Socio-economic factors, cultural values, national personality and antibiotics use: A cross-cultural study among European countries

Further Validation of the Persecutory Ideation Questionnaire in the Italian Context: Results From Classical and Modern Test Theory

The Persecutory Ideation Questionnaire (PIQ) is a valuable instrument to measure persecutory ideation. The aim of this study is to validate the scale in the Italian context and to extend the study of its psychometric properties using approaches from both classical and modern test theories. The results of the study, involving 700 individuals, confirmed the one-factor structure and the good validity and reliability of the scale. Full metric invariance and partial scalar and strict invariance were also supported across gender, age, and education level groups. Rasch analysis indicated that the 5-point response scale is well-functioning and that the PIQ is most appropriate to measure high levels of persecutory ideation. The results contribute to a better understanding of the measurement properties of the PIQ. The paper discusses the advantages and contributions of each method used to explore the measurement properties of the scale.

High prevalence of antibiotic resistance of Streptococcus species in saliva from non-hospitalized adults - a pilot study

Background

Antibiotic resistance (AR) is a recognized threat to global human health. However, the prevalence of AR in healthy adults is not well described. The present observational pilot study aimed to uncover the potential of using saliva samples for screening for antibiotic resistance.

Methodology

A laboratory protocol was developed for screening of AR in saliva samples, which was tested and validated using saliva samples collected from 100 study participants. The risk of AR was analyzed with descriptive statistics and evaluated using a risk-factor profile based on information on antibiotic usage within the last 12 months, education level and origin of birth.

Results

AR was identified in 43 (48%) saliva samples, out of which 60,0% and 17,1% of resistant strains displayed resistance to clindamycin and penicillin, respectively. Streptococcus salivarius and Streptococcus parasanguinis were most often identified with AR (51,4% of all cases). The risk of AR was not associated with self-perceived oral or general health, antibiotic use within the latest 12 months or any demographic or socioeconomic parameters recorded. The risk-factor profile was observed in 44% in the AR group versus 30% in the non-AR group (p = 0.19).

Conclusion

The present study showed that it is possible to perform non-invasive saliva-based screening for AR with a frequency of 48% of the samples, highlighting that saliva samples could be a valuable supplement to current surveillance methodologies for AR in the oral microbiota.

Harnessing biotechnology for penicillin production: Opportunities and environmental considerations

Since the discovery of antibiotics, penicillin has remained the top choice in clinical medicine. With continuous advancements in biotechnology, penicillin production has become cost-effective and efficient. Genetic engineering techniques have been employed to enhance biosynthetic pathways, leading to the production of new penicillin derivatives with improved properties and increased efficacy against antibiotic-resistant pathogens. Advances in bioreactor design, media formulation, and process optimization have contributed to higher yields, reduced production costs, and increased penicillin accessibility. While biotechnological advances have clearly benefited the global production of this life-saving drug, they have also created challenges in terms of waste management. Production fermentation broths from industries contain residual antibiotics, by-products, and other contaminants that pose direct environmental threats, while increased global consumption intensifies the risk of antimicrobial resistance in both the environment and living organisms. The current geographical and spatial distribution of antibiotic and penicillin consumption dramatically reveals a worldwide threat. These challenges are being addressed through the development of novel waste management techniques. Efforts are aimed at both upstream and downstream processing of antibiotic and penicillin production to minimize costs and improve yield efficiency while lowering the overall environmental impact. Yield optimization using artificial intelligence (AI), along with biological and chemical treatment of waste, is also being explored to reduce adverse impacts. The implementation of strict regulatory frameworks and guidelines is also essential to ensure proper management and disposal of penicillin production waste. This review is novel because it explores the key remaining challenges in antibiotic development, the scope of machine learning tools such as Quantitative Structure-Activity Relationship (QSAR) in modern biotechnology-driven production, improved waste management for antibiotics, discovering alternative path to reducing antibiotic use in agriculture through alternative meat production, addressing current practices, and offering effective recommendations.

Outpatient parenteral antimicrobial therapy (OPAT) across the world: a comparative analysis-what lessons can we learn?

This paper presents a comparative analysis of Outpatient Parenteral Antimicrobial Therapy (OPAT) structures and delivery options across different countries. OPAT, a cost-effective alternative to inpatient care for patients requiring IV antimicrobial therapy, has demonstrated multiple benefits such as patient satisfaction, economic cost savings, and reduced hospital-acquired infections. Despite these advantages, there is considerable international variation in OPAT use and implementation. By examining the OPAT structures of multiple countries, we aim to identify areas of variation and explore opportunities for expansion and improvement of OPAT services.

Dental antimicrobial stewardship: a qualitative study of perspectives among Canadian dentistry sector leaders and experts in antimicrobial stewardship

Objectives

Dentistry is a significant contributor to the burden of antimicrobial overprescribing and hence to the global problem of antimicrobial resistance. However, antimicrobial stewardship in Canadian dentistry is nascent, with an acknowledged need for research and coordinated stewardship efforts. This study aimed to gain insights into the perspectives of Canadian dentistry sector leaders and experts on the main drivers of dental antibiotic overprescribing and potential stewardship strategies.

Methods

Exploratory qualitative design. Data collection: four one-time, 1 h focus group discussions with 22 experts and stakeholders in antimicrobial stewardship in Canada, recruited through a mix of purposive and snowball sampling. Data analysis: inductive thematic analysis.

Results

The analysis yielded five themes: outdated patterns; antimicrobials as a Band-Aid; fear and risk aversion; behavioural change; and why reinvent the wheel? Overprescription in dentistry stems primarily from a perpetuation of outdated prescribing patterns, ubiquitous use of antibiotics as a temporary solution, and an overly cautious antibiotic use by risk-averse providers. Stewardship strategies should be grounded on behavioural change (motivation, robust data and enactment of new behaviours) and may be modelled after tested medical interventions.

Conclusions

This study presents a roadmap for behavioural change in dental antibiotic prescribing, and points to the fact that the success of a stewardship actionable plan for Canadian dentistry may depend more on concerted efforts for change than on the creation of novel strategies. Hence, contextualizing and testing medical stewardship programmes in Canadian dentistry may be effective in combatting antibiotic overprescription, thereby contributing to global efforts to reduce antimicrobial resistance.

Trends of antimicrobial use through selected antimicrobial indicators in Spanish hospitals, 2012 to 2021

BACKGROUND

Surveillance of antimicrobial consumption is an important component of control strategies to tackle antimicrobial resistance.

AIM

To evaluate the consumption of antimicrobials using six indicators proposed by the European Center for Disease Prevention and Control.

METHODS

Point prevalence survey data on antimicrobial use in Spanish hospitals throughout the period 2012-2021 were analysed. A descriptive analysis of each indicator by year is performed globally and by hospital size. A logistic regression model was used to identify significant time trends.

FINDINGS

515,414 patients and 318,125 antimicrobials were included. The prevalence of antimicrobial use remained stable throughout the study period (45.7%; 95%CI: 45.6-45.8). Percentages of antimicrobials for systemic use and those administered parenterally showed a small and significant increasing trend ([OR 1.02; 95% CI: 1.01-1.02]; [OR 1.03; 95% CI: 1.02-1.03], respectively). Small improvements were found in the percentages of antimicrobials prescribed for medical prophylaxis and with the reason for use documented in patients' medical records (-0.6%; 4.2% respectively). The percentage of surgical prophylaxis prescribed for more than 24 hours shows a significant improvement reducing from 49.9% (95% CI: 48.6-51.3) in 2012 to 37.1% (95%CI: 35.7-38.5) in 2021.

CONCLUSION

The results allow us to assess the national situation and the trends on antimicrobial use in the Spanish hospitalised population during the last decade. Spanish hospitals have a stable but high prevalence of antimicrobial use. Little to no improvement has been made in most of the indicators analysed, except for a reduction in the prescription of surgical prophylaxis for more than 24 hours.

Antimicrobial Resistance in the Global Health Network: Known Unknowns and Challenges for Efficient Responses in the 21st Century

Antimicrobial resistance (AMR) is one of the Global Health challenges of the 21st century. The inclusion of AMR on the global map parallels the scientific, technological, and organizational progress of the healthcare system and the socioeconomic changes of the last 100 years. Available knowledge about AMR has mostly come from large healthcare institutions in high-income countries and is scattered in studies across various fields, focused on patient safety (infectious diseases), transmission pathways and pathogen reservoirs (molecular epidemiology), the extent of the problem at a population level (public health), their management and cost (health economics), cultural issues (community psychology), and events associated with historical periods (history of science). However, there is little dialogue between the aspects that facilitate the development, spread, and evolution of AMR and various stakeholders (patients, clinicians, public health professionals, scientists, economic sectors, and funding agencies). This study consists of four complementary sections. The first reviews the socioeconomic factors that have contributed to building the current Global Healthcare system, the scientific framework in which AMR has traditionally been approached in such a system, and the novel scientific and organizational challenges of approaching AMR in the fourth globalization scenario. The second discusses the need to reframe AMR in the current public health and global health contexts. Given that the implementation of policies and guidelines are greatly influenced by AMR information from surveillance systems, in the third section, we review the unit of analysis ("the what" and "the who") and the indicators (the "operational units of surveillance") used in AMR and discuss the factors that affect the validity, reliability, and comparability of the information to be applied in various healthcare (primary, secondary, and tertiary), demographic, and economic contexts (local, regional, global, and inter-sectorial levels). Finally, we discuss the disparities and similarities between distinct stakeholders' objectives and the gaps and challenges of combatting AMR at various levels. In summary, this is a comprehensive but not exhaustive revision of the known unknowns about how to analyze the heterogeneities of hosts, microbes, and hospital patches, the role of surrounding ecosystems, and the challenges they represent for surveillance, antimicrobial stewardship, and infection control programs, which are the traditional cornerstones for controlling AMR in human health.

Combating coronavirus disease (COVID-19) in rural areas of Malawi: Factors affecting the fight

BACKGROUND

Owing to their detachment from urban areas, people living in rural areas of Malawi are on the receiving end of health services and socio-economic benefits. The study therefore explored how Malawians living in these areas are adhering to coronavirus disease 2019 (COVID-19) containment measures and the factors that affect the COVID-19 fight amongst this population.

AIM

The study investigated how the rural population in Malawi adheres to COVID-19 containment measures.

SETTING

The study was conducted in two districts in Northern Malawi.

METHODS

Data were collected from 263 participants. The chi-square (χ2) test was performed to determine the association between demographic variables and COVID-19 prevention practices and factors affecting the COVID-19 fight.

RESULTS

Education was significantly associated with wearing of masks (p = 0.01), use of sanitisers (p 0.01) and practising social distancing (p = 0.07). Monthly income was associated with the use of sanitisers (p 0.01). Women were more exposed to fake news about COVID-19 (p = 0.09); older people were more likely to disregard COVID-19 containment measures for cultural reasons (p = 0.07); and monthly income was associated with a lack of resources for following COVID-19 containment measures (p 0.01).

CONCLUSION

Findings show that factors affecting the COVID-19 fight are influenced by various socio-economic factors which should therefore be taken into account in policy planning aiming at controlling the pandemic.Contribution: The study provides health stakeholders with a policy direction that enhances better coordination, implementation and monitoring of COVID-19 response and recovery activities in rural areas in Malawi. The findings have implications on controlling current and future communicable diseases; the proposed strategies might be employed in fighting similar current and future pandemics.

Antibiotic use for respiratory tract infections among older adults living in long-term care facilities: a systematic review and meta-analysis

BACKGROUND

Antibiotics are commonly prescribed for respiratory tract infections (RTIs) among older adults in long-term care facilities (LTCFs), and this contributes to the emergence of antimicrobial resistance. The objective of this study was to determine the antibiotic prescribing rate for RTIs among LTCF residents, and to analyse the antibiotic consumption patterns with the AwaRe monitoring tool, developed by the World Health Organization.

METHODS

MEDLINE, EMBASE and CINAHL were searched from inception to March 2022. Original articles reporting antibiotic use for RTIs in LTCFs were included in this review. Study quality was assessed using the Joanna Briggs Institute's Critical Appraisal Checklist for Prevalence Data. A random-effects meta-analysis was employed to calculate the pooled estimates. Subgroup analysis was conducted by type of RTI, country, and study start year.

RESULTS

In total, 47 articles consisting of 50 studies were included. The antibiotic prescribing rate ranged from 21.5% to 100% (pooled estimate 69.8%, 95% confidence interval 55.2-82.6%). The antibiotic prescribing rate for lower respiratory tract infections (LRTIs) was higher than the rates for viral and general RTIs. Compared with Italy, France and the USA, the Netherlands had lower antibiotic use for LRTIs. A proportion of viral RTIs were treated with antibiotics, and all the antibiotics were from the Watch group. Use of antibiotics in the Access group was higher in the Netherlands, Norway, Switzerland and Slovenia compared with the USA and Australia.

CONCLUSION

The antibiotic prescribing rate for RTIs in LTCFs was high, and AWaRe antibiotic use patterns varied by type of RTI and country. Improving antibiotic use may require coordination efforts.

Knowledge, attitudes and behaviours regarding antibiotics use among Cypriot university students: a multi-disciplinary survey

BACKGROUND

The present study aims to investigate the knowledge and attitudes towards antibiotics among students studying medicine, dentistry, and pharmacy at the Near East University in Northern Cyprus. The influence of personality characteristics on antibiotic use were also evaluated, in order to identify predictors of antibiotic misuse.

METHODS

Students were enrolled in the study during the 2020-2021 academic year. Study participants were asked to complete an online questionnaire that measured their knowledge, attitudes and practice (KAP) towards antibiotic use and antibiotic resistance. The KAP of students from the three faculties were compared using Kruskall-Wallis H statistics, Mann-Whitney U statistics, and Spearman's rho. The influence of personality traits on the propensity to use antibiotics without a prescription, as well as their attitudes and knowledge of antibiotic use and misuse, were also investigated.

RESULTS

In total, 314 students completed the survey, 52% of which were female. The mean age of the students was 20.5 years. The results showed that among the different disciplines, medical students were significantly more knowledgeable about pharmacological agents, compared to dentistry and pharmacy students, while pharmacy students were more knowledgeable about the effectiveness of antibiotics against different pathogenic microorganisms. All student groups were aware of how antibiotic resistance develops and their role as healthcare personnel in implementing measures against resistance. Appropriate antibiotic use among the student community correlated with study year, highlighting the importance of knowledge and education in the prevention of antibiotic resistance. Personality traits were found to be a contributing factor in students' tendency to use antibiotics without a prescription.

CONCLUSION

This study demonstrates the importance of conveying knowledge about antimicrobials in the education programmes of future dentists, pharmacists and physicians.

Factors associated with self-medication of antibiotics by caregivers in pediatric patients attending the emergency department: a case-control study

Introduction

Antibiotic self-medication is a common practice in pediatric caregivers in low-income countries with limited resources and represents a public health problem. Our study sought to determine what factors are associated with this practice, including differences in knowledge or attitudes of caregivers who attend a pediatric emergency service.

Methods

Case-control study based on surveys of caregivers of pediatric patients brought to the emergency room with clinical symptoms suggestive of acute infection. Cases were defined as those caregivers who reported self-medication of antibiotics for the current illness and controls where those who did not report self-medication. Information was collected through a self-administered questionnaire that inquired about demographic and family characteristics, attitudes and knowledge toward self-medication of antibiotics. Data were compared using logistic regression and are presented with odd ratios and confidence intervals.

Results

A total of 728 caregivers, 182 cases and 546 controls were included. We found that higher parental education, both in mothers (OR 0.56, 95% CI 0.40-0.79) and fathers (OR 0.62, 95% CI 0.43-0.89) was associated with less self-medication. Attitudes such as always requesting antibiotics from their doctors (OR 3.92, 95% CI 1.59-9.66), frequently buying antibiotics without a prescription (OR 23.66, 95% CI 11.76-47.59) and giving advice on antibiotics among family members (OR 2.90, 95% CI 1.75-4.82) resulted in an increased likelihood of self-medication. There was also a higher probability of antibiotic self-medication in older children (OR 1.13, 95% CI 1.09-1.17), those with a greater number of siblings (OR 1.25, 95% CI 1.09-1.43) and in those cases that received antibiotics within the last 3 months (OR 6.27, 95% CI 4.35-9.04). Overall knowledge of risk of antibiotic self-medication was low.

Conclusions

Some patient and family characteristics such as age, number of siblings, recent antibiotic usage and inappropriate attitudes are strongly related to antibiotic self-medication. These findings will inform future interventions to reduce self-medication in children.

Do biomedical researchers differ in their perceptions of plagiarism across Europe? Findings from an online survey among leading universities

BACKGROUND

Existing research on perceptions of plagiarism and cultural influences mainly focuses on comparisons between the Western World and the Eastern World. However, possible differences within the Western World have hardly been assessed, especially among biomedical academics. The authors compared perceptions of plagiarism among European biomedical researchers who participated in an online survey.

METHODS

The present work is based on the data collected in a previous online survey done in 2018 among biomedical researchers working in leading European and Chinese universities. Respondents based in Europe were grouped into three geographical regions (northern Europe, southern Europe and northwestern Europe) and their responses were analyzed using logistic regression analysis with adjustments for demographic factors.

RESULTS

Data were available from 810 respondents (265 northern Europe, 101 southern Europe, 444 northwestern Europe). In addition to their generally similar responses, different perceptions of plagiarism were observed among respondents in the three European regions. In summary, among the three European regions, Nordic respondents identified the most types of practices as plagiarism. Compared to the southern respondents, Nordic and northwestern respondents were more likely to consider less evident practices as plagiarism, such as Rephrasing another person's work without crediting the source [aOR_N|S 1.99 (95%CI 1.08;3.67), aOR_S|NW 0.50 (95%CI 0.28;0.91)] and With permission from the original author, using another's text without crediting the source [aOR_N|S 3.16 (95%CI 1.90;5.25), aOR_S|NW 0.26 (95%CI 0.16;0.42)]. In contrast, the southern respondents were the most inclined to recognize recycling of one's previously rejected research proposal as plagiarism.

CONCLUSIONS

In spite of a generally similar response pattern, the present study indicates different perceptions of plagiarism among European biomedical researchers. These intra-European differences should be considered when addressing plagiarism.

Socio-cultural determinants of antibiotic resistance: a qualitative study of Greeks' attitudes, perceptions and values

Background

Antibiotic resistance is a complex phenomenon heavily influenced by social, cultural, behavioural, and economic factors that lead to the misuse, overuse and abuse of antibiotics. Recent research has highlighted the role that norms and values can play for behaviours that contribute to resistance development, and for addressing such behaviours. Despite comparatively high antibiotic consumption in Greece, both at the community and healthcare level, Greeks have been shown to be relatively aware of the connection between antibiotic overuse and antibiotic resistance. This suggests that Greeks’ non-judicious use cannot simply be explained by lack of awareness but may relate to other factors specific to Greek society. The present study aimed to explore attitudes, perceived norms, and values in relation to antibiotics, in order to improve understanding of socio-cultural determinants of antibiotic resistance in Greece.

Methods

Data were collected through online focus group discussions in 2021. Twenty Greeks were recruited through purposive sampling, aiming for as heterogeneous groups as possible regarding gender (12 women, 8 men), age (range 21–55, mean 33), and education level. Interview transcripts were analysed inductively using thematic content analysis.

Results

Participants considered antibiotic overconsumption as a consolidated habit influenced by ease of access, social expectations and, more generally, cultural practices. While critical of such norms and practices, participants opposed stewardship measures that would prioritize the societal interest in maintaining antibiotic effectiveness over individual needs. Participants considered responsibility for antibiotic resistance to be shared by the whole society, but the role of government actors and health professionals as well as of food producers was emphasized. Notably, scepticism about the prospect of effectively managing antibiotic resistance in Greece was commonly expressed.

Conclusions

The study makes explicit attitudes, perceived norms and values that, besides limited awareness, may contribute to non-judicious antibiotic use in Greece. These socio-cultural determinants of antibiotic resistance warrant further research and should be considered when designing measures aimed to mitigate this problem.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13855-w.

Power dynamics in doctor-patient relationships: A qualitative study examining how cultural and personal relationships facilitate medication requests in a minority with collectivist attributes

INTRODUCTION

This study examines personal patient-doctor relationships in a minority with collectivist attributes that facilitate medically inappropriate requests of patients.

METHODS

Personal interviews were conducted with 56 (27 family doctors/ 29 patients) members of the Arab minority in Israel. The interviews were transcribed, and thematically analyzed by two coders.

FINDINGS

Collectivist attributes and long-term patient-doctor relationships, patients' close and mostly familial affiliation to the doctor, and informal policies of recruiting members to sick funds by doctors could result in shifting power dynamics in patients' favor and enhance their confidence to request treatments from their doctor.

CONCLUSIONS

The present study highlights examining closely-knit patient-doctor relationships in a society with collectivist attributes that foster and reinforce patients' requests. These personal relationships challenge patient-doctor partnerships and the patient-centeredness approach. Instead of collaborating and discussing whether a treatment is needed, patients might pressure for inappropriate treatments and doctors accede. These relationships can be channelled to promote patient centeredness and patient-doctor collaboration.

PRACTICAL IMPLICATIONS

Programs promoting prudent provision of treatments can emphasize that collectivist attributes and personal relationships challenge professional boundaries in patient-doctor relationships. Also, doctors' experiences dealing with patients' pressures to prescribe medications, could serve as a base for these programs.

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

BACKGROUND

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

Thank Martin Luther that ciprofloxacin could cure your gonorrhoea? Ecological association between Protestantism and antimicrobial consumption in 30 European countries

Background: Higher consumption of antimicrobials plays an important role in driving the higher prevalence of antimicrobial resistance in Southern compared to Northern Europe. Poor controls on corruption (CoC), high uncertainty avoidance (UA) and performance vs. cooperation orientation (POCO) of societies have been found to explain much of this higher consumption in Southern European countries.  We hypothesized that these predictors were in turn influenced by the Protestant Reformation in the 16th century onwards. Methods: We used structural equation modelling (SEM) to assess the relationships between country-level proportions being Protestant, CoC, UA, POCO and four markers of antimicrobial consumption in the community (all antibacterials, cephalosporin, macrolides and fluoroquinolones). Results: The proportion of a country that was Protestant was negatively correlated with the consumption of all antibacterials. SEM revealed that UA predicted all antibacterial consumption (direct effect coef. 0.15, 95% Confidence Interval [CI] 0.04-0.26). The proportion Protestant exerted an indirect effect on consumption (coef. -0.13, 95% CI -0.21- -0.05). This effect was mediated predominantly via its effect on UA (direct effect coef. 0.15, 95% CI 0.04-0.26). The model explained 37% of the variation in consumption.  Similar results were obtained for each of the other three classes of antimicrobials investigated. Conclusions: Our results are compatible with the theory that contemporary differences in antimicrobial consumption in Europe stem in part from cultural differences that emerged in the Reformation. These findings may explain the differential efficacy of similar antibiotic stewardship campaigns in Northern and Southern European populations.

Values and Risk Perception Shape Canadian Dairy Farmers' Attitudes toward Prudent Use of Antimicrobials

Antimicrobial resistance (AMR) is an important challenge in public health. Ensuring rational antimicrobial use (AMU) on farms is one of the key components of antimicrobial stewardship. We aimed to describe a sample of Canadian dairy farmers' personal factors for AMUand their AMR risk perception, and to associate these factors with their attitude toward promotion of prudent AMU. We distributed an online survey among dairy farmers in Ontario and Atlantic Canada (New Brunswick, Nova Scotia, and Prince Edward Island). The questionnaire was designed to solicit information on dairy farmers' AMU decision-making process, attitudes toward AMU reduction, awareness of AMR, and individual values. We performed a factor analysis on 15 statements related to AMR awareness and AMU reduction and used a logistic regression model to identify variables associated with the probability of disagreeing with the need to increase promotion of responsible AMU in the dairy industry. Respondents' (n = 193) previous experience was the main reason to select an antimicrobial treatment for their cattle. We identified four groups of factors related to knowledge, risk perception, and emotional states among respondents. To the question "Should there be more initiatives to promote responsible use of antibiotics in the dairy industry?" 23% of respondents answered no, which was associated in a logistic regression model with being a farm owner, having a tie-stall barn, and considering their own experience as the most important factor in selecting antimicrobial treatments. The score for the conservation value dimension and score for a factor described as sense of responsibility when using antimicrobials were also retained in the final model. Our results indicate that tailored strategies to promote prudent AMU on dairy farms may be preferable to a generic strategy because there are individual differences in attitudes, values, and AMR awareness that shape AMR risk perception and willingness to modify current AMU practices.

Navigating the care between two distinct cultures: a qualitative study of the experiences of Arabic-speaking immigrants in Norwegian hospitals

Background

During the past decades, there has been an increase in the number of immigrants to European and Scandinavian countries. This has challenged the health-care systems, which cater to the needs of patients despite their cultural and linguistic barriers, in these countries. Most studies on this topic have focused on the perspectives of health-care providers in delivering their service. The purpose of this qualitative study was to explore how hospitalized Arabic-speaking patients experienced their interaction with the Norwegian health-care system.

Methods

In-depth interviews with 20 participants and researcher’s participant observation were conducted to explore the idiosyncratic details and ascribed meanings that foreign-born patients attach to their everyday experience of the Norwegian health-care system. Thematic analysis was performed on the transcribed and translated versions of the in-depth interviews.

Results

The findings of this study indicated three interrelated core themes. Firstly, there exist challenges in understanding and being understood because of linguistic and cultural differences of newly migrated patients. Secondly, some patients missed the holistic and direct care available in their home countries. Finally, patients were satisfied with the Norwegian health-care system because of its compassion, care, and respect toward them as well as advanced health-care equipment.

Conclusion

Arabic-speaking patients in Norwegian hospitals experienced long waiting times and linguistic problems. Hence, a better and specialized interpreter service may resolve problems emanating from communication within the system and the subsequent delays in treatment. Compassionate care and the feeling of respect and love is the core strength of the Norwegian system as perceived by the patients.

Point of care testing, antibiotic prescribing and prescribing confidence for respiratory tract infections in primary care: Prospective audit in 18 European countries

BACKGROUND

Between-country differences have been described in antibiotic prescribing for RTI in primary care, but not yet for diagnostic testing procedures and prescribing confidence.

AIM

To describe between-country differences in RTI management, particularly diagnostic testing and antibiotic prescribing, and investigate which factors relate to antibiotic prescribing and GPs' prescribing confidence.

DESIGN & SETTING

Prospective audit in 18 European countries.

METHOD

GPs registered patient-, clinical- and management characteristics, and confidence in their antibiotic prescribing decision for patients presenting with sore throat and/or lower RTI (n=4,982). Factors related to antibiotic prescribing and confidence were analysed using multi-level logistic regression.

RESULTS

Antibiotic prescribing proportions varied considerably:<20% in four countries, and >40% in six countries. There was also considerable variation in POC testing (0% in Croatia, Moldova, Romania, and >65% in Denmark, Norway, mainly CRP and Strep A), and in lab/hospital-based testing (<3% in Hungary, Netherlands, Spain, and >30% in Croatia, Georgia, Greece, Moldova, mainly chest X-ray and white blood cell counting). Antibiotic prescribing was related to illness severity, comorbidity, age, fever and 'country', but not to having performed a POC test. In nearly 90% of consultations, GPs were confident in their antibiotic prescribing decision.

CONCLUSION

Despite high confidence in decisions about antibiotic prescribing, there is considerable variation in the primary care of RTI in European countries, with GPs prescribing antibiotics overall more often than is considered appropriate. POC testing may enhance the quality of antibiotic prescribing decisions if it can safely reverse decisions confidently made on clinical grounds alone to prescribe antibiotics.

Global antibiotic consumption and usage in humans, 2000-18: a spatial modelling study

BACKGROUND

Antimicrobial resistance (AMR) is a serious threat to global public health. WHO emphasises the need for countries to monitor antibiotic consumption to combat AMR. Many low-income and middle-income countries (LMICs) lack surveillance capacity; we aimed to use multiple data sources and statistical models to estimate global antibiotic consumption.

METHODS

In this spatial modelling study, we used individual-level data from household surveys to inform a Bayesian geostatistical model of antibiotic usage in children (aged <5 years) with lower respiratory tract infections in LMICs. Antibiotic consumption data were obtained from multiple sources, including IQVIA, WHO, and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). The estimates of the antibiotic usage model were used alongside sociodemographic and health covariates to inform a model of total antibiotic consumption in LMICs. This was combined with a single model of antibiotic consumption in high-income countries to produce estimates of antibiotic consumption covering 204 countries and 19 years.

FINDINGS

We analysed 209 surveys done between 2000 and 2018, covering 284 045 children with lower respiratory tract infections. We identified large national and subnational variations of antibiotic usage in LMICs, with the lowest levels estimated in sub-Saharan Africa and the highest in eastern Europe and central Asia. We estimated a global antibiotic consumption rate of 14·3 (95% uncertainty interval 13·2-15·6) defined daily doses (DDD) per 1000 population per day in 2018 (40·2 [37·2-43·7] billion DDD), an increase of 46% from 9·8 (9·2-10·5) DDD per 1000 per day in 2000. We identified large spatial disparities, with antibiotic consumption rates varying from 5·0 (4·8-5·3) DDD per 1000 per day in the Philippines to 45·9 DDD per 1000 per day in Greece in 2018. Additionally, we present trends in consumption of different classes of antibiotics for selected Global Burden of Disease study regions using the IQVIA, WHO, and ESAC-net input data. We identified large increases in the consumption of fluoroquinolones and third-generation cephalosporins in North Africa and Middle East, and south Asia.

INTERPRETATION

To our knowledge, this is the first study that incorporates antibiotic usage and consumption data and uses geostatistical modelling techniques to estimate antibiotic consumption for 204 countries from 2000 to 2018. Our analysis identifies both high rates of antibiotic consumption and a lack of access to antibiotics, providing a benchmark for future interventions.

FUNDING

Fleming Fund, UK Department of Health and Social Care; Wellcome Trust; and Bill & Melinda Gates Foundation.

The Caregiving System Scale

Abstract. According to attachment theory, the propensity of human beings to care for others is governed by an inborn caregiving behavioral system that aims to promote welfare and reduce the distress of other people through effective provision of care. However, some individuals may develop non-optimal caregiving strategies, such as anxious hyperactivation and avoidant deactivation. These two non-optimal caregiving strategies can be evaluated in adults using the Caregiving System Scale (CSS). Recent findings suggested that the factor structure of the instrument may be more complex than was intended. The present work examines in-depth the factor structure of the CSS to provide a clearer understanding of the underlying dimensions. Gender invariance and the contribution of attachment orientations to CSS scores are also examined. Findings reveal that, whereas the CSS-deactivation subscale is unidimensional, the CSS-hyperactivation subscale is better represented by two distinct yet related constructs – caregiving-related worries/doubts and intrusive/coercive caregiving. Partial strict gender invariance is supported. The contribution of attachment orientations to non-optimal caregiving strategies is consistent with theoretical expectations. Results and future research directions are discussed in the final section.

Psychological Predictors of Precautionary Behaviors in Response to COVID-19: A Structural Model

The first lines of defense during an epidemic are behavioral interventions, including stay-at-home measures or precautionary health training, aimed at reducing contact and disease transmission. Examining the psychosocial variables that may lead to greater adoption of such precautionary behaviors is critical. The present study examines predictors of precautionary practices against coronavirus disease 2019 (COVID-19) in 709 Mexican participants from 24 states. The study was conducted via online questionnaire between the end of March and the beginning of April 2020, when the pandemic response was in its initial stages in Mexico. The instrument included demographic items, as well as scales assessing COVID-19-resembling symptoms, empathy, impulsivity, anhedonic depression, general health practices, alcohol consumption, and COVID-19-associated precautionary behaviors. Most participants reported adopting limited social distancing or other precautionary behaviors against COVID-19. The results of a structural equation model demonstrated that the presence of COVID-19 symptoms was related to impulsivity and general health behaviors. However, no direct association between precautionary behaviors and the presence of COVID-19 symptoms was found. In turn, precautionary behaviors were more prevalent among participants who reported higher empathy and general health behaviors and were inhibited indirectly by impulsivity via alcohol consumption. Furthermore, the model suggests that anhedonic depression symptoms have a negative indirect effect on precautionary behaviors via general health behaviors. Finally, impulsivity showed a negative direct effect on general health behavior. These results highlight the role that general physical health and mental health play on precautionary behavior and the critical importance of addressing issues such as depression, general health behaviors, and impulsivity in promoting safe actions and the protection of self and others.

The Relationship Between Cultural Value Orientations and the Changes in Mobility During the Covid-19 Pandemic: A National-Level Analysis

This study investigated the relationship between cultural value orientations and country-specific changes in mobility during the Covid-19 pandemic. The aim was to understand how cultural values relate to mobility behavior during the initial stages of the pandemic. The aggregated data include Schwartz's cultural orientations, Gross Domestic Product (GDP) per capita, number of Covid-19 cases per million, and mobility change during the Covid-19 pandemic (Google Mobility Reports; percentage decrease in retail and recreation mobility, transit station mobility, workplace mobility and percentage mobility increase in residential areas). Regression analyses showed that, after controlling for economy and severity of disease, hierarchy was the primary factor reducing mobility, such as staying at home, and mobility in public spaces, such as avoiding retail and recreation sites (marginally significant). The results are discussed in the light of previous literature and the implications for social distancing measures.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes

Aim:

The aim was to determine the association between healthcare workers’ (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention.

Background:

Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important.

Methods:

This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ² test and a linear mixed regression model were applied.

Findings:

Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (−7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (−5.64, P < 0.01). Native HCWs’ mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs’ mean change in knowledge-of-antibiotic score.

Conclusion:

Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Impact of a Social Marketing Intervention on General Practitioners' Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta

Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners' (GPs') antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs' antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs' antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.

Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta

BACKGROUND

Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta.

METHODS

Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour.

FINDINGS

We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed.

CONCLUSION

This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment.

TRIAL REGISTRATION NUMBER

NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.

Accounting for variation in and overuse of antibiotics among humans

Worldwide, antibiotic use is increasing, but many infections against which antibiotics are applied are not even caused by bacteria. Over-the-counter and internet sales preclude physician oversight. Regional differences, between and within countries highlight many potential factors influencing antibiotic use. Taking a systems perspective that considers pharmaceutical commodity chains, we examine antibiotic overuse from the vantage point of both sides of the therapeutic relationship. We examine patterns and expectations of practitioners and patients, institutional policies and pressures, the business strategies of pharmaceutical companies and distributors, and cultural drivers of variation. Solutions to improve antibiotic stewardship include practitioners taking greater responsibility for their antibiotic prescribing, increasing the role of caregivers as diagnosticians rather than medicine providers, improving their communication to patients about antibiotic treatment consequences, lessening the economic influences on prescribing, and identifying antibiotic alternatives.

Economic and Behavioral Influencers of Vaccination and Antimicrobial Use

Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.

What Is Driving the Epidemiology of Methicillin-Resistant Staphylococcus aureus Infections in Europe?

Introduction: The burden from infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in the European Union/European Economic Area (EU/EEA) has increased in recent years, especially in the higher prevalence southern and eastern countries. Addressing this challenge requires a clear knowledge of the factors driving this epidemiology to inform effective national interventions and campaigns. Methods: We identified national quality metrics for antibiotic use and hand hygiene from the 2016/2017 European Centre for Disease Control (ECDC) Point Prevalence study as well as structural, cultural, and governance indicators from other sources. We then utilized general linear modeling to identify parsimonious correlations with national MRSA proportions reported by the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results: The main process predictor of MRSA prevalence in EU/EEA countries was the use of more than one concurrent antibiotic per patient. The impact of hand hygiene was less clear, possibly because consumption of alcohol hand-rub was suboptimal throughout Europe. Hospital and infection control structural factors did not appear relevant at overall national level. Culture and governance were collectively key predictor groups; uncertainty avoidance, masculinity, and corruption indices strongly correlated with MRSA prevalence. Discussion: Our results suggest that the critical antibiotic stewardship factor associated with MRSA in EU/EEA countries is the quality of antibiotic prescribing, especially spectrum of activity, rather than overall consumption levels in hospitals or proportion of patients treated. Above all, MRSA hyperendemicity is correlated with a set of sociocultural behavioral constructs that typically manifest themselves in lack of urgency to address risk and normalization of deviance in relation to noncompliant practices.

Does culture matter social distancing under the COVID-19 pandemic?

This paper is the first to examine the role of the cultural dimension in practising social distancing across the world. By drawing the data from the Google COVID-19 community mobility reports and the Hofstede cultural factors for 58 countries over the period from 16 February to 29 March 2020, we find that countries with higher 'Uncertainty Avoidance Index' predict the lower proportion of people gathering in public such as retail and recreation, grocery and pharmacy, parks, transit stations, workplaces. However, we do not find any predictive factor in having a relationship with the percentage of citizens staying in their residential areas. Our results are robust by adding the control variable as the wealth status, GDP per capita. Hence, this paper suggests some effective communications to contain the COVID-19 pandemic by emphasizing the role of uncertainties.

Broad-spectrum antibiotic use in Europe: more evidence of cultural influences on prescribing behaviour

OBJECTIVES

Sociocultural factors have been hypothesized as important drivers of inappropriate antibiotic prescribing in European ambulatory care. This study sought to assess whether they can also explain the reported variation in broad-spectrum antibiotic (Br-Ab) use among EU/European Economic Area (EEA) countries.

METHODS

Correlation and regression analysis were performed, using the bootstrap method, between Br-Ab ratios reported from 28 EU countries by the ECDC, and national Hofstede cultural dimensions and control of corruption (CoC) scores.

RESULTS

Significant bootstrapping correlation coefficients were identified between Br-Ab ratios and the dimension of uncertainty avoidance (UAI) as well as CoC. However, following both bootstrapping multiple regression and generalized linear modelling, only UAI was retained as the sole predictor. A logarithmic model explained 58.6% of the variation in European Br-Ab variability solely using national UAI scores (P < 0.001).

CONCLUSIONS

Br-Ab prescribing appears to be driven by the level of UAI within the country. Any interventions aimed at reducing Br-Ab in high-consuming EU/EEA countries need to address this cultural perception to maximize their chances of success.

Antibiotic Resistance: Moving From Individual Health Norms to Social Norms in One Health and Global Health

Antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients (individual health). Nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. It is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. In this regard, the health of humans, animals, and local antibiotic-resistance-polluted environments should influence the health of the whole interconnected local ecosystem (One Health). In addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. Consequently, antibiotic resistance is a pandemic that requires Global Health solutions. Social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. In this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human-natural ecosystem interactions.

Antimicrobial use trends, Israel, 2012 to 2017

BackgroundIn 2012, Israel's National Center for Infection Control initiated a national stewardship programme that included mandatory annual reporting of antimicrobial use. Here we present nationwide Israeli data for the period 2012 to 2017.AimThe goal of this study was to detect trends in antimicrobial use in Israel following the introduction of the stewardship programme, as part of an assessment of the programme's impact.MethodsIn this retrospective observational study, data were collected from Israel's health maintenance organisations (HMOs), acute care hospitals and post-acute care hospitals (PACHs). Acute care hospital data were collected for general medical and surgical wards, and medical/surgical intensive care units (ICUs). Data were converted into defined daily doses (DDD), with use rates presented as DDD per 1,000 insured/day in the community and DDD per 100 patient-days in hospitals and PACHs. Trends were analysed using linear regression.ResultsAntimicrobial use decreased across sectors between 2012 and 2017. In the community, the decrease was modest, from 22.8 to 21.8 DDD per 1,000 insured per day (4.4%, p = 0.004). In acute care hospitals, antibiotic DDDs per 100 patient-days decreased from 100.0 to 84.0 (16.0%, p = 0.002) in medical wards, from 112.8 to 94.2 (16.5%, p = 0.004) in surgical wards and from 154.4 to 137.2 (11.1%, p = 0.04) in ICUs. Antimicrobial use decreased most markedly in PACHs, from 29.1 to 18.1 DDD per 100 patient-days (37.8%, p = 0.005).ConclusionBetween 2012 and 2017, antimicrobial use decreased significantly in all types of healthcare institutions in Israel, following the introduction of the nationwide antimicrobial stewardship programme.

Prevention and Control of Multidrug-Resistant Bacteria in The Netherlands and Germany-The Impact of Healthcare Structures

The Netherlands and Germany are neighbouring countries within the European Union but are differently affected by multidrug-resistant microorganisms (MDRO). In this narrative review, we summarize data about antibiotic use, the occurrence of MDRO and healthcare-associated infections in these two countries, as well as data about organizational and structural differences between the Dutch and German healthcare systems. These results are discussed with a focus on whether or how the organization of healthcare influences MDRO prevention. We found that from the point of view of MDRO prevention, a higher density of inpatient care, a higher number of hospitals, a longer length of stay and lower staffing ratios might facilitate MDRO dissemination in German hospitals.

Prevention of antibiotic resistance - an epidemiological scoping review to identify research categories and knowledge gaps

BACKGROUND

Antibiotics have become the cornerstone for the treatment of infectious diseases and contributed significantly to the dramatic global health development during the last 70 years. Millions of people now survive what were previously life-threatening infections. But antibiotics are finite resources and misuse has led to antibiotic resistance and reduced efficacy within just a few years of introduction of each new antibiotic. The World Health Organization rates antibiotic resistance as a 'global security threat' impacting on global health, food security and development and as important as terrorism and climate change.

OBJECTIVES

This paper explores, through a scoping review of the literature published during the past 20 years, the magnitude of peer-reviewed and grey literature that addresses antibiotic resistance and specifically the extent to which "prevention" has been at the core. The ultimate aim is to identify know-do gaps and strategies to prevent ABR.

METHODS

The review covers four main data bases, Web of Science, Medline, Scopus and Ebsco searched for 2000-17. The broader research field "antibiotic OR antimicrobial resistance" gave 431,335 hits. Narrowing the search criteria to "Prevention of antibiotic OR antimicrobial resistance" resulted in 1062 remaining titles. Of these, 622 were unique titles. After screening of the 622 titles for relevance, 420 abstracts were read, and of these 282 papers were read in full. An additional 53 references were identified from these papers, and 64 published during 2018 and 2019 were also included. The final scoping review database thus consisted of 399 papers.

RESULTS

A thematic structure emerged when categorizing articles in different subject areas, serving as a proxy for interest expressed from the research community. The research area has been an evolving one with about half of the 399 papers published during the past four years of the study period. Epidemiological modelling needs strengthening and there is a need for more and better surveillance systems, especially in lower- and middle-income countries. There is a wealth of information on the local and national uses and misuses of antibiotics. Educational and stewardship programmes basically lack evidence. Several studies address knowledge of the public and prescribers. The lessons for policy are conveyed in many alarming reports from national and international organizations.

CONCLUSIONS

Descriptive rather than theoretical ambitions have characterized the literature. If we want to better understand and explain the antibiotic situation from a behavioural perspective, the required approaches are lacking. A framework for an epidemiological causal web behind ABR is suggested and may serve to identify entry points for potential interventions.

General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections: A phenomenographic study

BACKGROUND

Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta.

METHODS

This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach.

FINDINGS

General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon.

CONCLUSIONS

In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required.

TRIAL REGISTRATION NUMBER

NCT03218930.

Prevalence of antibiotic prescription in southern Italian outpatients: real-world data analysis of socioeconomic and sociodemographic variables at a municipality level

Purpose

The aim of this study was to analyze the geographic variation in systemic antibiotic prescription at a regional level and to explore the influence of socioeconomic and sociodemographic variables.

Methods

This study was a retrospective analysis of reimbursement pharmacy records in the outpatient settings of Italy’s Campania Region in 2016. Standardized antibiotic prescription rates were calculated at municipality and Local Health Unit (LHU) level. Antibiotic consumption was analyzed as defined daily doses (DDD)/1000 inhabitants per day (DID). Logistic regression was performed to evaluate the association between antibiotic prescription and sociodemographic and socioeconomic determinants at a municipality level.

Results

The average antibiotic prevalence rate was 46.8%. At LHU level, the age-adjusted prevalence rates ranged from 41.1% in Benevento to 51.0% in Naples2. Significant differences were found among municipalities, from 15.2% in Omignano (Salerno LHU [Sa-LHU]) to 61.9% in Moschiano (Avellino [Av-LHU]). The geographic distribution also showed significant differences in terms of antibiotic consumption, from 6.7 DID in Omignano to 41.6 in San Marcelino (Caserta [Ce-LHU]). Logistic regression showed that both municipality type and average annual income level were the main determinants of antibiotic prescription. Urban municipalities were more than eight times as likely to have antibiotic high prevalence rates compared to rural municipalities (adjusted odds ratio [OR]: 8.62; 95% confidence interval [CI]: 4.06–18.30, P<0.001). Low average annual income level municipalities were more than eight times as likely to have antibiotic high prevalence rates compared to high average annual income level municipalities (adjusted OR: 8.48; 95% CI: 3.45–20.81, P<0.001).

Conclusion

We provide a snapshot of Campania’s antibiotic consumption, evidencing the impact of both socioeconomic and sociodemographic factors on the prevalence of antibiotic prescription. The observed intraregional variability underlines the lack of shared therapeutic protocols and the need for careful monitoring. Our results can be useful for decision makers to plan educational interventions, thus optimizing health resources and improving rational drug use.