Hospital Medical Information Network-Clinical Trial Registry ( UMIN000027955) based on recommendations from the International Committee of Medical Journal Editors (ICMJE) on July 1 st 2017.

Advances in optimizing the prescription of antibiotics in outpatient settings

The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

BACKGROUND

Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections.

AIMS

To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions.

METHODS

Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review.

RESULTS

Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education.

CONCLUSION

There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.

Interventions to reduce inappropriate prescribing of antibiotics for acute respiratory tract infections: summary and update of a systematic review

Objective

Antibiotic overuse contributes to antibiotic resistance and adverse consequences. Acute respiratory tract infections (RTIs) are the most common reason for antibiotic prescribing in primary care, but such infections often do not require antibiotics. We summarized and updated a previously performed systematic review of interventions to reduce inappropriate use of antibiotics for acute RTIs.

Methods

To update the review, we searched MEDLINE®, the Cochrane Library (until January 2018), and reference lists. Two reviewers selected the studies, extracted the study data, and assessed the quality and strength of evidence.

Results

Twenty-six interventions were evaluated in 95 mostly fair-quality studies. The following four interventions had moderate-strength evidence of improved/reduced antibiotic prescribing and low-strength evidence of no adverse consequences: parent education (21% reduction, no increase return visits), combined patient/clinician education (7% reduction, no change in complications/satisfaction), procalcitonin testing for adults with RTIs of the lower respiratory tract (12%–72% reduction, no increased adverse consequences), and electronic decision support systems (24%–47% improvement in appropriate prescribing, 5%–9% reduction, no increased complications).

Conclusions

The best evidence supports use of specific educational interventions, procalcitonin testing in adults, and electronic decision support to reduce inappropriate antibiotic prescribing for acute RTIs without causing adverse consequences.

Booklet for Childhood Fever in Out-of-Hours Primary Care: A Cluster-Randomized Controlled Trial

PURPOSE

Fever is the most common reason for a child to be taken to a physician, yet the level of unwarranted antibiotic prescribing remains high. We aimed to determine the effect on antibiotic prescribing of providing an illness-focused interactive booklet on fever in children to out-of-hours primary care clinicians.

METHODS

We conducted a cluster-randomized controlled trial in 20 out-of-hours general practice centers in the Netherlands. Children aged younger than 12 years with fever were included. Family physicians at the 10 intervention sites had access to an illness-focused interactive booklet between November 2015 and June 2016. The primary outcome was antibiotic prescribing during the index consultation. Analysis was performed by fitting 2-level random intercept logistic regression models.

RESULTS

The trial took place among 3,518 family physicians and 25,355 children. The booklet was used in 28.5% of 11,945 consultations in the intervention group. Compared with usual care, access to the booklet did not significantly alter antibiotic prescribing during the index consultation (odds ratio = 0.90; 95% CI, 0.79-1.02; prescription rate, 23.5% vs 25.2%; intracluster correlation coefficient = 0.005). In contrast, use of the booklet significantly reduced antibiotic prescribing (odds ratio = 0.83; 95% CI, 0.74-0.94; prescription rate, 21.9% vs 25.2%; intracluster correlation coefficient = 0.002). Children managed by family physicians with access to the booklet were less likely to receive any drug prescription, and parents in the booklet group showed a reduced intention to consult again for similar illnesses.

CONCLUSIONS

Benefit of an illness-focused interactive booklet in improving outcomes of childhood fever in out-of-hours primary care was largely restricted to the cases in which family physicians actually used the booklet. Insight into reasons for use and nonuse may inform future interventions of this type.

Parents' attitudes and views regarding antibiotics in the management of respiratory tract infections in children: a qualitative study of the influence of an information booklet

BACKGROUND

Respiratory tract infection (RTI) is the most common reason to consult a GP during childhood, and often results in unnecessary prescribing of antibiotics. Using an information booklet during the consultation has been shown to be a promising tool to reduce antibiotic prescribing. The influence of such information on parents' views, knowledge, and expectations has not been investigated yet.

AIM

To explore the reported attitude and knowledge of parents towards antibiotics and management of childhood RTI, as well as the added influence of an information booklet, as perceived by parents.

DESIGN & SETTING

Qualitative interviews were conducted with Dutch parents who consulted the GP with their child for RTI symptoms and received an information booklet.

METHOD

Semi-structured interviews were audio-recorded, transcribed, coded, and analysed using framework analysis by open-axial coding and describing themes.

RESULTS

Eighteen parents were interviewed. Four themes were identified: prior reticence towards antibiotics; expectations of the consultation and trust in the GPs' treatment decision; confirmation and reassurance by the booklet; self-management and future consultation intentions. Dutch parents felt reassured and more confident about their pre-existing reticent attitude towards antibiotic treatment; therefore, they thought their opinion and attitude had not really been changed by the booklet.

CONCLUSION

In a low-prescribing country like the Netherlands, information should focus on enhancing self-efficacy and providing concrete safety-netting advice. For other countries with less reticence towards antibiotics, it is recommended that the knowledge, attitude, and perceptions of the population is studied, in order to be able to tailor interventions.

Dyspnea in Children as a Symptom of Acute Respiratory Tract Infections and Antibiotic Prescribing

BACKGROUND:

Dyspnea is an unpleasant feeling of breathing difficulty, shortness of breath and inability to satisfy the hunger for air. The role of family physicians is to be prepared to recognise dyspnea as a symptom of acute respiratory infections (ARI), to perform triage and managing of children with acute dyspnea and make continuous education of parents. In the treatment of acute dyspnea more important is to treat dyspnea as a symptom than the prescribing of antibiotics (AB). Nowadays, even more often large amount of children, because of the noncompliance in the treatment and the pressure from the parents, unnecessary is hospitalised and frequently used antibiotics: According to the guidelines, a small percentage of children with ARI should be treated with AB. The rate of antibiotic prescription should be around 15-20% and lower.

AIM:

To assess doctor’s AB prescriptions in Primary care practices in Macedonia, for ARI and dyspnea in children we use the data from a National project about antibiotic prescribing for acute respiratory tract infections, which has been run in 2014 November as a part of E - quality program.

METHODS:

Eighty-six general practitioners from Macedonia have taken participation in it. The group of 3026 children, from 0-5 years of age, with symptoms of dyspnea, was analysed. We have found a rate of 54.6% antibiotic prescriptions (AB). From 3026 children with dyspnea, AB got 1519 children, 852 of which were prescribed by a specialist.

RESULTS:

The children were mostly diagnosed with upper ARI, in 57.7%. The most used AB is amoxicillin + clavulonic acid. We concluded that there was an increased and inappropriate prescribing of antibiotics in children with ARI, presented with dyspnea in Macedonia.

CONCLUSION:

Perceptions and the parent’s attitudes do not correlate with the severity of clinical picture of the disease in children and lack of use Evidence-based medicine (EBM), insecurity, fear, loss of patients effect on antibiotic prescribing of the doctors.

Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews

BACKGROUND

Antibiotic resistance is a worldwide health threat. Interventions that reduce antibiotic prescribing by clinicians are expected to reduce antibiotic resistance. Disparate interventions to change antibiotic prescribing behaviour for acute respiratory infections (ARIs) have been trialled and meta-analysed, but not yet synthesised in an overview. This overview synthesises evidence from systematic reviews, rather than individual trials.

OBJECTIVES

To systematically review the existing evidence from systematic reviews on the effects of interventions aimed at influencing clinician antibiotic prescribing behaviour for ARIs in primary care.

METHODS

We searched the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, CINAHL, PsycINFO, and Science Citation Index to June 2016. We also searched the reference lists of all included reviews. We ran a pre-publication search in May 2017 and placed additional studies in 'awaiting classification'.We included both Cochrane and non-Cochrane reviews of randomised controlled trials evaluating the effect of any clinician-focussed intervention on antibiotic prescribing behaviour in primary care. Two overview authors independently extracted data and assessed the methodological quality of included reviews using the ROBIS tool, with disagreements reached by consensus or by discussion with a third overview author. We used the GRADE system to assess the quality of evidence in included reviews. The results are presented as a narrative overview.

MAIN RESULTS

We included eight reviews in this overview: five Cochrane Reviews (33 included trials) and three non-Cochrane reviews (11 included trials). Three reviews (all Cochrane Reviews) scored low risk across all the ROBIS domains in Phase 2 and low risk of bias overall. The remaining five reviews scored high risk on Domain 4 of Phase 2 because the 'Risk of bias' assessment had not been specifically considered and discussed in the review Results and Conclusions. The trials included in the reviews varied in both size and risk of bias. Interventions were compared to usual care.Moderate-quality evidence indicated that C-reactive protein (CRP) point-of-care testing (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.66 to 0.92, 3284 participants, 6 trials), shared decision making (odds ratio (OR) 0.44, 95% CI 0.26 to 0.75, 3274 participants, 3 trials; RR 0.64, 95% CI 0.49 to 0.84, 4623 participants, 2 trials; risk difference -18.44, 95% CI -27.24 to -9.65, 481,807 participants, 4 trials), and procalcitonin-guided management (adjusted OR 0.10, 95% CI 0.07 to 0.14, 1008 participants, 2 trials) probably reduce antibiotic prescribing in general practice. We found moderate-quality evidence that procalcitonin-guided management probably reduces antibiotic prescribing in emergency departments (adjusted OR 0.34, 95% CI 0.28 to 0.43, 2605 participants, 7 trials). The overall effect of these interventions was small (few achieving greater than 50% reduction in antibiotic prescribing, most about a quarter or less), but likely to be clinically important.Compared to usual care, shared decision making probably makes little or no difference to reconsultation for the same illness (RR 0.87, 95% CI 0.74 to 1.03, 1860 participants, 4 trials, moderate-quality evidence), and may make little or no difference to patient satisfaction (RR 0.86, 95% CI 0.57 to 1.30, 1110 participants, 2 trials, low-quality evidence). Similarly, CRP testing probably has little or no effect on patient satisfaction (RR 0.79, 95% CI 0.57 to 1.08, 689 participants, 2 trials, moderate-quality evidence) or reconsultation (RR 1.08, 95% CI 0.93 to 1.27, 5132 participants, 4 trials, moderate-quality evidence). Procalcitonin-guided management probably results in little or no difference in treatment failure in general practice compared to normal care (adjusted OR 0.95, 95% CI 0.73 to 1.24, 1008 participants, 2 trials, moderate-quality evidence), however it probably reduces treatment failure in the emergency department compared to usual care (adjusted OR 0.76, 95% CI 0.61 to 0.95, 2605 participants, 7 trials, moderate-quality evidence).The quality of evidence for interventions focused on clinician educational materials and decision support in reducing antibiotic prescribing in general practice was either low or very low (no pooled result reported) and trial results were highly heterogeneous, therefore we were unable draw conclusions about the effects of these interventions. The use of rapid viral diagnostics in emergency departments may have little or no effect on antibiotic prescribing (RR 0.86, 95% CI 0.61 to 1.22, 891 participants, 3 trials, low-quality evidence) and may result in little to no difference in reconsultation (RR 0.86, 95% CI 0.59 to 1.25, 200 participants, 1 trial, low-quality evidence).None of the trials in the included reviews reported on management costs for the treatment of an ARI or any associated complications.

AUTHORS' CONCLUSIONS

We found evidence that CRP testing, shared decision making, and procalcitonin-guided management reduce antibiotic prescribing for patients with ARIs in primary care. These interventions may therefore reduce overall antibiotic consumption and consequently antibiotic resistance. There do not appear to be negative effects of these interventions on the outcomes of patient satisfaction and reconsultation, although there was limited measurement of these outcomes in the trials. This should be rectified in future trials.We could gather no information about the costs of management, and this along with the paucity of measurements meant that it was difficult to weigh the benefits and costs of implementing these interventions in practice.Most of this research was undertaken in high-income countries, and it may not generalise to other settings. The quality of evidence for the interventions of educational materials and tools for patients and clinicians was either low or very low, which prevented us from drawing any conclusions. High-quality trials are needed to further investigate these interventions.