European survey on principles of prudent antibiotic prescribing teaching in undergraduate students

Exploring Knowledge, Attitudes, and Behaviors Toward Antibiotics Use Among Adolescents in Southern Italy

BACKGROUND

This study explored knowledge, attitudes, and behaviors regarding antibiotics among adolescents.

METHODS

The cross-sectional study was conducted from February to April 2024.

RESULTS

Overall, 65.2% of adolescents believed that antibiotics should only be used when prescribed, this was more likely among women and those who needed additional information regarding antibiotics. Women and adolescents without a parent with a chronic disease, who believed that it is not possible to stop antibiotics when symptoms improve and who disagreed that antibiotics are faster treatment for flu were more likely to prefer prescribed antibiotics. Antibiotic use without a medical prescription was reported by 37.4% of participants, and this was more likely among men and adolescents who had a parent with a chronic disease, who needed additional information regarding antibiotics, and who disagreed that antibiotics should only be used when prescribed. Adolescents who are afraid that antimicrobial resistance (AMR) may affect their health, who received previous information about AMR, who know that antibiotics are not useful for viral infection treatment, and who need additional information regarding antibiotics, were more likely to believe that it is important to talk about AMR at school.

CONCLUSIONS

Interventions on AMR and antibiotic use among adolescents are needed.

Prescription patterns and drug utilization in respiratory tract infections: implications for antimicrobial stewardship at a tertiary care teaching hospital

Respiratory tract infections (RTIs) are common causes of hospital admissions and are often treated with multiple medications, including antibiotics, contributing to antimicrobial resistance. Effective drug utilization evaluation (DUE) is essential for ensuring rational drug use in RTI management. This study aimed to assess prescription patterns and drug utilization in RTI patients at a tertiary care hospital, focusing on the rationality of drug use, polypharmacy, adherence to clinical guidelines, and implications for antimicrobial stewardship. A cross-sectional study was conducted at Vivekananda General Hospital, Hubballi, India, from August 2023 to January 2024. Data from 200 RTI inpatients, including demographics, medication types, administration routes, and prescription patterns, were analyzed. Descriptive and inferential statistics were used to evaluate adherence to guidelines and rational drug use. DUE revealed that 50.99% of patients were not prescribed cough syrup. Oral (52%) and intravenous (48%) routes were the most common. Budesonide was the most frequently prescribed bronchodilator (26.49%), and 72.45% of patients received oxygen. Ceftriaxone (12.68%) and azithromycin (11.88%) were the most commonly prescribed antibiotics. A high prevalence of polypharmacy was identified, with 39.50% of patients receiving more than three antibiotics, raising concerns about drug interactions and rationality. The study underscores the need for stricter adherence to clinical guidelines and targeted antimicrobial stewardship in RTI management. Enhanced DUE practices could improve patient outcomes and promote rational drug use.

Assessing the Reliability and Validity of a Questionnaire Evaluating Medical Students' Attitudes, Knowledge, and Perceptions of Antibiotic Education and Antimicrobial Resistance in University Training

The misuse and overuse of antibiotics represent a critical global issue and one of the most pressing public health challenges of the 21st century. Training future healthcare professionals effectively is essential for ensuring responsible antibiotic use. This study aimed to validate a questionnaire designed to evaluate the knowledge, attitudes, and perceptions of medical students regarding the education they receive on infectious diseases, antimicrobial resistance, and antibiotic stewardship during their university studies. Methods: A self-administered questionnaire was developed and distributed to medical students at the University of Santiago de Compostela. Comprising 44 items, the questionnaire assessed eight key dimensions: "infection diagnosis", "criteria for not prescribing antibiotics", "initial antibiotic therapy", "re-evaluation of therapy", "quality of care", "communication skills", "antibiotic resistance", and "teaching methodology". Validation was carried out in two stages: Phase 1 involved content and face validity, while Phase 2 focused on reliability analysis. Results: A total of 295 students completed the questionnaire, with a mean age of 23.15 ± 1.78 years. The sample included 86 male (29.2%) and 209 female (70.8%) respondents. Content and face validity were established by a nominal group of five experts and a focus group of medicine and pharmacy students to ensure consensus on item understanding in the Spanish language. The questionnaire demonstrated high internal consistency with a Cronbach's alpha of 0.92 and satisfactory item discrimination. Construct validity was confirmed through principal component analysis, which supported the presence of the eight predefined dimensions. Conclusions: The validated questionnaire exhibited strong reliability and validity, making it a valuable tool for assessing medical students' training in antibiotic-related topics. Its application will enable the identification of areas for improvement in university curricula, ultimately contributing to the promotion of appropriate antibiotic use and the reduction of antimicrobial resistance.

A Global Evaluation of Generic Antimicrobial Prescribing Competencies for Use in Veterinary Curricula

The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) developed consensus-based generic competencies in antimicrobial prescribing and stewardship. These may be useful in structuring and evaluating antimicrobial prescribing education to veterinary students, but their applicability has not been evaluated. We aimed to evaluate whether the ESCMID competencies are currently taught and how relevant they are to veterinary prescribing in veterinary schools globally. A multi-center, cross-sectional survey was performed by administering an online questionnaire to academics teaching antimicrobial prescribing to veterinary students. Targeted recruitment was undertaken to ensure the representation of diverse geographical locations. Responses (48) were received from veterinary schools in Europe (26), North America (7), Asia (6), Australia (3), Central and South America (3), and Africa (3). Of the 37 ESCMID prescribing competencies, only 6 were considered only "slightly" or "not at all" relevant by more than 10% of respondents. Of the 37 competencies, 25 of the competencies were taught in more than 90% of schools and another 6 were taught in 80%-89% of schools. Time spent teaching was "too little" or "far too little" for five competencies according to more than 50% of the respondents. Additional competencies to address extra-label drug use; the use of compounded antimicrobials; the use of antimicrobials for metaphylaxis, prophylaxis, and growth promotion; and the importance rating of antimicrobials were suggested. The ESCMID antimicrobial prescribing competencies had broad relevance and were widely covered in the veterinary curriculum globally.

2015 versus 2021: Self-Reported Preparedness to Prescribe Antibiotics Prudently among Final Year Medical Students in Sweden

Cross-sectional surveys have found variations in how prepared medical students feel to prescribe antibiotics responsibly, but insights are lacking on the stability of these outcomes. In a 2015 survey, final-year Swedish medical students reported very high preparedness levels across a comprehensive range of relevant curriculum topics. We repeated this survey in 2021 to assess the stability of previous findings and to capture the potential impacts of the COVID-19 pandemic. Final-year students in 2015 and 2021 at all seven Swedish medical schools were eligible to participate in an online survey covering curricula topics, teaching methods and COVID-19 impacts (2021). Eligible students received email invitations and reminders from local coordinators. Students from six of seven medical schools participated in both surveys, with response rates of 24.1% (309/1281) in 2021 and 21.3% (239/1124) in 2015. The average global preparedness was 77.0% and 83.2%, respectively (p < 0.001), with lower preparedness levels in 24/27 curriculum topics in 2021. Students at certain universities reported COVID-19 impacts on antibiotic prescribing education (format, duration and perceived quality). Self-reported preparedness levels have fallen slightly but remain high compared with 2015 levels in other European countries. Students consistently reported lower preparedness in specific topics; improvement efforts should consider focusing on these areas, particularly in the context of the ongoing implementation of programmes leading to a full licence upon graduation.

French healthcare students and antibiotics: are they ready to promote their appropriate use?

Objectives

French healthcare students are required to carry out primary prevention interventions as part of the Healthcare Service by Healthcare Students (HSHS). The purpose of this study was to explore students' perceptions of preparedness to address the public's concerns about antibiotic use and how their perceptions changed after implementing their intervention.

Methods

A questionnaire was sent twice during the 2020-2021 academic year to 920 multidisciplinary healthcare students (nursing, medicine, physiotherapy, pharmacy and midwifery students) enrolled in the HSHS in Franche-Comté (HSHS-FC).

Results

This study included 870/920 students (94.6%). Medical and pharmacy students were the most concerned about the issue of antimicrobial resistance. Before enrollment in the HSHS-FC, 463 of the 870 students included (53.2%) reported having sufficient knowledge about antibiotics to lead preventive interventions, reaching 87.9% (58/66) for pharmacy students. Despite this relative lack of knowledge, 77.2% of students felt confident to promote the appropriate use of antibiotics in the healthcare service context. This rate ranged from 68.0% (17/25) for midwifery students to 93.9% (62/66) for pharmacy students. Irrespective of the topic of the intervention, students significantly improved their knowledge and ability to promote antibiotic use after training in the HSHS-FC.

Conclusions

Theoretical prerequisites and a feeling of concern vary widely depending on the curriculum. The HSHS-FC promotes multidisciplinary collaboration and can contribute to improving students' knowledge. The support of an expert in antimicrobial resistance may be necessary to validate the content of the interventions proposed by the students.

Comparison of knowledge, attitude, practice and predictors of self-medication with antibiotics among medical and non-medical students in Tanzania

Introduction: Self-medication with antibiotics (SMA) is a widespread problem in developing nations, including Tanzania. Methods: This study compared knowledge, attitudes, practices, and factors influencing antibiotic SMA among medical and non-medical students. Results: The prevalence of SMA among medical students was 49.1% and 59.2% among non-medical students, respectively. The mean knowledge score of medical students (6.4) was significantly higher (p-value <0.001) than that of non-medical students (5.6). The main factors influencing SMA practices were the availability of antibiotics without a prescription, easy access to pharmacies, and a lack of knowledge about the risks of SMA. This experience was pivotal in influencing medical students to take antibiotics, with a substantial proportion of 67.5% as opposed to 59.4% of non-medical students. Medical students were 1.6 times more likely to self-medicate with antibiotics than non-medical students (Adjusted Odds Ratio (AOR): 1.6; 95% Confidence Interval (CI): 1.2-2.3, p-value = 0.004). Age was also associated with self-medication, with an AOR of 1.1 (95% CI: 1.04-1.2, p-value = 0.006) per year increase in age. Additionally, attitude was associated with self-medication, with an AOR of 1.05 (95% CI: 1.04-1.1, p-value = 0.001) per unit increase in attitude score. Discussion: No significant associations were found between sex, marital status, having children, year of study, knowledge score, and self-medication with antibiotics. This study emphasizes the importance of educational interventions and public awareness campaigns to promote antimicrobial stewardship, appropriate antibiotic use, and preventing pharmacies from dispensing antibiotics without a prescription.

Antimicrobial Prescribing Preparedness of Croatian Medical Students-Did It Change between 2015 and 2019?

BACKGROUND

Antimicrobials are some of the most prescribed drugs by junior doctors, but studies suggest most medical graduates feel unprepared for their future prescribing tasks. The aim of the present study was to compare the self-reported preparedness to prudently prescribe antimicrobials of final-year medical students in Croatia in 2015 and 2019.

METHODS

The same self-reported web-based survey on the preparedness to prescribe antibiotics was used in both 2015 and 2019. All final-year students at all four medical schools in Croatia (Osijek, Rijeka, Split, and Zagreb) were invited to participate in both 2015 and 2019. Preparedness scores were divided into "topic preparedness scores" and "global preparedness scores". Topic preparedness scores represented the percentage of students at a medical school who felt sufficiently prepared for each topic. They were first established at a medical school level and then at the national level. Global preparedness scores were determined for each student separately and then calculated at the medical school and national levels.

RESULTS

The country's global preparedness score, representing the average proportion of topics in which students felt sufficiently prepared, was slightly higher in 2015 compared with the 2019 results (62.7% vs. 56.5%; p = 0.191). Croatian students reported higher preparedness in 2015 than in 2019 for 25 out of 27 topics included in the survey. The majority of students reported a need for more education on antibiotic use both in 2015 and 2019 (78.0% vs. 83.0%; p = 0.199).

CONCLUSIONS

Despite increasing antimicrobial stewardship activities in various healthcare settings, medical students who are about to start prescribing antibiotics on their own do not feel sufficiently prepared to do so. Antimicrobial stewardship programs should be designed to incorporate undergraduate medical student education, for instance, as a specific, mandatory course or integrated into other courses, such as clinical pharmacology.

Understanding of Final Year Medical, Pharmacy and Nursing Students in Pakistan towards Antibiotic Use, Antimicrobial Resistance and Stewardship: Findings and Implications

Antimicrobial resistance (AMR) is a leading public health threat, which is exacerbated by the high and inappropriate use of antibiotics. Consequently, there is a need to evaluate knowledge regarding antibiotic use, AMR and the readiness to implement antimicrobial stewardship programs (ASPs) among final year medical, pharmacy and nursing students in Pakistan. This reflects the high and increasing rates of AMR in the country, and students as future healthcare professionals (HCPs). A cross-sectional study was conducted among 1251 final year students from 23 public and private educational institutions in Punjab. The majority of the surveyed participants possessed good knowledge of antibiotic use, AMR and the potential causes of AMR. The most common sources of the information on antibiotics were smartphones (69.9%), peers (35.9%) and medical textbooks (30.6%). However, most surveyed participants were not fully prepared to participate in ASPs. They knew, though, how to reduce AMR by educating HCPs about appropriate prescribing, implementing ASPs and improving laboratory facilities. There was a significant association between antibiotic knowledge and causes of AMR with sex, family income and student type (p < 0.05). Being a student at a public sector university (OR = 4.809; CI = 3.261−7.094; p < 0.001) and age (OR = 0.524, CI = 0.327−0.842; p < 0.008) were among the key factors impacting students’ training on ASPs. Educational curricula must be improved to include more information about appropriate antibiotic use and ASPs, along with sufficient training, workshops and clinical rotations in the final year, to fully equip students by graduation.

Knowledge, Attitude, and Behavior about Antimicrobial Use and Resistance among Medical, Nursing and Pharmacy Students in Jordan: A Cross Sectional Study

The present study aimed to survey medical, nursing and pharmacy students' knowledge, attitude and practice regarding antimicrobial use and resistance. Additionally, the study assessed the teaching and assessment activities received regarding antibiotic use. A cross sectional online survey was distributed to undergraduate students currently in clinical studies in their degree program. A total of 716 medicine, nursing and pharmacy undergraduate students were included. Respondents scored more than 76% on knowledge on effective use, unnecessary use and associated side effects of antibiotics, and 65.2% regarding knowledge on the spread of antibiotic resistance. Some participants (21.0%) agreed or strongly agreed that there has been good promotion of prudent antimicrobial use. Students were aware (13.1%), unaware (29.1%), or unsure (57.8%) that there is a national action plan relating to antimicrobial resistance. A total of 62.8% of the respondents strongly agreed or agreed that they have a key role in helping control antibiotic resistance. Participants reported that they require more information about resistance to antibiotics (53.9%), medical conditions for which antibiotics are used (51.7%) and how to use antibiotics (51.0%). Discussion of clinical cases and vignettes and small group teaching were reported as very useful or useful teaching strategies (79.9% and 74.2%, respectively). The findings from this study determined the current situation in relation to education on prudent antimicrobial use for undergraduates and highlighted areas for informing better curriculum design.

Medical interns' views on the strategies for reducing antibiotic misuse in the hospitals-what guidelines do they follow?

Objectives

Although the topic of antibiotic misuse is taught in medical schools, interns (fresh medical graduates) still encounter barriers to appropriate antibiotic prescription when they practice in hospitals under supervision. The impact of teaching in medical school, antibiotics stewardship program (ASP), and prescription guidelines was uncertain. This study explored the medical interns' views on antibiotic use and resistance, and their perceived enablers to appropriate antibiotic prescription.

Methods

Two focus groups were conducted among medical interns with rotation experiences in different public hospitals of Hong Kong. The identified themes about attitudes to antibiotic resistance and enablers to appropriate antibiotic prescription were further examined by a questionnaire survey with 77 respondents.

Results

The interns had lower preferences for tackling antibiotic resistance as they feared of delayed prescriptions. Guidelines provided by international evidence-based clinical resources and the interns' working hospitals were stronger enablers to appropriate antibiotic use than education materials from schools and the government. Qualitative findings revealed that the interns were aware of the existing ASP but doubted its effectiveness as it failed to get the prescribers' attention. They followed guidelines in their wards but perceived guidelines from local health authorities user-unfriendly. Knowledge from medical school was not very applicable. Varying prescribing practices between hospitals and the densely placed hospital beds made it difficult to prevent the spread of antimicrobial resistance.

Conclusions

Minimizing delayed prescription is of a higher priority than tackling antibiotic resistance in medical interns' perspective. Interventions should target guidelines in hospitals and simplify the interface of local guidelines.

Exploring the Antimicrobial Stewardship Educational Needs of Healthcare Students and the Potential of an Antimicrobial Prescribing App as an Educational Tool in Selected African Countries

Antimicrobial resistance (AMR) is a global health threat and one of the top 10 global public health threats facing humanity. AMR contributes to 700,000 deaths annually and more deaths, as many as 10 million are projected to happen by 2050. Antimicrobial stewardship (AMS) activities have been important in combating the ripple effects of AMR and several concerted efforts have been taken to address the issues of antimicrobial resistance. The Commonwealth Pharmacists Association through the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme has been enhancing the capacity of health institutions in Low-Middle-Income Countries (LMIC) to combat AMR. Through such efforts, an antimicrobial prescribing app (CwPAMS app) was launched and delivered to support antimicrobial prescribing and improve AMS practice in four African countries; Ghana, Uganda, Zambia, and Tanzania. The app provides easy access to infection management resources to improve appropriate use of antimicrobials in line with national and international guidelines. This study aimed to identify and explore the potential for the usability of the CwPAMS app among healthcare students across selected African countries that are part of the Commonwealth. The study equally evaluated the healthcare students’ understanding and attitudes towards antimicrobial resistance and stewardship. Despite 70% of the respondents indicating that they had been taught about prudent use of antibiotics, diagnosis of infections and their management using antibiotics in their universities, notable knowledge gaps were discovered: 52.2% of the respondents had no prior information on the term AMS, 50.6% of them reported a lack of resources for accessing up-to-date information on drugs, for instance only 36% had had an opportunity to access an app as a learning resource even when 70% of the respondents thought that a mobile app would support in increasing their knowledge. Those challenges reveal an opportunity for the CwPAMS App as a potential option to address AMR and AMS gaps among healthcare students.

A Multicentric Survey of Indian Medical Students about their Knowledge and Perception on Antimicrobial Stewardship

Antimicrobial stewardship (AMS) and appropriate infection prevention practices are essential to decrease the rising trend of antimicrobial resistance (AMR). Good antimicrobial prescribing habits formed early in the medical career can make a paradigm shift in combating the menace of AMR. Scarce data is available about the knowledge and perceptions of Indian undergraduates on AMS. This study was planned to analyse the knowledge, attitude and perceptions (KAP) of Indian medical undergraduates on rational antimicrobial prescribing, so that the lacunae in the training curriculum can be identified and addressed effectively. A cross-sectional questionnaire-based survey was carried out, on the pre-final and final year medical students (6th to 9th semester) from six medical colleges across different states of India. A scoring system was used to rate the knowledge, attitude and perceptions of the respondents as poor, average, or good. A total of 1505 students (83.61%) participated in the survey. Majority of the students (81.7%) from all medical colleges favoured more education on antimicrobials and to incorporate AMS in the undergraduate curriculum through integrated teaching. The results showed that overall, 70.9% students had a “good” score for knowledge on antimicrobial use, whereas only 55% scored “good” for being confident in rational antimicrobial prescribing. Surprisingly, only 56.5% correct responses for knowledge on selection of broad-spectrum antibiotics over narrow-spectrum antibiotics were recorded in our study. Most of the students (79.9%) were conscious that irrational prescribing can result to AMR. On the other hand, 54.9% students believed that the supply of new antimicrobials would take care of AMR eventually. 78.1% of our students believed that they were confident in making the right diagnosis of infection, whereas, 63.7% of respondents believed that they were not confident in identifying the clinical scenarios where antibiotics are not required. Significant association (p<0.05) was seen for both “good” knowledge and perception scores with the higher academic semesters reflecting more clinical exposure in later in course semesters. The study has highlighted the areas of clinical weakness and dilemma regarding prescription of antimicrobials. Efforts to address these issues on basic principles of antimicrobial stewardship, is critical for laying the foundation of successful AMS program and contributing in overcoming the antimicrobial resistance. The study recommends targeted training, articulating fine details of prescribing antimicrobials with real time case scenarios through a multi-disciplinary approach. The Indian undergraduate medical curriculum needs to incorporate early well-structured training on AMS by integrating pharmacology and microbiology teaching with the clinical subjects to ensure appropriate antibiotic prescribing practices by the future prescribers.

Antimicrobial Prescribing Confidence and Knowledge Regarding Drug Resistance: Perception of Medical Students in Malaysia and the Implications

Worldwide, microbes are becoming more challenging by acquiring virulent skills to adapt and develop antimicrobial resistance (AMR). This is a concern as AMR increases morbidity, mortality, and costs. Consequently, physicians need to be trained on appropriate antimicrobial prescribing, starting as medical students. Objective: To evaluate medical students’ confidence in antimicrobial prescribing and AMR. Methods: Cross-sectional study assessing medical students’ knowledge, perception, and confidence in prescribing antimicrobials and AMR in a Malaysian University. A universal sampling method was used. Results: Most responding students believed that educational input regarding overall prescribing was sufficient. Regarding the principle of appropriate and accurate prescriptions, female medical students had less knowledge (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.25–0.99; p = 0.050). Year-IV and Year-V medical students had more excellent knowledge than Year-III students regarding confidence in potential antibiotic prescribing once qualified. Year-V students also showed an appreciably higher confidence in the broad principles of prescribing, including antibiotics for infectious diseases, compared to those in other years. Conclusion: Overall, medical students gain more knowledge and confidence regarding the potential prescribing of antimicrobials as their academic careers progress. This is important given concerns with the current excessive use of antimicrobials in Malaysia.

Educational resource for antimicrobial resistance and stewardship for dentistry programmes: a research protocol

INTRODUCTION

Antimicrobial resistance (AMR) is a global public and patient safety issue. With the high AMR risk, ensuring that the next generation of dentists that have optimal knowledge and confidence in the area of AMR is crucial. A systematic approach is vital to design an AMR content that is comprehensive and clinically relevant. The primary objective of this research study will be to implement a consensus-based approach to elucidate AMR content and curriculum priorities for professional dentistry programmes. This research aims to establish consensus along with eliciting opinion on appropriate AMR topics to be covered in the Bachelor of Dental Surgery syllabus.

METHODS AND ANALYSIS

A three-phase approach to validate content for curriculum guidelines on AMR will be adopted. First, literature review and content analysis were conducted to find out the available pertinent literature in dentistry programmes. A total of 23 potential literature have been chosen for inclusion within this study following literature review and analysis in phase 1. The materials found will be used to draft curriculum on antimicrobials for dentistry programmes. The next phase involves the validation of the drafted curriculum content by recruiting local and foreign experts via a survey questionnaire. Finally, Delphi technique will be conducted to obtain consensus on the important or controversial modifications to the revised curriculum.

ETHICS AND DISSEMINATION

An ethics application is currently under review with the Institute of Health Science Research Ethics Committee, Universiti Brunei Darussalam. All participants are required to provide a written consent form. Findings will be used to identify significant knowledge gaps on AMR aspect in a way that results in lasting change in clinical practice. Moreover, AMR content priorities related to dentistry clinical practice will be determined in order to develop need-based educational resource on microbes, hygiene and prudent antimicrobial use for dentistry programmes.

Knowledge-Based Attitudes of Medical Students in Antibiotic Therapy and Antibiotic Resistance. A Cross-Sectional Study

We aimed to evaluate the knowledge-based attitudes of antibiotics and antibiotic resistance among medical students of Medical University of Warsaw using the questionnaire prepared by the study's authors. In May-June 2018, we carried out a cross-sectional study among the students of all years, embracing 291 respondents. The students were divided into two groups: A (students in their first to third years) and B (students in their fourth to sixth years). Our study has shown that students are aware of the dangers of antibiotic resistance, seeing the leading cause as antibiotic misuse. We have shown that they are also aware of their insufficient knowledge and believe that more antibiotic therapy classes should be included in the curriculum of Medical University of Warsaw. Our questionnaire also focused on attitudes towards antibiotics based on knowledge. One in four respondents (23.7%), based on their knowledge, negated antibiotic therapy ordered by a doctor in the event of their illness, and four in ten (40.9%) in the occurrence of disease of a family member or friend. The vast majority of students (92.4%) would like to broaden their knowledge on antibiotic therapy. However, only one-fifth of students have heard about the European Antibiotic Awareness Day campaign. We recommend increasing the number of hours on antibiotic therapy and resistance education combined with topics on hand hygiene.

Antibiotic Use and Resistance Among Prescribers: Current Status of Knowledge, Attitude, and Practice in Egypt

Introduction

The problem of antimicrobial resistance (AMR) is rising worldwide. One of the most significant factors influencing antimicrobial resistance in low- and middle-income countries is the lack of the skills and knowledge of health care providers for proper antimicrobial use.

Aim

To identify knowledge, characterize practices and describe the attitude of Egyptian prescribers towards antibiotic use.

Methods

A self-administered validated questionnaire was distributed among Egyptian prescribers.

Results

Five hundred Egyptian physicians responded to the questionnaire, 113 (22.6%) reported having Antibiotic Stewardship Program (ASP) at their workplace, 99 (19.8%) use international antibiotic guidelines as the main source for prescribing activity, 358 (71.6%) recorded adequate knowledge. Elder prescribers and those who work in private or university hospitals were significantly more knowledgeable (p=0.031 and 0.001, respectively). Forty-seven (9.4%) showed a positive attitude towards proper antibiotic prescription. The type of work institution; primary health clinics and private, or university hospital and the specialty are significantly associated with a positive attitude (p=0.009 and 0.015, respectively). Seventy-eight (15.6%) expressed a proper antibiotic prescription practice. Elder age, more experienced and trained prescribers showed more proper practice. The implementation of ASP and using proper sources of information were significantly associated with proper practice (p=0.012 and 0.008, respectively).

Conclusion

Egyptian prescribers have a good level of knowledge about antibiotics. However, low rates of positive attitude and proper practice towards the problem of AMR and ASP are recorded.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

Knowledge, attitude, and practice regarding antibiotic use and resistance among medical students in Colombia: a cross-sectional descriptive study

BACKGROUND

This study was designed to describe the knowledge, attitude, and practice regarding antibiotic use and resistance among medical students in Medellín, Colombia.

METHODS

A cross-sectional study was conducted among medical students from three universities from September to December 2018. The sample size was calculated, the classrooms were visited, and those students who were willing to participate were invited to do so. The data collection instrument was constructed in three stages: i) the literature was systematically reviewed, ii) the items from the studies identified were extracted, and iii) item reduction was performed with exploratory factor analysis. Data were analyzed by calculating absolute and relative frequencies and means for quantitative variables. The indexes of knowledge, attitude, and practice were transformed to a scale from 0 (worst possible score) to 100. Comparisons were performed using the Mann-Whitney U test, Kruskall-Wallis H test, and linear regressions.

RESULTS

Five hundred and thirty-two medical students were included with a response rate of 96%. Of the total participants, 49.1% reported having used antibiotics within the past year. Regarding knowledge, only 18.2% had heard of the term "antimicrobial stewardship" and 69.3% were aware that empiric antibiotic therapy contributes to antibiotic resistance. Regarding attitude, 11.6% considered that antibiotics should be discontinued as soon as symptoms disappear and 24.6% stated that it is better to prescribe broad-spectrum antibiotics to ensure that the patient is cured. Regarding practice, 28.5% recognized that resistance is a multifactorial problem, but they do not act on it because they consider that individual actions would have little impact. The adjusted linear regression showed that the variables associated with knowledge, attitude, and practice were socioeconomic status, training cycle, university, previous experience of research or education, the general perception of the training received, and antibiotic consumption.

CONCLUSION

Knowledge, attitude, and practice differ widely depending on the university, training cycle, and socioeconomic status, and a significant proportion of students consider that the standard of training received at the university on antibiotics and bacterial resistance is poor or mediocre. These findings show that there is a need to strengthen the medical students' curriculum on antibiotics, mechanisms of antibiotic resistance, and the prudent use of antibiotics as an important strategy to combat problem-resistant public health, primarily in endemic countries.

Knowledge, Attitudes and Perceptions of Medical Students on Antimicrobial Stewardship

Antimicrobial Resistance (AMR) is an ongoing threat to modern medicine throughout the world. The World Health Organisation has emphasized the importance of adequate and effective training of medical students in wise prescribing of antibiotics Furthermore, Antimicrobial Stewardship (AMS) has been recognized as a rapidly growing field in medicine that sets a goal of rational use of antibiotics in terms of dosing, duration of therapy and route of administration. We undertook the current review to systematically summarize and present the published data on the knowledge, attitudes and perceptions of medical students on AMS. We reviewed all studies published in English from 2007 to 2020. We found that although medical students recognize the problem of AMR, they lack basic knowledge regarding AMR. Incorporating novel and effective training methods on all aspects of AMS and AMR in the Medical Curricula worldwide is of paramount importance.

Designing and evaluating an interprofessional education conference approach to antimicrobial education

BACKGROUND

Arguably, Medical School curricula are deficient in learning opportunities related to the safe and effective use of medicines, in particular antimicrobials. Infection management is complex and multidisciplinary, and learning opportunities should reflect these principles. Aligned to the complexity of the subject matter, simulation and interprofessional based teaching are methods that can foster the collaborative skills required of future healthcare professionals. There have been calls to develop these methods in the teaching of safe prescribing and the management of infections; however, reports of such studies are limited.

METHODS

We developed an interprofessional education (IPE) conference for second year undergraduate medical and pharmacy students based in the North East of England. We considered contact theory in the design of three small group interprofessional workshops, on the broad themes of antimicrobial stewardship, infection management and patient safety. A mixed methods approach assessed students' attitudes towards IPE, barriers and facilitators of learning, and perceived learning gains. Qualitative data from workshop evaluation forms were analysed thematically, while quantitative data were analysed descriptively and differences between medical and pharmacy cohorts analysed using unpaired two-tailed t-tests.

RESULTS

226/352 students returned the workshop evaluation forms (66% of pharmacy students, 62% of medical students). 281/352 students responded to a series of Likert scale questions on the value of interprofessional education (88% of pharmacy students, 70% of medical students). Students reported acquisition of knowledge and skills, including concepts and procedures related to infection management and antimicrobial prescribing, and the development of problem-solving and critical evaluation skills. Students reflected on their attitude towards interprofessional collaboration. They reported a greater understanding of the roles of other healthcare professionals, reflected on the importance of effective communication in ensuring patient safety, and were more confident to work in interprofessional teams after the conference.

CONCLUSIONS

A robust IPE event, theoretically underpinned by contact theory and developed collaboratively, achieved interprofessional learning at scale and helped develop healthcare professionals willing to collaborate across disciplines. The resources, and evaluation insights based on the 3P (presage, process, and product) model of learning and teaching, will be of value to other educators who seek to develop theoretically-sound IPE interventions.

Young doctors' perspectives on antibiotic use and resistance: a multinational and inter-specialty cross-sectional European Society of Clinical Microbiology and Infectious Diseases (ESCMID) survey

BACKGROUND

Postgraduate training has the potential to shape the prescribing practices of young doctors.

OBJECTIVES

To investigate the practices, attitudes and beliefs on antibiotic use and resistance in young doctors of different specialties.

METHODS

We performed an international web-based exploratory survey. Principal component analysis (PCA) and bivariate and multivariate [analysis of variance (ANOVA)] analyses were used to investigate differences between young doctors according to their country of specialization, specialty, year of training and gender.

RESULTS

Of the 2366 participants from France, Greece, Italy, Portugal, Slovenia and Spain, 54.2% of young doctors prescribed antibiotics predominantly as instructed by a mentor. Associations between the variability of answers and the country of training were observed across most questions, followed by variability according to the specialty. Very few differences were associated with the year of training and gender. PCA revealed five dimensions of antibiotic prescribing culture: self-assessment of knowledge, consideration of side effects, perception of prescription patterns, consideration of patient sickness and perception of antibiotic resistance. Only the country of specialization (partial η2 0.010-0.111) and the type of specialization (0.013-0.032) had a significant effect on all five identified dimensions (P < 0.01). The strongest effects were observed on self-assessed knowledge and in the perception of antibiotic resistance.

CONCLUSIONS

The country of specialization followed by the type of specialization are the most important determinants of young doctors' perspectives on antibiotic use and resistance. The inclusion of competencies in antibiotic use in all specialty curricula and international harmonization of training should be considered.

Italian young doctors' knowledge, attitudes and practices on antibiotic use and resistance: A national cross-sectional survey

OBJECTIVES

Antimicrobial resistance (AMR) is one of the major health issues worldwide. Clinicians should play a central role to fight AMR, and medical training is a pivotal issue to combat it; therefore, assessing levels of knowledge, attitudes and practices among young doctors is essential for future antimicrobial stewardship (AMS) programmes.

METHODS

A nationwide, cross-sectional, multicentre survey was conducted in Italy. A descriptive analysis of knowledge and attitudes was performed, along with a univariate and multivariate analysis of their determinants.

RESULTS

Overall, 1179 young doctors accessed the survey and 1055 (89.5%) completed all sections. Regarding the knowledge section of the questionnaire, almost all participants declared to know the different species of bacteria proposed, however the percentage of participants who correctly responded to clinical quizzes was 23% for the question on vancomycin-resistant enterococci (VRE), 42% on carbapenem-resistant Enterobacteriaceae (CRE), 32% on extended-spectrum β-lactamase-producing enterobacteria (ESBL) and 27% on methicillin-resistantStaphylococcus aureus (MRSA). Similarly, 81% of participants disagreed in stating that AMR was adequately addressed during their medical training and 71% disagreed that they received the right example from their tutors. Finally, a high rate of agreement with the proposed actions to combat AMR was documented; in particular, the percentage agreement was 76% for respondents who agreed to be part of an active surveillance system or AMS programme.

CONCLUSIONS

Tackling AMR should be a priority for politicians and for all health workers. Inclusion of competencies in antibiotic use in all specialty curricula is urgently needed.

Mapping knowledge and comprehension of antimicrobial stewardship and biosecurity among veterinary students

OBJECTIVES

As an important public health concern, antimicrobial resistance (AMR) is related to lack of knowledge among healthcare professionals. Since the Global Action Plan on AMR highlights the importance of training all healthcare professionals, it is essential to focus our attention on the education related to judicious antimicrobial use. The current study was the first attempt in southeastern Europe to quantify the knowledge about antimicrobial usage and biosecurity measure among veterinary students.

METHODS

This questionnaire-based study was performed between April and May of 2019 on 213 veterinary students of the University of Novi Sad, Serbia and the University of Zagreb, Croatia.

RESULTS

Veterinary students appeared to be little aware of antimicrobial use in veterinary medicine contribution to overall AMR since only 56.8% have chosen strong contribution as the answer. Of the students surveyed, only 22.1%/35.7% of them strongly agreed/agreed that the amount of teaching time for pharmacology was about right. Students who denied having good knowledge of the pharmacology of antimicrobials showed higher knowledge about systemic use of antimicrobials in different clinical scenarios (p = 0.002). High importance of some antimicrobials for human medicine was not recognized by surveyed students. Only 8.5% of them identified gentamicin correctly, as first-line therapy. Students expected to graduate later were more likely to identify the importance of rating antimicrobials correctly than those who thought they would graduate earlier (p = 0.002). More than half of students gave correct answer at scenario regarding a dog with recurrent pyoderma by choosing culture and susceptibility (C & S) testing. Our students who think they will graduate sooner have higher knowledge level on C & S testing sample submission for range of clinical scenarios (p = 0.004). Moreover, appropriate use of PPE (personal protective equipment) procedure and biosecurity measure were reported for two thirds of our students in case of only for two clinical scenarios.

CONCLUSION

This study reveals that among veterinary students from Croatia and Serbia improved undergraduate education is needed on the AMR with emphasis on antimicrobial stewardship (AMS) and appropriate biosecurity.

Tackling Antimicrobial Resistance by promoting Antimicrobial stewardship in Medical and Allied Health Professional Curricula

INTRODUCTION

Antimicrobial resistance poses a serious threat to global health with significantly higher morbidity, mortality, and economic burden. This review aims to discuss the importance of the promotion of antimicrobial stewardship in medical and allied health professional curricula and training/educating tomorrow's doctors in combatting antimicrobial resistance. A narrative literature review was conducted to retrieve relevant information related to antimicrobial resistance and stewardship and their implications on medical and allied health professional education and training from searches of computerized databases, hand searches, and authoritative texts.

AREAS COVERED

Antimicrobial stewardship programs improve rational antibiotic use, reduce antimicrobial resistance, decrease complications of antibiotic use, and improve patient outcomes. Though health professional students recognize the importance and impact of antibiotic prescribing knowledge, many studies have consistently demonstrated low levels of confidence and competencies amongst students, highlighting that health professional schools failed to prepare them to prescribe antibiotics accurately.

EXPERT OPINION

There is an urgent call for the integration of antimicrobial stewardship teaching at the undergraduate level of medical education to train future prescribers on this critical aspect of public health. Proper undergraduate education on rational antibiotics use would enable health professional graduates to enter clinical practice with adequate competencies to become rational prescribers.

Educational antimicrobial stewardship programs in medical schools: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify the available evidence on antimicrobial stewardship programs for teaching medical students about rational antimicrobial use, including the content taught and the method of instruction used.

INTRODUCTION

Antibiotics are life-saving drugs and their discovery is one of the most important advances of the 20th century. They have transformed modern medicine by playing a critical role in the management of infectious diseases. However, the rapid development of resistance of pathogens to antibiotics is gradually affecting this initial success. Antimicrobial stewardship programs have been shown to reduce the burden of antimicrobial resistance in hospitals.

INCLUSION CRITERIA

This scoping review will consider papers conducted in medical school curricula to improve the prescribing of antimicrobial medication. Studies that include other health profession students, such as nursing, pharmacy, or dentistry students, will be excluded. Studies published in English from 1996 onwards will be included.

METHODS

Databases to be searched are PubMed, Wiley Online library, CINAHL Complete, Web of Knowledge, Scopus and Education Resources Information Center. Unpublished studies and gray literature will be included. Searching will follow a three-step process and will be conducted by two reviewers. Data will be extracted by two independent reviewers. Any disagreements that arise between the reviewers during the study selection process or data extraction will be resolved through discussion, or with a third reviewer. Results will be presented in tabular or diagrammatic form, together with a narrative summary.

A comparison of five paediatric dosing guidelines for antibiotics

Objective

To compare dosing guidance in the paediatric formularies of high- and middle-income countries for 32 commonly prescribed antibiotics on the World Health Organization’s (WHO’s) 2017 Model list of essential medicines for children.

Methods

We identified paediatric antibiotic guidelines that were either widely used internationally or originated from countries in which antibiotic use has increased markedly in recent years (i.e. Brazil, China, India, the Russian Federation and South Africa).

Findings

The study analysis considered five leading antibiotic guidelines: (i) the Manual of childhood infections: the blue book; (ii) the BNF (British national formulary) for children; (iii) the Red book^®: 2018–2021 report of the committee on infectious diseases; (iv) WHO’s Pocket book of hospital care for children; and (v) Indian National treatment guidelines for antimicrobial use in infectious diseases. There was marked heterogeneity in the recommended dosing (i.e. daily dose, age dosing bands and dose frequency) for most commonly used antibiotics. The rationale for dosing recommendations was generally unclear.

Conclusion

The pharmacokinetic, pharmacodynamic and clinical evidence supporting paediatric antibiotic dosing, particularly on total doses and on age or weight dosing bands, needs to be improved. Future research should consider whether the variations in guidance identified stem from different clinical disease patterns, varying levels of antibiotic resistance or drug availability rather than historical preferences. Interested global parties could collaborate with WHO’s Model list of essential medicines antibiotic working group to develop an evidence-based consensus and identify research priorities.

Pediatric pharmacokinetics of the antibiotics in the access and watch groups of the 2019 WHO model list of essential medicines for children: a systematic review

Introduction: Pharmacokinetic-pharmacodynamic (PK-PD) studies of antibiotics in pediatrics are limited. Pediatric dosing regimens for many antimicrobial drugs have been historically derived from adult pharmacokinetic data. Most pediatric formularies and dosing guidelines globally are expert-based and provide no rationale for the recommended doses, leading to heterogeneous guidance.Areas covered: We systematically reviewed the current dosing for 28 antibiotics listed in the Access and Watch groups of the 2019 World Health Organization (WHO) Essential Medicines List for children (EMLc). PubMed and EMBASE were searched for all PK-PD and pharmacological studies in pediatrics up to May 2018. In total, 262 pediatric related articles were deemed eligible. The most studied drugs were those where therapeutic drug monitoring is routine (aminoglycosides, glycopeptides) and study reporting detail was variable, with only 60.0% using the PK-PD results in make dosing recommendations. Based on this evidence, dose recommendations for each antibiotic were made.Expert opinion: We provide an up-to-date review of the limited available evidence on pediatric dosing for the 28 commonly prescribed antibiotics in the 2019 WHO EMLc. We propose synthesized dosing recommendations for those antibiotics administered systemically for the treatment of serious infections. Further PK-PD studies in children, particularly with underlying conditions, are needed.

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.

Appropriate antibiotic prescribing among final-year medical students in Europe

Little is known about undergraduate education on antibiotic prescribing in Europe and even less about the antibiotic prescribing skills of nearly-graduated medical students. This study aimed to evaluate the antibiotic prescribing skills of final-year medical students across Europe and the education they received during medical training. In a cross-sectional study, final-year medical students from 17 medical schools in 15 European countries were asked to prescribe for two written case reports of infectious diseases (acute bronchitis and community-acquired pneumonia). The appropriateness of antimicrobial therapy was determined using a scoring form based on local guidelines. Teachers from each medical school were asked to complete a standardised questionnaire about the teaching and assessment of undergraduate education on antibiotic use. In total, 856 final-year medical students (95.6%) completed the assessment and 16 teachers (94.1%) completed the questionnaire. Overall, 52.7% (range 26-83%) of the 1.683 therapies prescribed were considered appropriate. The mean number of contact hours for undergraduate education on antimicrobials was 25.6 (range 2-90). Differences in education styles were found to have a significant impact on students' performance, with a problem-based learning style being associated with more appropriate antimicrobial prescribing than a traditional learning style (46.0% vs. 22.9%; P < 0.01). Although there are differences between medical schools, final-year medical students in Europe lack prescribing skills for two common infectious diseases, possibly because of inadequate undergraduate education on antibiotic use and general prescribing. To improve students' skills, interactive teaching methods such as prescribing for simulated and real patients should be used.

Preparedness to prescribe antibiotics responsibly: a comparison between final year medical students in France and Sweden

Students should graduate from medical school feeling prepared to prescribe antibiotics responsibly. We assessed self-reported preparedness among students at medical schools in Europe, and we focus here on the results from students in Sweden and France, countries with wide differences in the intensity of antibiotic consumption and burden of antibiotic resistance. We conducted a cross-sectional web-based survey in 2015, based on a comprehensive set of topics related to prudent antibiotic use. All final year students at a medical school in France or Sweden were eligible to participate. Preparedness scores were calculated for each student, and mean scores were compared at medical school and country levels. Comparisons were also made on availability of teaching methods. We received responses from 2085/7653 (response rate 27.2%) students from 31/34 eligible medical schools in France and 302/1124 (26.9%) students from 7/7 schools in Sweden. The relative ranking order of curriculum topics by preparedness level was consistent between countries, but students in Sweden had higher self-reported levels of preparedness in 21/27 topics. There was higher availability for eight of nine teaching methods at Swedish medical schools. Students in France were more likely to report a need for further education on antibiotic use (63.5% vs. 20.3%, p < 0.001). Final year students in France report lower levels of preparedness, less availability of teaching methods and higher needs for more education on antibiotic use. Furthermore, we have identified specific areas for improvement in education on prudent antibiotic use in both Sweden and France.

Assessment of Awareness about Antibiotic Resistance and Practices Followed by Veterinarians for Judicious Prescription of Antibiotics: An Exploratory Study in Eastern Haryana Region of India

The rise of antibiotic resistance and its global outreach has recently become a subject of increasing importance in veterinary research with an objective to reduce the load of antibiotic resistance in dairy farming practices. The present study was designed to analyze antibiotic prescriptions by veterinarians and to evaluate the appropriateness of prescribing behavior in consistent with prudent use of antibiotics. A total of 48 veterinarians were selected randomly from government Veterinary hospitals constituting a total of 48 veterinarians as respondents. The study revealed that most of prescriptions corresponded sound to prudent use of antibiotic and its treatment guidelines. To assess their awareness about antibiotic resistance and its related veterinary practices, an exclusively Awareness Index of antibiotic resistance was developed. It was observed that antibiotics were prescribed in initial encounter of diagnosis; thus, antibiotic conservation practices were found lacking. The ethical awareness of veterinarians was found lacking to establish valid veterinary-client relationship and ensure active involvement of stakeholders. This study largely looks into this angle by unearthing the drug prescribing behavior in order to shape the interdisciplinary research on this biological and profoundly social issue.

Perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance

OBJECTIVES

To assess the perceptions, attitudes, and practices of French junior physicians regarding antibiotic use and resistance, and then to identify the characteristics of junior physicians associated with appropriate practices of antibiotic use.

METHOD

European junior physicians received an email invitation to complete a 49 item web questionnaire between September 2015 and January 2016. We present the French data. Multivariate regression models were used to identify the characteristics of junior physicians associated with appropriate prescription practices and with consideration of the antibiotic prescription consequences.

RESULTS

The questionnaire was completed by 641 junior physicians: family medicine (37%), other medical specialties (e.g., pediatrics, internal medicine, neurology: 45%), surgical specialties (11%), and anesthesiology-intensive care specialty (7%). Most respondents (93%) declared being aware of the risk of bacterial resistance and 41% acknowledged prescribing antibiotics more often than necessary. Two factors were independently associated with appropriate prescription practices: a high perceived level of education on antibiotic use (OR=1.51; 95% CI [1.01-2.30]) and a medical specialty (OR=1.69; 95% CI [1.16-2.46]). Factors independently associated with taking into account adverse events of antibiotics were a good perceived knowledge of antibiotics (OR=3.71; 95% CI [2.09-6.61]), and a high perceived education level on antibiotics (OR=1.70; 95% CI [1.11-2.58]).

CONCLUSION

Our data can help better define interventions targeting junior physicians in antibiotic stewardship programs.

Role of Education in Antimicrobial Stewardship

The ability to treat infectious diseases with antimicrobials is an essential component of medical management. Antimicrobial therapy is based on the characteristics of the patient, drug, microorganisms causing the infection, and colonizing flora. Prudent antibiotic use is the only option to delay the emergence of resistance. Training in infectious diseases and knowledge of the principles of responsible antibiotic prescribing and uses must be improved. To change practice, health care professionals should be educated at all levels of their training.

Knowledge, Attitude, and Practice with Respect to Antibiotic Use among Chinese Medical Students: A Multicentre Cross-Sectional Study

Objective: Inappropriate antibiotic use leads to antibiotic resistance. This has become a serious global crisis, with more multi-drug resistant infections and fewer effective antibiotics available. This study aims to understand knowledge, attitude, and practice (KAP) with respect to antibiotic use for self-limiting illnesses among medical students in China. Methods: An online cross-sectional survey instrument questionnaire was distributed in six regional universities in China from September to November 2015. Overall, 1819 medical students were enrolled. A pre-tested questionnaire was delivered by the researchers. KAP scores were calculated to determine the appropriation. Chi-squared and multivariable logistic regression and adjusted odd ratios (aORs) with 95% confidence interval (CI) were used to assess the relationship between the demographic characteristics and antibiotic use knowledge and behaviour. Results: In total, 11,192 students completed the questionnaires, with a response rate of 95%. In total, 529 (29%) medical students reported at least one self-limiting illness in the prior month. Of those with a self-limiting illness, 285 (54%) self-medicated, with 77 (27%) using antibiotics; 111 (21%) went to see a doctor, of which 64 (58%) were prescribed antibiotics, and 133 did nothing (25%). In the past year, 279 (15%) of medical students had used antibiotics as prophylaxis, and 273 (15%) of medical students had demanded an antibiotic from a doctor. Meanwhile, 1166 (64%) of them kept a personal stock of antibiotics, and 1034 (57%) of them had bought antibiotics at a pharmacy, of which 97% were purchased without a prescription. Students with high KAP scores with respect to antibiotics were significantly less likely to self-medicate with antibiotics (aOR 0.37, 95% CI 0.15–0.91, p = 0.031), use antibiotics for prophylaxis (aOR 0.35, 95% CI 0.21–0.60, p < 0.0001), or demand an antibiotic (aOR 0.46, 95% CI 0.26–0.81, p = 0.007) from the doctor. Logistical regression showed that students whose fathers had a higher education level, whose mothers had medical background, who were from urban areas were more likely to stock antibiotics and self-medicate with antibiotics. Conclusion: High rates of antibiotic self-medication for self-limiting illness and stocking of antibiotics among medical students were observed. Along with the high rates of medical students receiving unnecessary antibiotics from their doctors were observed. The students’ knowledge and attitude towards to antibiotics, which drive prescribing, highlight the urgent need for effective antibiotic stewardship and training programs in Chinese healthcare institutes and medical schools.

A review of antimicrobial stewardship training in medical education

OBJECTIVES

We reviewed the published literature on antimicrobial stewardship training in undergraduate and postgraduate medical education to determine which interventions have been implemented, the extent to which they have been evaluated, and to understand which are most effective.

METHODS

We searched Ovid MEDLINE and EMBASE from inception to December 2016. Four thousand three hundred eighty-five (4385) articles were identified and underwent title and abstract review. Only those articles that addressed antimicrobial stewardship interventions for medical trainees were included in the final review. We employed Kirkpatrick's four levels of evaluation (reaction, learning, behaviour, results) to categorize intervention evaluations.

RESULTS

Our review included 48 articles. The types of intervention varied widely amongst studies worldwide. Didactic teaching was used heavily in all settings, while student-specific feedback was used primarily in the postgraduate setting. The high-level evaluation was sparse, with 22.9% reporting a Kirkpatrick Level 3 evaluation; seventeen reported no evaluation. All but one article reported positive results from the intervention. No articles evaluated the impact of an intervention on undergraduate trainees' prescribing behaviour after graduation.

CONCLUSIONS

This study enhances our understanding of the extent of antimicrobial stewardship in the context of medical education. While our study demonstrates that medical schools are implementing antimicrobial stewardship interventions, rigorous evaluation of programs to determine whether such efforts are effective is lacking. We encourage more robust evaluation to establish effective, evidence-based approaches to training prescribers in light of the global challenge of antimicrobial resistance.

Master of Pharmacy students' knowledge and awareness of antibiotic use, resistance and stewardship

INTRODUCTION

Antibiotic resistance has become a global public health concern. In this study, we investigated the knowledge and awareness of antibiotic use, resistance and stewardship, held by the pharmacy students currently studying at the University of Brighton.

METHODS

This was a cross-sectional, online survey, and email invitations to participate were sent to all students attending our Master of Pharmacy (MPharm) course (n=583). Students' knowledge was assessed with 29 items; responses for these were totaled before comparison among students. Comparison of scores between groups of students was performed using the Kruskal-Wallis or the Mann-Whitney U test, as appropriate.

RESULTS

The response rate was 32%. The overall median knowledge score was 7.9. There was a statistically significant difference in knowledge scores between years of study (p=0.02), particularly between year of study 1 (7.6) and 4 (8.3). A statistically significant difference was found between the knowledge scores of male (8.4) and female (7.9) students (p=0.03). Most students believed a strong knowledge of antibiotics, and microbiology and infection control is important for their pharmacy careers and more than 90% agreed that antibiotic resistance will be a greater clinical problem in the future.

DISCUSSION AND CONCLUSIONS

Although the MPharm students studied achieved good overall knowledge scores, a significant proportion showed a lack of understanding with regards to some important aspects of antibiotic resistance mechanisms, factors promoting the emergence and spread of antibiotic resistance, and antibiotic stewardship policies.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines

OBJECTIVE

The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy.

METHODS

Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015.

RESULTS

The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data.

CONCLUSION

Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Attitudes and perceptions regarding antimicrobial use and resistance among medical students in Central China

OBJECTIVES

Senior medical students, who are future doctors, should be prepared to use antimicrobials appropriately and will be important partners in antimicrobial stewardship. This survey was designed to investigate the attitudes and perceptions of senior medical students regarding antimicrobial use and resistance.

METHODOLOGY

We performed a multi-center survey involving a questionnaire handed out to all fourth year medical students from five representative teaching hospitals in Central China. The survey was completed within 1 month (October to November, 2015). Antimicrobial stewardship programs were taught in all of the teaching hospitals, yet only part of the respondents took part in it.

RESULTS

A total of 611 out of 728 students completed our survey. The majority of the respondents (92 %) believed that inappropriate use of antimicrobials causes antimicrobial resistance and agreed with the importance of a strong knowledge of antimicrobials in their medical careers. Most students (67 %) rated their education concerning antimicrobial use and resistance as useful or very useful, but only 25 % recalled having courses on this subject. The overall mean number of correct answers on a section of 11 knowledge questions was 3.78 (standard deviation 1.57, P value for score between hospitals <0.001).

CONCLUSIONS

We should make an effort to optimize curriculum system in Chinese institutions, and this may contribute to making our future doctors better prepared for antimicrobial stewardship and prudent antimicrobial prescribing.

A needs assessment study for optimising prescribing practice in secondary care junior doctors: the Antibiotic Prescribing Education among Doctors (APED)

Background

Appropriate antimicrobial prescribing is essential for patient care, yet up to half of antimicrobial prescriptions written in the UK are sub-optimal. Improving prescriber education has recently been promoted as a mechanism to optimise antimicrobial use, but identification of key learning objectives to facilitate this is so far lacking. Using qualitative methods we investigated junior doctor knowledge, attitudes, and behaviours around antimicrobial prescribing to identify key areas to address in future educational programmes.

Methods

A cross-sectional survey of qualified doctors in training in West London was undertaken exploring antimicrobial prescribing practices and educational needs.

Results

Among 140 junior doctors from 5 London hospitals, a third (34 %) reported prescribing primarily unsupervised, and two thirds (67 %) reported difficulties obtaining prescribing support outside of hours. 20 % stated not feeling confident in writing an antimicrobial prescription, but confidence was increased through having confirmatory diagnostic results (24) and obtaining advice from a senior doctor (26 %); whether this senior was from their own specialty, or an infection-specialist, varied significantly (p < 0.01) by experience. Only a small percentage (5–13 %; depending on number of years post-qualification) of participants stated their previous antimicrobial education was effective. 60 % of those in their first year post qualification reported wanting further education in antimicrobial prescribing, rising to 74 % among more experienced junior doctors. Specific areas of educational need identified were (i) principles of antimicrobial prescribing, (ii) diagnosis of infections, (iii) clinical review of patients with infections, (iv) prescribing in the context of antimicrobial resistance, and (v) laboratory testing and test results.

Conclusions

A significant proportion of junior doctors report lone prescribing of antimicrobials in the context of low self-perceived confidence and knowledge in this field, and frequent difficulty in accessing help when necessary. Innovative training, targeting five specific areas identified through this needs assessment, is urgently needed by junior doctors practising in secondary care.

Mapping Antimicrobial Stewardship in Undergraduate Medical, Dental, Pharmacy, Nursing and Veterinary Education in the United Kingdom

Objectives

To investigate the teaching of antimicrobial stewardship (AS) in undergraduate healthcare educational degree programmes in the United Kingdom (UK).

Participants and Methods

Cross-sectional survey of undergraduate programmes in human and veterinary medicine, dentistry, pharmacy and nursing in the UK. The main outcome measures included prevalence of AS teaching; stewardship principles taught; estimated hours apportioned; mode of content delivery and teaching strategies; evaluation methodologies; and frequency of multidisciplinary learning.

Results

80% (112/140) of programmes responded adequately. The majority of programmes teach AS principles (88/109, 80.7%). ‘Adopting necessary infection prevention and control precautions’ was the most frequently taught principle (83/88, 94.3%), followed by 'timely collection of microbiological samples for microscopy, culture and sensitivity’ (73/88, 82.9%) and ‘minimisation of unnecessary antimicrobial prescribing’ (72/88, 81.8%). The ‘use of intravenous administration only to patients who are severely ill, or unable to tolerate oral treatment’ was reported in ~50% of courses. Only 32/88 (36.3%) programmes included all recommended principles.

Discussion

Antimicrobial stewardship principles are included in most undergraduate healthcare and veterinary degree programmes in the UK. However, future professionals responsible for using antimicrobials receive disparate education. Education may be boosted by standardisation and strengthening of less frequently discussed principles.