Assessing the impact of national antibiotic campaigns in Europe

Assessment of global antimicrobial resistance campaigns conducted to improve public awareness and antimicrobial use behaviours: a rapid systematic review

INTRODUCTION

Public health campaigns with a well-defined outcome behaviour have been shown to successfully alter behaviour. However, the complex nature of antimicrobial resistance (AMR) creates challenges when evaluating campaigns aimed at raising awareness and changing behaviour.

AIMS

To determine what campaigns have been conducted and which reported being effective at improving awareness of antimicrobial resistance and changing behaviour around antimicrobial use in members of the public. It also sought to determine the outcome measures studies have used to assess campaign effectiveness.

METHODS

A systematic search of Ovid MEDLINE and Embase, was conducted in October 2022 using a predefined search strategy. Studies which were published between 2010 and September 2022 that outlined a campaign or invention aimed at the public and focusing on AMR or antibiotic usage were eligible for inclusion and studies which solely targeted healthcare professionals (HCP) were excluded.

RESULTS

Literature searches retrieved 6961 results. De-duplication and screening removed 6925 articles, five articles from grey literature and reference screening were included, giving a total of 41 studies and 30 unique interventions. There was a distribution of campaigns globally with the majority run in Europe (n = 15) with most campaigns were conducted nationally (n = 14). Campaigns tended to focus on adult members of the public (n = 14) or targeted resources towards both the public and HCPs (n = 13) and predominately assessed changes in knowledge of and/or attitudes towards AMR (n = 16). Campaigns where an improvement was seen in their primary outcome measure tended to use mass media to disseminate information, targeted messaging towards a specific infection, and including the use of HCP-patient interactions.

DISCUSSION

This review provides some evidence that campaigns can significantly improve outcome measures relating to AMR and antibiotic usage. Despite a lack of homogeneity between studies some common themes emerged between campaigns reported as being effective. However, the frequent use of observational study designs makes it difficult to establish causation between the campaign and changes seen in the studies outcome measures. It is important that clear evaluation processes are embedded as part of the design process for future campaigns; a campaign evaluation framework for use by campaign developers may facilitate this.

Public knowledge of antibiotics, self-medication, and household disposal practices in Jordan

BACKGROUND

This study aimed to assess public understanding of antibiotics, self-medication, and drug disposal practices.

METHODS

A cross-sectional self-administered online survey was undertaken in Jordan.

RESULTS

The study was completed by 1,105 participants. When asked about their knowledge of antibiotics, rational antibiotic use, and disposal practices, 16% percent believed they should discontinue antibiotics once they felt better, and 12% agreed to take the same antibiotics prescribed to others for the same illness. Self-medication with antibiotics was practiced by 44% of the participants. Prior experience, healthcare costs, and pharmacy location were all major determinants of self-medication. Only 6.4% of unneeded antibiotics were returned to the pharmacy, 60% were kept at home, and 26.6% were disposed of at home. Almost half of those who kept the antibiotics said they would use them again, and one-third said they would give them to friends and family. Respondents who had used antibiotics within the previous 6 months (p = 0.052) and relied on medication leaflets (p = 0.031) and physician recommendations (p = 0.001) were less likely to self-medicate with antibiotics.

CONCLUSIONS

The study highlighted areas of inappropriate use of antibiotics, self-medication and the improper antibiotic disposal that can inform antimicrobial stewardship.

The Association between Perceived Annoyances in the Indoor Home Environment and Respiratory Infections: A Danish Cohort Study with up to 19 Years of Follow-Up

The increasing prevalence of reported annoyances in the indoor environment threatens public health. This study aimed to investigate the association between perceived annoyances from the home environment and respiratory infections among individuals with and without asthma or chronic obstructive pulmonary disease (COPD). A total of 16,688 individuals from the Danish Health and Morbidity Survey initiated in 2000 were grouped according to their patterns of perceived annoyances. Information on respiratory infections (all causes, bacterial, viral, and those leading to hospital admissions) was obtained from Danish registers up to 19 years after the survey. Poisson regression of incidence rates (IRs) was applied to estimate incidence rate ratios (IRRs). Annoyances significantly increased the IR for respiratory infections of all causes and bacterial respiratory infections in individuals without asthma or COPD, adjusted IRR 1.16 (95% CI: 1.01, 1.34) and 1.15 (95% CI: 1.02, 1.31), respectively. However, no difference was observed for viral respiratory infections nor hospital admissions. Individuals with asthma or COPD and a high level of annoyances had a non-significantly increased IR in all four analyses of respiratory infections. These findings provide support for perceived annoyances as an important risk factor for respiratory infections.

Community drug retail outlet staff's knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns

INTRODUCTION

Some evidence suggests that knowledge and attitudes towards rational antibiotic use influences dispensing practice in community drug retail outlets. However, there is limited evidence in resource limited countries, including Ethiopia. We aimed to assess the knowledge and attitudes surrounding antibiotic use or supply and antibiotic resistance, and the non-prescribed antibiotic dispensing practices in community drug retail outlets in non-urban Ethiopia.

METHODS

We conducted a cross-sectional survey of community drug retail outlet staff in the Amhara region, Ethiopia with a focus on non-urban towns. An expert validated self-administered questionnaire was used. Following exploratory factor analysis and best items selection, we summarised our findings and assessed factors associated with non-prescribed antibiotic dispensing. The data were analysed using Stata Statistical Software version 17. P-values < 0.05 were considered significant.

RESULTS

A total of 276 participants from 270 drug outlets completed the questionnaire. The participants median age was 30 (Interquartile range (IQR) = 25-35) years and 79.7% were pharmacy assistants. The majority demonstrated good levels of knowledge about antibiotic use or supply and antibiotic resistance (77.9% and 76% of the participants responded correctly to more than half of the items, respectively). We identified four attitude domains: the role of antibiotics in recovering from diseases regardless of their cause (median score = 2 (IQR = 2-4), beliefs inconsistent with good practice); professional competency to supply non-prescribed antibiotics, and the non-prescribed antibiotics supply (median score for each domain = 4 (IQR = 4-5), attitudes consistent with good practice); and positive attitudes towards actions to prevent antibiotic resistance and promote appropriate antibiotic use (median score = 4 (IQR = 4-5). Fifty eight percent of the participants reported that they had dispensed antibiotics without a prescription. Participants who did not perceive that they were competent to supply non-prescribed antibiotics (adjusted odds ratio = 0.86, 95% confidence interval = 0.78-0.93) were less likely to report non-prescribed antibiotics dispensing.

CONCLUSION

While most of the participants had appropriate knowledge about and attitudes to antibiotic use and antibiotic resistance, basic knowledge and attitude gaps remain. Despite Ethiopia's regulatory restrictions, the non-prescribed antibiotic provision continues to be a common practice. Our study highlights the need for multifaceted interventions that may include a strict regulatory system, staff training and public education.

No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies

BACKGROUND

Non-prescription dispensing of antibiotics, one of the main sources of antibiotic misuse or over use, is a global challenge with detrimental public health consequences including acceleration of the development of antimicrobial resistance, and is facilitated by various intrinsic and extrinsic drivers. The current review aimed to systematically summarise and synthesise the qualitative literature regarding drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries.

METHODS

Four electronic databases (PubMed, CINAHL, Scopus and Google Scholar) and reference lists of the relevant articles were searched. The Joanna Briggs Institute's Critical Appraisal Checklist for qualitative studies was used to assess the quality of included studies. The enhancing transparency in reporting the synthesis of qualitative research statement was used to guide reporting of results. Data were coded using NVivo 12 software and analysed using both inductive and deductive thematic analysis.

RESULTS

A total of 23 articles underwent full text review and 12 of these met the inclusion criteria. Four main themes were identified in relation to facilitators of non-prescribed sale of antibiotics among community drug retail outlets: i) the business orientation of community drug retail outlets and tension between professionalism and commercialism; ii) customers' demand pressure and expectation; iii); absence of or a lax enforcement of regulations; and iv) community drug retail outlet staff's lack of knowledge and poor attitudes about antibiotics use and scope of practice regarding provision.

CONCLUSIONS

This review identified several potentially amendable reasons in relation to over the counter dispensing of antibiotics. To contain the rise of antibiotic misuse or over use by targeting the primary drivers, this review suggests the need for strict law enforcement or enacting new strong regulation to control antibiotic dispensing, continuous and overarching refresher training for community drug retail outlet staff about antibiotic stewardship, and holding public awareness campaigns regarding rational antibiotic use.

Prevalence and Characterization of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae in Major Hospitals in Gabon

In Gabon, few data exist on extended-spectrum beta-lactamases-producing Enterobacteriaceae (ESBL-PE). This study investigated ESBL-PE prevalence and the associated resistance genes in clinical samples (n = 5,956) and anal swabs (n = 78) analyzed in eight hospitals and a medical analysis laboratory in Gabon from January 2016 to March 2018. Matrix-Assisted Laser Desorption Ionization-Time Of Flight (MALDI-TOF) mass spectrometry analysis identified 790 Enterobacteriaceae isolates (n = 712 clinical samples and n = 78 fecal samples). ESBL-PE prevalence (Müller-Hinton agar disk diffusion method and double-disk synergy test) was 11.8% (84/712) in clinical samples (15.5% from inpatients and 7.1% from outpatients; p < 0.05) and 16.7% (13/78) in carriage isolates. Most ESBL-PE were isolated from urine samples (46/84). In clinical and carriage ESBL-PE isolates, Escherichia coli was predominant (42.8% and 61.5%; phylogroups A, B1, B2, and D), followed by Klebsiella pneumoniae (41.7% and 23.1%). Multiplex PCR and bi-directional sequencing showed that CTX-M group 1 (blaCTX-M-15) was predominant in clinical and carriage ESBL-PE (94% and 92.3%) among which 85.7% and 92.3% also harbored one to three β-lactamase-encoding genes (blaTEM-1, blaOXA-1, or blaSHV-1). Resistance genes were detected in all hospitals in Gabon. ESBL-PE prevalence in Gabon has not reached alarming levels yet, but corrective and monitoring measures are needed to curb their emergence.

Non-prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African countries: a systematic review and meta-analysis

BACKGROUND

The development of antimicrobial resistance, which is partially attributable to the overuse and/or misuse of antibiotics in health care, is one of the greatest global public health challenges. In Sub-Saharan African (SSA) countries, non-prescribed dispensing of antibiotics in community drug retail outlets (CDROs) has been flagged as one of the contributing factors for the widespread misuse of antibiotics in the community.

OBJECTIVE

The current review aimed to estimate the proportion of non-prescription antibiotics requests or consultations that resulted in provision of antibiotics without a valid prescription among CDROs in SSA region, and describe the type of antibiotics dispensed.

METHODS

A literature search was conducted using PubMed, CINAHL, Scopus and Google Scholar. We also searched reference lists of relevant articles. Random effect model meta-analysis was employed to determine the pooled proportion of over the counter sale of antibiotics. Subgroup and meta-regression was undertaken to explore the potential cause of heterogeneity in effect size across studies.

RESULTS

Of 671 total citations retrieved, 23 met the inclusion criteria (seven cross-sectional questionnaire-based surveys and 16 cross-sectional client-based studies). The overall pooled proportion of non-prescription antibiotics requests or consultations that resulted in supply of antibiotics without prescription was 69% (95% CI 58-80). Upper respiratory tract infections and/or acute diarrhoea were the most frequently presented case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed antibiotics to treat those symptoms.

CONCLUSIONS

Non-prescribed dispensing of antibiotics was found to be a common practice among CDROs in several SSA countries. Ease of access to and overuse of antibiotics can potentially accelerate the emergence of resistance to antibiotics available in the region. Our review highlights the need for a stringent enforcement of existing policies and/or enacting new regulatory frameworks that would regulate antibiotic supply, and training and educational support for pharmacy personnel (e.g. pharmacists, pharmacy assistants) regarding judicious use of antibiotics and the importance of antimicrobial stewardship.

Inadequate knowledge on appropriate antibiotics use among clients in the Moshi municipality Northern Tanzania

BACKGROUND

Poor knowledge concerning appropriate antibiotic use significantly influences the misuse of antibiotics within the community, especially in developing countries where there are weaker health systems to regulate antibiotic dispensing. Antibiotic misuse leads to antibiotic resistance. This study assessed knowledge of appropriate antibiotic use among buyers in the Moshi municipality, Northern Tanzania.

METHODS

We conducted a cross-sectional study in Moshi municipality between April and May 2017. Adults who bought antibiotics at drug outlets were invited to participate in the study. An exit interview was conducted with participants to collect their demographics and assess their knowledge concerning appropriate use of antibiotics. A logistic regression model was performed to determine factors associated with correct knowledge concerning antibiotic use.

RESULTS

A total of 152 adults with a median age of 30.5 (IQR 25-42) years, were enrolled in the study. Slightly over half (n = 89, 58.6%), responded that they should stop antibiotics after finishing the dose as directed. Half (n = 77, 50.7%) thought that it was acceptable to share antibiotics with other individuals and over half of respondents (n = 95, 65.1%) thought that they should request the same antibiotics if they had used them to treat a similar illness in the past. Only 38 (25%) had adequate knowledge about the use of antibiotics. Sore throat and flu were respectively identified by 62.5% and 46.1% of respondents as conditions that can be treated with antibiotics. Higher levels of education (aOR = 4.11 95%CI = 1.44-11.71) and having health insurance (aOR = 9.05 95%CI = 3.35-24.45) were associated with better levels of knowledge concerning antibiotic use in various illnesses.

CONCLUSION

There is inadequate knowledge concerning the indications for antibiotics and their appropriate usage. Health promotion campaigns are needed to educate the population about appropriate antibiotic use and reduce their irrational use.

Spatial patterns and social-economic influential factors of population aging: A global assessment from 1990 to 2010

The world's population is aging rapidly. In this paper, three population aging indicators were collected to represent the elderly population, the oldest-old population, and centenarians. The spatial patterns of three population aging indicators and the influencing social-economic factors and their spatial spillover effects in the world from 1990 to 2010 were investigated. The empirical strategy was based on application of spatial autocorrelation methods and spatial error modeling. The results revealed the significant positive spatial autocorrelation as well as the obvious spatial disparities and clusters of the aging indicators in the world. Furthermore, spatial spillover effects of population aging indicators were detected with positive influence of several social-economic factors (e.g., per capita GNI, urbanization rate, and life expectancy) not only of population aging in a country itself, but in its neighboring counties. In sum, these findings indicated that population aging are a spatio-temporal process, and the spatial spillover effects from neighbors also vary among these indicators, which should be considered into the differentiated policies in response to the challenge of an aging society.

A governance framework for development and assessment of national action plans on antimicrobial resistance

Strengthening governance is an essential strategy to tackling antimicrobial resistance (AMR) at all levels: global, national, regional, and local. To date, no systematic approach to governance of national action plans on AMR exists. To address this issue, we aimed to develop the first governance framework to offer guidance for both the development and assessment of national action plans on AMR. We reviewed health system governance framework reviews to inform the basic structure of our framework, international guidance documents from WHO, the Food and Agriculture Organization, the World Organisation for Animal Health, and the European Commission, and sought the input of 25 experts from international organisations, government ministries, policy institutes, and academic institutions to develop and refine our framework. The framework consists of 18 domains with 52 indicators that are contained within three governance areas: policy design, implementation tools, and monitoring and evaluation. To consider the dynamic nature of AMR, the framework is conceptualised as a cyclical process, which is responsive to the context and allows for continuous improvement and adaptation of national action plans on AMR.

Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries

Introduction: Inappropriate prescription practices, patient and provider knowledge and attitudes, variable availability of diagnostic and surveillance systems, and the unrestricted use of antimicrobials in animals and plants are contributory factors to the global crisis of antimicrobial resistance (AMR). Areas covered: Notwithstanding that interventions to revert AMR should be tailored to the socio-politico-economic landscape, there is a global consensus for the implementation and enhancement of antimicrobial stewardship strategies. Yet the implementation of Antimicrobial Stewardship Programs (ASPs) remains relatively limited within healthcare settings and faces complex challenges in resource-limited countries. The current review summarizes the limitations of current ASPs, translation challenges in resource-limited countries, and potential solutions. Expert opinion: Suboptimal ASP implementation in hospitals is multifactorial. Restriction of antimicrobial use should be informed by risk-benefit analyses, including the potential for substitute prescribing, and displacement of selection pressures. Thresholds in population use of antibiotics above which AMR increases may provide quantitative targets for ASPs. Horizontal and vertical collaborations involving policymakers and the general public are of paramount importance. While impactful prescribing changes require sustained engagement of the public and health-care professionals, we warn against over-estimating the benefits of behavioral interventions. We advocate for population-level stewardship interventions in addition to investment in structural factors that will aid ASP implementation.

Articulating citizen participation in national anti-microbial resistance plans: a comparison of European countries

Background

National action plans determine country responses to anti-microbial resistance (AMR). These plans include interventions aimed at citizens. As the language used in documents could persuade certain behaviours, we sought to assess the positioning and implied responsibilities of citizens in current European AMR plans. This understanding could lead to improved policies and interventions.

Methods

Review and comparison of national action plans for AMR (NAP-AMR) obtained from the European Centre for Disease Prevention and Control (plans from 28 European Union and four European Economic Area/European Free Trade Association countries), supplemented by European experts (June-September 2016). To capture geographical diversity, 11 countries were purposively sampled for content and discourse analyses using frameworks of lay participation in healthcare organization, delivery and decision-making.

Results

Countries were at different stages of NAP-AMR development (60% completed, 25% in-process, 9% no plan). The volume allocated to citizen roles in the plans ranged from 0.3 to 18%. The term 'citizen' was used by three countries, trailing behind 'patients' and 'public' (9/11), 'general population' (6/11) and 'consumers' (6/11). Increased citizen awareness about AMR was pursued by ∼2/3 plans. Supporting interventions included awareness campaigns (11/11), training/education (7/11) or materials during clinical encounters (4/11). Prevention of infection transmission or self-care behaviours were much less emphasized. Personal/individual and social/collective role perspectives seemed more frequently stimulated in Nordic countries.

Conclusion

Citizen roles in AMR plans are not fully articulated. Documents could employ direct language to emphasise social or collective responsibilities in optimal antibiotic use.

How to improve antibiotic awareness campaigns: findings of a WHO global survey

INTRODUCTION

We aimed to examine the characteristics of antibiotic awareness campaigns (AAC) conducted on a national or regional level since 2010.

METHODS

In October 2016, the WHO invited stakeholders involved in the planning or conduct of AACs to answer a web questionnaire. We solicited general information about the characteristics of the AAC, with a particular focus on key messages supporting optimal use of antibiotics.

RESULTS

Stakeholders in 93 countries were contacted and 55 countries responded. Overall, 60 AACs from 16 low/middle-income countries (LMIC) and 31 high-income countries were identified. Forty-five campaigns (75%) were conducted on a national level and most of them (47/60; 78%) were organised by public health authorities and publicly funded. There were no major differences between LMICs and high-income countries in the types of key messages. The scientifically questionable 'Finish your prescription' slogan was used by 31 AACs (52%). A One Health approach was mentioned in 13/60 AACs (22%). Most messages were universally applicable; adaptation to locally prevalent public misconceptions was not systematic. The evaluation of the impact of campaigns was still incomplete, as only 18 AACs (30%) assessed their impact on antibiotic use.

CONCLUSION

For future AACs, it seems essential to base messages more rigorously on scientific evidence, context specificities and behavioural change theory. A new generation of messages that encourage first-choice use of narrow spectrum antibiotics is needed, reflecting international efforts to preserve broad spectrum antibiotic classes. Evaluation of the impact of AACs remains suboptimal.

The challenge of antimicrobial resistance: What economics can contribute

As antibiotic consumption grows, bacteria are becoming increasingly resistant to treatment. Antibiotic resistance undermines much of modern health care, which relies on access to effective antibiotics to prevent and treat infections associated with routine medical procedures. The resulting challenges have much in common with those posed by climate change, which economists have responded to with research that has informed and shaped public policy. Drawing on economic concepts such as externalities and the principal–agent relationship, we suggest how economics can help to solve the challenges arising from increasing resistance to antibiotics. We discuss solutions to the key economic issues, from incentivizing the development of effective new antibiotics to improving antibiotic stewardship through financial mechanisms and regulation.

Pain management in acute otitis media: a qualitative study of parents' views and expectations

BACKGROUND

For unclarified reasons, parents tend to be cautious about administering analgesics to their children, potentially leading to suboptimal management of AOM symptoms. We aim to understand parents' views and expectations of pain management in acute otitis media (AOM) in children.

METHODS

Qualitative study alongside a cluster-randomised controlled trial (PIM-POM study) aimed at optimising pain management in childhood AOM. We purposefully sampled 14 parents of children diagnosed with AOM by their GP, who were recruited to the trial between November 2017 and May 2018. Semi-structured interviews were held at home in the first two weeks after trial enrollment. Interviews were audio-recorded, transcribed and analyzed thematically.

RESULTS

Parents experienced difficulties in recognising earache and other symptoms of an ear infection. They consulted the GP for a diagnosis, for reassurance and for management advice. Parents shared that, prior to consultation, they had insufficient knowledge of the benefits of correctly dosed pain medication at regularly scheduled intervals. Parents valued the GP's advice on pain management, and were happy to accept pain medication as standalone therapy, provided that the GP explained why antibiotics would not be needed. Parents' views and expectations of pain management in AOM were shaped by previous experiences of AOM within their family; those with a positive experience of pain medication are more likely to use it in subsequent AOM episodes.

CONCLUSIONS

Parents of children with AOM consult the GP to help cope with uncertainties in recognising symptoms of AOM, and to receive management advice. It is important that GPs are aware of parents' lack of understanding of the role of pain medication in managing AOM, and that they address this during the consultation.

TRIAL REGISTRATION

Netherlands Trial Register, identifier NTR4920 (registration date: 19 December 2014).

Analysis of citizens' subjective perception of safe antibiotic use in European Union countries

OBJECTIVES

Antibiotic consumption is high and varies between different European Union countries. One of the reasons could be different subjective perception of safe antibiotic use. The aim of our study was to analyse citizens' subjective perception of safe antibiotic use in the European Union countries in the context of different antibiotic policies. Some countries are prepared comprehensive national strategies and action plans and implement many activities in different areas while other countries implement actions only in particular fields and even do not have prepared strategy or action plan.

METHODS

This article is based on conception of security by Barry Buzan. Variables collected from the Special Eurobarometer public opinion on Antimicrobial Resistance in European Union countries in 2016 were used for creation the factor of subjective perception of safe antibiotic use. Six contextual factors were selected from the scientific literature and their impact on subjective perception of safe antibiotic use was investigated.

RESULTS

High differences in subjective perception of safe antibiotic use were observed in countries despite general European Union recommendations on antibiotic policy. The highest subjective perception of safe antibiotic use was in Netherlands, Finland, Sweden, Luxembourg, and Denmark. Significant negative correlation was observed between factor of subjective perception of safe antibiotic use and antibiotic consumption (r=-0.41, p<0.05). Created factor of information and communication technology (ICT) development, gross domestic product (GDP) and health expenditure had impact on subjective perception of safe antibiotic use (t=4.69, p<0.01). Consumption of antibiotics also had influence on subjective perception of safe antibiotic use (t=-2.43, p<0.05).

CONCLUSIONS

Individuals' subjective perception of safe antibiotic use which is related to antibiotic consumption highly varies between different EU countries despite general EU recommendations on antibiotic policies and depends on ICT development, GDP, health expenditure and consumption of antibiotics.

Variation in antibiotic use among and within different settings: a systematic review

Objectives

Variation in antibiotic use may reflect inappropriate use. We aimed to systematically describe the variation in measures for antibiotic use among settings or providers. This study was conducted as part of the innovative medicines initiative (IMI)-funded international project DRIVE-AB.

Methods

We searched for studies published in MEDLINE from January 2004 to January 2015 reporting variation in measures for systemic antibiotic use (e.g. DDDs) in inpatient and outpatient settings. The ratio between a study's reported maximum and minimum values of a given measure [maximum:minimum ratio (MMR)] was calculated as a measure of variation. Similar measures were grouped into categories and when possible the overall median ratio and IQR were calculated.

Results

One hundred and forty-three studies were included, of which 85 (59.4%) were conducted in Europe and 12 (8.4%) in low- to middle-income countries. Most studies described the variation in the quantity of antibiotic use in the inpatient setting (81/143, 56.6%), especially among hospitals (41/81, 50.6%). The most frequent measure was DDDs with different denominators, reported in 23/81 (28.4%) inpatient studies and in 28/62 (45.2%) outpatient studies. For this measure, we found a median MMR of 3.7 (IQR 2.6-5.0) in 4 studies reporting antibiotic use in ICUs in DDDs/1000 patient-days and a median MMR of 2.3 (IQR 1.5-3.2) in 18 studies reporting outpatient antibiotic use in DDDs/1000 inhabitant-days. Substantial variation was also identified in other measures.

Conclusions

Our review confirms the large variation in antibiotic use even across similar settings and providers. Data from low- and middle-income countries are under-represented. Further studies should try to better elucidate reasons for the observed variation to facilitate interventions that reduce unwarranted practice variation. In addition, the heterogeneity of reported measures clearly shows that there is need for standardization.

Systematic review of public-targeted communication interventions to improve antibiotic use

Background

Excessive use of antibiotics accelerates the acquisition/spread of antimicrobial resistance. A systematic review was conducted to identify the components of successful communication interventions targeted at the general public to improve antibiotic use.

Methods

The databases MEDLINE, EMBASE, CINAHL, Web of Science and Cochrane Library were searched. Search terms were related to the population (public, community), intervention (campaign, mass media) and outcomes (antibiotic, antimicrobial resistance). References were screened for inclusion by one author with a random subset of 10% screened by a second author. No date restrictions were applied and only articles in the English language were considered. Studies had to have a control group or be an interrupted time-series. Outcomes had to measure change in antibiotic-related prescribing/consumption and/or the public's knowledge, attitudes or behaviour. Two reviewers assessed the quality of studies. Narrative synthesis was performed.

Results

Fourteen studies were included with an estimated 74-75 million participants. Most studies were conducted in the United States or Europe and targeted both the general public and clinicians. Twelve of the studies measured changes in antibiotic prescribing. There was quite strong ( P  < 0·05 to ≥ 0·01) to very strong ( P  < 0·001) evidence that interventions that targeted prescribing for RTIs were associated with decreases in antibiotic prescribing; the majority of these studies reported reductions of greater than -14% with the largest effect size reaching -30%.

Conclusion

Multi-faceted communication interventions that target both the general public and clinicians can reduce antibiotic prescribing in high-income countries but the sustainability of reductions in antibiotic prescribing is unclear.

The correlation between regulatory conditions and antibiotic consumption within the WHO European Region

BACKGROUND

In a global perspective, bacterial infections are still a major cause of morbidity and mortality; therefore, effective antibiotics are needed. However, the emergence of antibiotic resistance due to irrational use has now become a serious public health problem. Hence, the objective of this study was to analyse the association of regulatory aspects with antibiotic consumption.

METHODS

A data set representing 20 countries throughout the WHO European Region was chosen based on data availability so as to analyse the correlation between specific regulatory conditions and antibiotic consumption, using total consumption data for 2011 and information about national provisions regarding rational use of medicines. Linear regression models were designed in order to evaluate individual aspects as well as the overall level of regulation.

RESULTS

A high level of regulation, assessed by an overall index, was significantly correlated with lower antibiotic consumption; however, of all individual items analysed, only the presence of Standard Treatment Guidelines for hospital care as well as paediatric conditions, the non-availability of antibiotics without a prescription, and the existence of training modules for pharmacists covering rational use of medicines gave significant results, i.e. lower use of antibiotics, when regarded in isolation.

CONCLUSION

Although national regulatory conditions intended to foster rational use of antibiotics seem to be correlated with antibiotic consumption, this association is potentially influenced by a wide range of contextual aspects.

Systematic Review of Factors Associated with Antibiotic Prescribing for Respiratory Tract Infections

Antibiotic use is a modifiable driver of antibiotic resistance. In many circumstances, antibiotic use is overly broad or unnecessary. We systematically assessed factors associated with antibiotic prescribing for respiratory tract infections (RTI). Studies were included if they used actual (not self-reported or intended) prescribing data, assessed factors associated with antibiotic prescribing for RTIs, and performed multivariable analysis of associations. We searched Medline, Embase, and International Pharmaceutical Abstracts using keyword and MeSH (medical subject headings) search terms. Two authors reviewed each abstract and independently appraised all included texts. Data on factors affecting antibiotic prescribing were extracted. Our searches retrieved a total of 2,848 abstracts, with 97 included in full-text review and 28 meeting full inclusion criteria. Compared to other factors, diagnosis of acute bronchitis was associated with increased antibiotic prescribing (range of adjusted odds ratios [aOR], 1.56 to 15.9). Features on physical exam, such as fever, purulent sputum, abnormal respiratory exam, and tonsillar exudate, were also associated with higher odds of antibiotic prescribing. Patient desire for an antibiotic was not associated or was modestly associated with prescription (range of aORs, 0.61 to 9.87), in contrast to physician perception of patient desire for antibiotics, which showed a stronger association (range of aORs, 2.11 to 23.3). Physician's perception of patient desire for antibiotics was strongly associated with antibiotic prescribing. Antimicrobial stewardship programs should continue to expand in the outpatient setting and should emphasize clear and direct communication between patients and physicians, as well as signs and symptoms that do and do not predict bacterial etiology of upper respiratory tract infections.

Antibiotic prescribing in Danish general practice 2004-13

OBJECTIVES

Antibiotic consumption in the primary care sector is often perceived as synonymous with consumption in general practice despite the fact that few countries stratify the primary care sector by providers' medical specialty. We aimed to characterize and quantify antibiotic use in Danish general practice relative to the entire primary care sector.

METHODS

This was a registry-based study including all patients who redeemed an antibiotic prescription between July 2004 and June 2013 at a Danish community pharmacy. Antibiotic use was expressed as DDDs and treatments/1000 inhabitants/day (DIDs and TIDs, respectively) and assessed according to antibiotic spectrum (narrow versus broad) and their anatomical therapeutic classification codes in total as well as in six age groups.

RESULTS

The contribution of general practice to the entire antibiotic use in the primary care sector declined during the study period (TIDs, 79%-75%; DIDs, 77%-73%). Antibiotic use in general practice increased 8% when expressed as DIDs, while a 9% decrease was observed when expressed as TIDs. The use of broad-spectrum agents increased while narrow-spectrum agents decreased. The decline in antibiotic use was most prominent in children aged <5 years, while elderly patients were increasingly prescribed antibiotics.

CONCLUSIONS

Using the entire primary care sector as a proxy for general practice prescribing is imprecise. Antibiotic use in general practice is at a stable high level, but DID and TID analyses show different trends and both should be applied when detailing changes in antibiotic consumption. While children are prescribed fewer narrow-spectrum agents, the observed increase in the use of broad-spectrum agents is worrisome and should be addressed in future interventions.

Tackling the threat of antimicrobial resistance: from policy to sustainable action

Antibiotics underpin all of modern medicine, from routine major surgery through to caesarean sections and modern cancer therapies. These drugs have revolutionized how we practice medicine, but we are in a constant evolutionary battle to evade microbial resistance and this has become a major global public health problem. We have overused and misused these essential medicines both in the human and animal health sectors and this threatens the effectiveness of antimicrobials for future generations. We can only address the threat of antimicrobial resistance (AMR) through international collaboration across human and animal health sectors integrating social, economic and behavioural factors. Our global organizations are rising to the challenge with the recent World Health Assembly resolution on AMR and development of the Global Action plan but we must act now to avoid a return to a pre-antibiotic era.

Antimicrobial resistance: one world, one fight!

The lack of new antibiotic classes calls for a cautious use of existing agents. Yet, every 10 min, almost two tons of antibiotics are used around the world, all too often without any prescription or control. The use, overuse and misuse of antibiotics select for resistance in numerous species of bacteria which then renders antimicrobial treatment ineffective. Almost all countries face increased antimicrobial resistance (AMR), not only in humans but also in livestock and along the food chain. The spread of AMR is fueled by growing human and animal populations, uncontrolled contamination of fresh water supplies, and increases in international travel, migration and trade. In this context of global concern, 68 international experts attending the fifth edition of the World HAI Resistance Forum in June 2015 shared their successes and failures in the global fight against AMR. They underlined the need for a “One Health” approach requiring research, surveillance, and interventions across human, veterinary, agricultural and environmental sectors. This strategy involves concerted actions on several fronts. Improved education and increased public awareness are a well-understood priority. Surveillance systems monitoring infections need to be expanded to include antimicrobial use, as well as the emergence and spread of AMR within clinical and environmental samples. Adherence to practices to prevent and control the spread of infections is mandatory to reduce the requirement of antimicrobials in general care and agriculture. Antibiotics need to be banned as growth promoters for farm animals in countries where it has not yet been done. Antimicrobial stewardship programmes in animal husbandry have proved to be efficient for minimising AMR, without compromising productivity. Regarding the use of antibiotics in humans, new tools to provide highly specific diagnoses of pathogens can decrease diagnostic uncertainty and improve clinical management. Finally, infection prevention and control measures – some of them as simple as hand hygiene – are essential and should be extended beyond healthcare settings. Aside from regulatory actions, all people can assist in AMR reduction by limiting antibiotic use for minor illnesses. Together, we can all work to reduce the burden of AMR.

The long-term effects of restrictive interventions on consumption and costs of antibiotics

In the last decade, Slovenia introduced restrictive measures for some antibiotic classes in ambulatory care as well as regulatory interventions to reduce costs. The aim of this study was to analyse the effects of these interventions on consumption and costs of antibiotics in ambulatory care. Consumption data were expressed in defined daily doses/1000 inhabitants per day (DID), number of packages/1000 inhabitants per day and number of prescriptions/1000 inhabitants per year. In 2000, Slovenia introduced restrictive measures for prescription of amoxicillin/clavulanic acid (AMC) and fluoroquinolones, in 2005 for oral third-generation cephalosporins and in 2009 for macrolides. Segmented regression analysis of interrupted time series was used to estimate the effects of restrictive interventions on antibiotic consumption. Total outpatient consumption of antibacterial drugs decreased by 29.65% from 20.27 DID in 1999 to 14.26 DID in 2012. Three years after the introduction of restrictions, consumption of AMC, fluoroquinolones and macrolides decreased by 29.3%, 23.8% and 28.8%, respectively, compared with the year before the intervention, and of non-restricted antibiotics by 3.3% (in 2003). Twelve years after the introduction of restrictive interventions, use of AMC and fluoroquinolones decreased by 28.1% and 28.5%, respectively, and use of non-restricted antibiotics by 18.8% (in 2012). In the same time period, the costs of AMC and fluoroquinolones were reduced by 63.3% and 52.4%, respectively, and of non-restricted antibiotics by 46.9%. Restrictive interventions in ambulatory care are effective in reducing antibiotic consumption and costs. Restrictive interventions had a significantly greater impact on consumption 3 years post-intervention than after 12 years.

Success stories of implementation of antimicrobial stewardship: a narrative review

It has been increasingly recognized that antimicrobial stewardship (AMS) has to be a key component of any efforts that aim to mitigate the current global antimicrobial resistance (AMR) crisis. It has also become evident that AMR is a problem that cannot be tackled by single institutions or physicians, but needs concerted actions at regional, national and supra-national levels. However, it is easy to become discouraged, given the problems that are often encountered when implementing AMS. The aim of this review is to highlight some of the success stories of AMS strategies, and to describe the actions that have been taken, the outcomes that have been obtained, and the obstacles that have been met. Although the best approach to effective AMS remains elusive and may vary significantly among settings, these diverse examples from a range of healthcare contexts demonstrate that effective AMS is possible. Such examples will inform others and encourage them to formally evaluate and share their results with the global stewardship community.

The risk/benefit of predicting a post-antibiotic era: is the alarm working?

There have been concerns about antimicrobial resistance since the first widespread use of antibiotics in humans. More recently, this concern has grown and become the focus of clinical, scientific, and political activity. In part, the political interest is a consequence of publicizing a bleak picture of a post-antibiotic world. There are, however, dangers in using a discourse of fear. In this article, we discuss whether the evidence base is available to justify such claims and, more importantly, put this in the policy context with which it is used. Many governments now use a risk assessment approach to identify security concerns, based on reasonable worst-case scenarios. There is no doubt that for effective policy-based action to occur, antimicrobial resistance needs to be seen as a national and international security priority, particularly as the major cost of inaction will mostly be felt in the future. We conclude that presenting the evidence in a manner that is used to encourage prioritization of security policy is not only justified, it is essential to drive action in this area.

Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial

OBJECTIVES

To test the hypothesis that a multifaceted, local public campaign could be feasible and influence antibiotic prescribing for outpatients.

DESIGN

Community level, controlled, non-randomised trial.

SETTING

Provinces of Modena and Parma in Emilia-Romagna, northern Italy, November 2011 to February 2012.

POPULATION

1,150,000 residents of Modena and Parma (intervention group) and 3,250,000 residents in provinces in the same region but where no campaign had been implemented (control group).

INTERVENTIONS

Campaign materials (mainly posters, brochures, and advertisements on local media, plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists). General practitioners and paediatricians in the intervention area participated in designing the campaign messages.

MAIN OUTCOMES MEASURES

Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months, measured as defined daily doses per 1000 inhabitants/day, using health districts as the unit of analysis.

RESULTS

Antibiotic prescribing was reduced in the intervention area compared with control area (-4.3%, 95% confidence interval -7.1% to -1.5%). This result was robust to "sensitivity analysis" modifying the baseline period from two months (main analysis) to one month. A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase, consistent with the content of the newsletter on antibiotic resistance directed at health professionals. The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period (main analysis), but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis. Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas.

CONCLUSIONS

A local low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population's knowledge and attitudes about antibiotic resistance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01604096.