Quality measures of antimicrobial drug use

Quantitative and qualitative evaluation of antimicrobial usage: the first step for antimicrobial stewardship

The identification of antimicrobial use patterns is essential for determining key targets for antimicrobial stewardship interventions and evaluating the effectiveness thereof. Accurately identifying antimicrobial use patterns requires quantitative evaluation, which focuses on measuring the quantity and frequency of antimicrobial use, and qualitative evaluation, which assesses the appropriateness, effectiveness, and potential side effects of antimicrobial prescriptions. This paper summarizes the quantitative and qualitative methods used to evaluate antimicrobials, drawing insights from overseas and domestic cases.

Field Study on Antibiotic Use and Associated Risks Among Saudi Arabian Community Members

<b>Background and Objective:</b> Antibiotic resistance is a problem that needs to be solved, according to the World Health Organization (WHO). The main objective of this study was to uncover knowledge, attitudes and practices related to the use of antibiotics and the associated risks. <b>Materials and Methods:</b> A descriptive survey method was used to collect data from a purposive sample of Saudi citizens. A total of 2067 participants completed the study questionnaire in the period of March, 2023 to June, 2023. Questionnaire included a number of 14 questions related to the demographic characteristics of the study sample and about knowledge, attitudes and practices related to the use of antibiotics. The IBM SPSS was used to statistically evaluate the survey findings and the data were reported as frequencies and percentages. <b>Results:</b> There is a high level of awareness about what antibiotics are, their medical efficacy and how to use them among respondents, as a large percentage of respondents are convinced of the importance of taking antibiotics to treat diseases related to bacterial infection under the supervision of a specialized doctor and not based on the recommendations of their acquaintances or relatives. People with low levels of education should be among the categories specifically targeted for educational intervention regarding proper antibiotic usage. <b>Conclusion:</b> The participants who were knowledgeable about the use of antibiotics exhibited a favorable attitude towards them. While people with low levels of education needs a proper education regarding antibiotics and their uses.

Current Status and Prospect of Qualitative Assessment of Antibiotics Prescriptions

Identifying inappropriately prescribed antibiotics for infectious diseases by monitoring the quality of antibiotics use is essential for effective implementation of antibiotic stewardship. Qualitative assessment of the use of antibiotics has been conducted in some countries, including Korea, since the 2000s. The qualitative assessment generally involves an assessment of each component of the antibiotics prescription process, based on specific criteria. However, there is no standardized assessment method or cycle, and infectious diseases or antibiotics included in the assessments vary from country-to-country. According to the results reported in the United States, Europe, Australia, and Korea so far, approximately 20 - 55% of all antibiotics prescriptions are inappropriate. In this review, we describe the current progress in the quality assessment of the use of antibiotics on a global scale. Further, we highlight the future directions to improve antibiotic stewardship activities and the quality assessment of the use of antibiotics in Korea.

Antimicrobial use in cattle and poultry production on occurrence of multidrug resistant Escherichia coli. A systematic review with focus on sub-Saharan Africa

Antimicrobial use in livestock production has been linked to antimicrobial resistance (AMR) worldwide; however, optimization of their use has been considered an important strategy in dealing with it. The aims of this study were as follows: (a) to assess the literature on antimicrobial usage (practices, frequency, class, type) in cattle and poultry production with regard to resistance in Escherichia coli (E. coli) including multidrug resistance (MDR) (b) summarize evidence for quantitative (volumes of active antimicrobial ingredients) and quality (identify and quantify active ingredient) and (c) to identify data gaps. Peer reviewed literature search was conducted by querying two online databases: PubMed and Google scholar from November 15, 2018 to February 2019. The inclusion criteria for eligibility were articles: published in English between 2008 and 2018, including poultry (chicken) or cattle or both, E. coli bacteria of choice, antimicrobial use on farms, quantitative data and quality of antimicrobial used. Microsoft Excel was used for data extraction and Rayyan software for eligibility studies. The search retrieved 1,446 probable articles including those from the reference list of significant papers, of which twenty-four articles remained on full text review with more than a third of the studies being conducted in Nigeria. Farm surveys and antimicrobial sales were identified as the main sources of data and the mean quantities of antimicrobials based on sales data were 23,234, 41,280.87, and 1,538,443 kg of the active ingredient in Nigeria, Zambia and South Africa, respectively. One study from Cameroon determined the quantities of active ingredients based on dose metrics while another study still from Cameroon mentioned the quality of antimicrobials. Tetracyclines, beta-lactams/aminoglycosides and fluoroquinolones were the most common classes of antimicrobials (antibiotics) used. Our review reveals a dearth of information in Sub- Saharan Africa on the quantity and quality of veterinary drugs and yet they play a role in the overall picture of antimicrobial resistance. This finding gives an opportunity in the area of focus for future research as far as resistance and multidrug resistance are concerned in food producing animals.

Prescriptions patterns and appropriateness of usage of antibiotics in non-teaching community hospitals in South Korea: a multicentre retrospective study

Background

Although non-teaching community hospitals form the majority of healthcare providers in South Korea, there is limited data on antibiotic usage in them. To evaluate the pattern of antibiotic usage and its appropriateness in hospitals with < 400 beds in South Korea.

Methods

A multicentre retrospective study was conducted in 10 hospitals (six long-term care hospitals, three acute care hospitals, and one orthopaedic hospital), with < 400 beds in South Korea. We analysed patterns of antibiotic prescription in 2019, and their appropriateness in the participating hospitals. For the evaluation of the appropriateness of the prescription, 25 patients under antibiotic therapy were randomly selected at each hospital, over two separate periods. Due to the heterogeneity of their characteristics, the orthopaedics hospital was excluded from the analysis.

Results

The most commonly prescribed antibiotics in long-term care hospitals was fluoroquinolone, followed by beta-lactam/beta-lactamase inhibitor (anti-pseudomonal). In acute care hospitals, these were third generation cephalosporin, followed by first generation cephalosporin, and second generation cephalosporin. The major antibiotics that were prescribed in the orthopedics hospital was first generation cephalosporin Only 2.3% of the antibiotics were administered inappropriately. In comparison, 15.3% of patients were prescribed an inappropriate dose. The proportion of inappropriate antibiotic prescriptions was 30.6% of the total antibiotic prescriptions.

Conclusions

The antibiotic usage patterns vary between non-teaching community hospitals in South Korea. The proportion of inappropriate prescriptions exceeded 30% of the total antibiotic prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01082-2.

Knowledge, Attitudes and Practices Regarding Antibiotic Use and Resistance among Veterinary Students in Bangladesh

The use of antibiotics in animals for both therapeutic and non-therapeutic purposes is a major driver of the emergence and spread of antimicrobial resistance (AMR). While several studies have investigated prescription and consumption patterns in humans, little attention has been paid to the veterinary sector. A cross-sectional study was conducted in 3002 veterinary students (VS) and non-medical students (NMS) from 12 universities in Bangladesh to explore their knowledge, attitudes and practices (KAP) about antibiotics and AMR using a self-administered questionnaire, and assess the influence of the veterinary curriculum. KAP regarding antibiotic use and AMR was significantly higher in veterinary than non-medical students, and in first-year than final-year students. However, gaps in knowledge and practices were highlighted, suggesting deficiencies in training. Moreover, final-year veterinary students were found to be more likely than first-year students to use antibiotics without instructions, which could indicate deficiencies in their curriculum. Although the study suggested a positive impact of the veterinary curriculum on KAP about antibiotics and AMR in Bangladesh, critical gaps remain that are likely to contribute to inadequate use in their future practice. Therefore, there is scope for improving educational programs on AMR in professional curricula.

Development of key quality indicators for appropriate antibiotic use in the Republic of Korea: results of a modified Delphi survey

Background

An effective antibiotic stewardship program relies on the measurement of appropriate antibiotic use, on which there is a lack of consensus. We aimed to develop a set of key quality indicators (QIs) for nationwide point surveillance in the Republic of Korea.

Methods

A systematic literature search of PubMed, EMBASE, and Cochrane Library (publications until 20th November 2019) was conducted. Potential key QIs were retrieved from the search and then evaluated by a multidisciplinary expert panel using a RAND-modified Delphi procedure comprising two online surveys and a face-to-face meeting.

Results

The 23 potential key QIs identified from 21 studies were submitted to 25 multidisciplinary expert panels, and 17 key QIs were retained, with a high level of agreement (13 QIs for inpatients, 7 for outpatients, and 3 for surgical prophylaxis). After adding up the importance score and applicability, six key QIs [6 QIs (Q 1–6) for inpatients and 3 (Q 1, 2, and 5) for outpatients] were selected. (1) Prescribe empirical antibiotic therapy according to guideline, (2) change empirical antibiotics to pathogen-directed therapy, (3) obtain culture samples from suspected infection sites, (4) obtain two blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan. In surgical prophylaxis, the QIs to prescribe antibiotics according to the guideline and initiate antibiotic therapy 1 h before incision were selected.

Conclusions

We identified key QIs to measure the appropriateness of antibiotic therapy to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.

The Proportion of Infectious Disease Cases, Its Associated Factors, and the Appropriateness of Antimicrobial Prescription Among Rohingya Refugee Pediatric Patients in IMARET Mobile Clinics

The Rohingyas fled from their home to escape ethnic persecution. Due to their status as refugees they have difficulties in accessing healthcare leading to avoidable mortality and morbidity. Infectious diseases are reported to be among the causes. To ease access to healthcare, IMAM Response and Relief Team (IMARET) provides a free monthly clinic for them. The objective of this study is to determine the proportion of infectious diseases and appropriateness of antimicrobial usage among its pediatrics patients. It was conducted in 2017, through universal sampling. Information retrieved were via interviews and medical records. The majority diagnosis were infectious diseases (57.1%), which include respiratory infections (77.3%), skin (13.6%), gastrointestinal (4.5%), eye and ear infection (both 1%). Albendazole (40.7%) was the most prescribed. Only 7.4% were appropriately prescribed antimicrobials. Age (p = 0.005) and BMI (p = 0.006) were significantly associated with infections.

'What a dog will see and kill, a cat will see and ignore it': An exploration of health-related help-seeking among older Ghanaian men residing in Ghana and the United Kingdom

BACKGROUND

Health care utilization rates are lower among men; however, little is known about how men's health care utilization is affected by migration. The aim of this study was to explore health-related help-seeking decisions among older Ghanaian men residing in the United Kingdom and in Ghana.

METHODS

Twenty-six men aged 50 years or over were recruited from community locations within two large cities in the UK and Ghana. Face-to-face semi-structured interviews were undertaken to explore the illness and help-seeking experiences of older men.

RESULTS

Help-seeking experiences differed among the Ghanaian men living in the UK and in Ghana. Three themes were identified that impacted on help-seeking decisions: (1) pluralistic approaches to managing health and illness and (2) perceptions of formal health services in Ghana and UK and (3) financial constraints and masculinity norms as barriers to help-seeking.

CONCLUSION

This is the first study to look at help-seeking decisions among older men residing in the UK and Ghana. Findings highlight how older migrant men's explanatory models of their health encompass enduring faith-based beliefs around causation of illness and approaches to management, as well as the use of pluralistic approaches to managing health. This study supports the call for culturally sensitive community-based interventions to increase engagement and facilitate improved health outcomes for migrant populations, particularly older men.

A case study on Staphylococcus aureus bacteraemia: available treatment options, antibiotic R&D and responsible antibiotic-use strategies

Objectives

This case study addresses: (i) antibiotic treatment options for Staphylococcus aureus bacteraemia (SAB), for both empirical and targeted therapy; (ii) the current status of and priorities for the antibiotic pipeline to ensure access of effective antibiotics for SAB; and (iii) strategies for responsible antibiotic use relevant to the clinical management of SAB.

Methods

Evidence to address the aims was extracted from the following information sources: (i) EUCAST and CLSI recommendations, summaries of product characteristics (SPCs), antibiotic treatment guidelines and the textbook Kucers’ The Use of Antibiotics; (ii) the www.clinicaltrial.gov database; and (iii) quality indicators for responsible antibiotic use.

Results

Current monotherapy treatment options for SAB include only three drug classes (β-lactams, glycopeptides and lipopeptides), of which two also cover MRSA bacteraemia (glycopeptides and lipopeptides). The analysis of the antibiotic pipeline and ongoing clinical trials revealed that several new antibiotics with S. aureus (including MRSA) coverage were developed in the past decade (2009–19). However, none belonged to a new antibiotic class or had superior effectiveness and their added clinical value for SAB remains to be proven. Responsible antibiotic use for the treatment of SAB was illustrated using 11 quality indicators.

Conclusions

Awareness of the problem of a limited antibiotic arsenal, together with incentives (e.g. push incentives), is needed to steer the R&D landscape towards the development of novel and effective antibiotics for treating SAB. In the meantime, responsible antibiotic use guided by quality indicators should preserve the effectiveness of currently available antibiotics for treating SAB.

University students' knowledge, attitudes, and practice regarding antibiotic use and associated factors: a cross-sectional study in the United Arab Emirates

Purpose: Antibiotic resistance is one of the world’s most fatal health crises. Medical students are the antibiotic prescribers of tomorrow, so better understanding of their knowledge, attitudes, and practice (KAP) pertaining to antibiotic use is crucial.

Objectives: This study aimed to assess the KAP of antibiotics and associated factors among university students in the United Arab Emirates (UAE).

Methods: This was a descriptive cross-sectional study conducted among a random sample of undergraduate students from Ajman University in the UAE. A self-administered pretested questionnaire was used to collect data on students’ demographics and their KAP regarding antibiotic use. Data were analysed using STATA version 14.2. P<0.05 was considered statistically significant.

Results: This study showed that university students have a high rate of antibiotic self-medication. The average KAP score was 56% (95% CI 55%–57%). Statistical modeling showed that major, study year, age, and sex were strong determinants of KAP regarding antibiotic use.

Conclusion: There is a need to develop an effective and comprehensive antibiotic-stewardship program as part of undergraduate education. Moreover, reinforcing antibiotic-use policies, involving pharmacies, drug supply, distribution, and sale, are also urgently needed.

Knowledge, attitude and practice of antibiotic use among university students: a cross sectional study in UAE

BACKGROUND

Antibiotic resistance became a marker of irrational and overuse of these medicines in many countries. This study aims to evaluate the knowledge, attitude and practice (KAP) of medical students (MS) and non-medical students (NS) towards antibiotic use in the United Arabs Emirates (UAE).

METHOD

A descriptive cross-sectional study was conducted amongst 1200 MS and NS from Ajman University in UAE. A self-administered questionnaire was used to assess the knowledge, attitude and practice of antibiotic use. The later was composed into knowledge, attitude and practice of antibiotic use. Descriptive analysis was used to analyse the qualitative variables while quantitative variables were summarised using mean ± Standard Deviation (±SD). A Chi-square test was used to compare differences in the proportions of qualitative variables. Unpaired student's t-test was used to test the average differences in quantitative variables across medical and non-medical students. A p < 0.05 was considered statistically significant.

RESULTS

One thousand two hundred students (MS: 600 and NS: 600) were considered valid for analysis. On average, participants scored higher in attitude score followed by knowledge and practice scores. The average attitude score was 76% (95% CI: [75, 78%]) compared to 59% for knowledge (95% CI: [58, 60%]) and 45% (95% CI: [44, 47%]) for practice. The results suggest that overall, medical students scored remarkably better than non-medical students on KAP of antibiotic use, respectively (p = 0.0001), (p = 0.000) and (p = 0.002).

CONCLUSION

The students' knowledge, attitude and practice regarding antibiotic use, which drive the practice of self-medication, reflect a gap in medical curricula in UAE institutes and medical colleges.

Veterinary medicinal product usage among food animal producers and its health implications in Central Ethiopia

Background

Antimicrobials and anthelmintics are the most commonly used veterinary drugs to control animal diseases. However, widespread use of these drugs could contribute to the emergence of drug resistance. Information on the practice of antimicrobial usage among food animal raising communities in Central Ethiopia is scarce. We used a standardised questionnaire survey to assess knowledge, awareness, and practices related to drug use and resistance in food animals among the farmers in and around Bishoftu town.

Results

Of the total of 220 livestock owners interviewed, around 80% of the respondents were not able to define what antimicrobials are and for what purposes they are used. Only 14.1% (n = 31) of the respondents had awareness about antimicrobial resistance (AMR) and its consequences; and 35.5% (n = 11/31) and 9.7% (n = 3/31) of them agreed that the irrational use of antimicrobials in animals could lead to AMR in animals and humans. Oxytetracycline was the most commonly available antibiotic in veterinary drug shops/pharmacies and the most widely used drug in the area. However, 43.3% of the respondents did not see clinical improvements after using antibiotics. Similarly, the respondents explained that no response was observed in 73.3, 70.8 and 52.5% of the cases after medication with anthelmintics, antiprotozoal and acaricides, respectively. About 56.7% of the respondents considered traditional medicines equally important to modern medicines. It was also noted that there were illegal drug vendors, dispensing medicines under unfavourable conditions which include a direct exposure to sunlight, which practice violates the drug handling and storage recommendations given by WHO.

Conclusion

The study revealed that there is a general lack of awareness among food animal owners about the correct use of antibiotics and anthelmintics. The widespread misuse and improper drug dispensing and handling practices observed in this study can affect the drug quality and can also contribute to the development of drug resistance in central Ethiopia.

Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure

Background

Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input.

Methods

A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting.

Results

The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use.

Conclusions

Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.

A survey of awareness related to the use of antibiotics for dental issues among non-medical female university students in Riyadh, Saudi Arabia

Inappropriate use of antibiotics may lead to adverse side effects. This cross-sectional survey aimed to investigate the knowledge and attitude of female non-medical students regarding the medical and dental use of antibiotics. Four hundred validated self-administered questionnaires were distributed in Princess Norah Bint-Abdurrahman University, Riyadh, Saudi Arabia. The questionnaire included questions about accessibility, attitude toward usage, efficacy, side effects, resistance, and usage for dental issues. Knowledge was estimated for every respondent by counting the correct answers, which were considered as points. The scores were categorized as poor, moderate, and high. Of the respondents, 77.8% answered they get antibiotics according to a doctor's prescription; however, 31% stops taking antibiotics when they feel well. Only 38.8% of respondents knew that antibiotics may cause allergic reactions while 59.8% believed the human body can be resistant to antibiotics. The percentages of answers related to dental issues were: antibiotics relieve dental pain (68.8%), antibiotics can be harmful for children's teeth (27.3%), antibiotics are best avoided in pregnancy (56.7%) and no need for antibiotics after scaling (33.8%), root canal treatment (16%), or simple extraction (40.3%). Of respondents, 68% had poor scores about antibiotics efficacy, side effects, and resistance while 86.8% had poor scores related to dental problems. This study noticed a bad attitude related to antibiotics usage, with many misconceptions and poor knowledge. Moreover, the necessity of antibiotics for treatment of dental disease or after dental procedures was totally unclear for the respondents. Community campaigns are recommended every university semester to educate students about the indications, efficacy, and side effects of antibiotics.

Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey

This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.

Evaluation of rational use of veterinary drugs especially antimicrobials and anthelmintics in Bishoftu, Central Ethiopia

Background

Rational use of drugs in veterinary medicine has numerous benefits, such as increasing efficacy, decreasing the potential adverse effects, reducing risk of drug residue and combating development of microorganism’s drug resistance.

Methods

A retrospective study with the aim of evaluating the current rational use of veterinary drugs was conducted at college of veterinary medicine and agriculture veterinary teaching hospital and Ada district veterinary clinic, central Ethiopia. One thousand eight hundred and nineteen animal patients’ encounters were randomly selected for the study from prescription papers and prescription registration books retrospectively.

Results

The average number of drugs prescribed per encounter was 1.23 with maximum of five. The percentage of encounters in which antimicrobials and anthelmintics was prescribed were 54.4 % (1216/2235) and 38.9 % (869/2235), respectively. The percentages of drugs prescribed by generic name and from essential veterinary drug list were 90.1 % (2014/2235) and 99.7 % (2229/2235), respectively. The most commonly prescribed antimicrobials and anthelmintics were oxytetracycline 1016 (45.5 %), penicillin and streptomycin combination 168 (7.5 %), sulfa drugs 23 (1.0 %), and albendazole 732 (32.8 %) and ivermectin 137 (6.1 %). Among the 1819 animal-patient encounters, only 57 % (n = 1037) of the prescriptions were written adequately, 43 % (n = 782) incorrectly prescribed and 1179 cases of the adequately specified prescription were tentatively diagnosed. For 656 (53.9 %) and 233 (26.8 %) inadequately specified cases antimicrobials and anthelmintics were prescribed, respectively. Antibiotics were prescribed irrationally for cases which were tentatively diagnosed as parasitic 21.6 % (n = 262) and viral to prevent secondary bacterial complications 6.0 % (n = 73). Among all patients that were admitted to veterinary clinics, 96.6 % (1757) were treated empirically without getting correct laboratory-supported diagnosis. Chi Square test for trend analysis showed a statistically significant association between irrational drug usage and year (p = 0.000).

Conclusions

The findings had shown problems in generic prescribing, incorrect diagnosis, and non-availability of standard veterinary treatment guideline and drug formulary in the study area. Therefore, veterinary drugs, specially, antimicrobial agents should be judiciously used; and a wide scale study to safeguard the public from drug residual effects and antimicrobial resistance development is recommended.

Evaluation of antibiotic prescription in the Lebanese community: a pilot study

Background

Antibiotics are considered among the most commonly prescribed drug classes in developing countries. Inappropriate prescription of antibiotics is a major public health concern and is related to the development of antimicrobial resistance.

Objective

This study aimed at assessing the appropriateness of antibiotic prescription by non-infectious disease physicians in a community setting in Lebanon.

Methods

A pilot cross-sectional study was undertaken on community pharmacy patients presenting with antibiotic prescription. It was performed over a period of 4 months in different regions of Lebanon. Participants answered a questionnaire inquiring about socio-demographic characteristics, medical conditions, symptoms that required medical attention, the doctor's diagnosis, the prescribed antibiotic, and whether laboratory tests were ordered to identify the causative organism or not. Data were analyzed using SPSS 17.

Results

We studied 270 patients (49.3% males and 50.7% females). This study showed that the most-prescribed antibiotics were the cephalosporins (82%) and that almost half of the illnesses for which antibiotics were prescribed were respiratory tract infections (41%). The study also showed that the choice of the prescribed antibiotic was appropriate in 61.5% of the studied cases, while the prescribed dose and the duration of the treatment were inaccurate in 52 and 64% of the cases, respectively. In addition, fever seemed to be a factor that influenced the physician's prescriptions, since the choice of drug conformity to guidelines increased from 53.7% (1 day of fever) to 88.9% (1 week of fever), and the dose prescription compliance to guidelines was higher (55.9%) for patients suffering from fever compared to those with no fever (38.1%).

Conclusion

This study showed a high prevalence of inappropriate antibiotic prescriptions in Lebanon. Therefore, actions should be taken to optimize antibiotic prescription.

Measuring antimicrobial prescribing quality in Australian hospitals: development and evaluation of a national antimicrobial prescribing survey tool

OBJECTIVES

Antimicrobial stewardship (AMS) programmes have been developed with the intention of reducing inappropriate and unnecessary use of antimicrobials, while improving the quality of patient care and locally helping prevent the development of antimicrobial resistance. An important aspect of AMS programmes is the qualitative assessment of prescribing through antimicrobial prescribing surveys (APS), which are able to provide information about the prescribing behaviour within institutions. Owing to lack of standardization of audit tools and the resources required, qualitative methods for the assessment of antimicrobial use are not often performed. The aim of this study was to design an audit tool that was appropriate for use in all Australian hospitals, suited to local user requirements and included an assessment of the overall appropriateness of the prescription.

METHODS

In November 2011, a pilot APS was conducted across 32 hospitals to assess the usability and generalizability of a newly designed audit tool. Following participant feedback, this tool was revised to reflect the requirements of the respondents. A second pilot study was then performed in November 2012 across 85 hospitals.

RESULTS

These surveys identified several areas that can be targets for quality improvement at a national level, including: documentation of indication; surgical prophylaxis prescribed for >24 h; compliance with prescribing guidelines; and the appropriateness of the prescription.

CONCLUSIONS

By involving the end users in the design and evaluation, we have been able to provide a practical and relevant APS tool for quantitative and qualitative data collection in a wide range of Australian hospital settings.

Descriptive analysis of antibiotic-resistant patterns of methicillin-resistant Staphylococcus aureus (MRSA) st398 isolated from healthy swine

BACKGROUND

Livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) such as the MRSA ST398 strain has spread all over the world and the most worrying aspect of this fact appears to be its capacity to easily spread to humans. The excessive use of antibiotics has made swine a reservoir of MRSA. The aim of the present study was to determine the antibiotic resistance profile of MRSA samples isolated from healthy swine of the island of Tenerife (Spain).

METHODS

A total of 256 MRSA isolates from swine samples and five MRSA isolates from pig worker samples were investigated for MRSA antibiotic resistant patterns.

RESULTS

Analysis of the susceptibility status of MRSA pig isolates revealed that 39 isolates were resistant to one antibiotic, 71 isolates were resistant to two antibiotics and 96 isolates were resistant to three or more antibiotics. SCCmec typing revealed the presence of types IV and V. Isolates having SCCmec IV had an increased resistance to the antimicrobial agents tested than those having SCCmec V. We observed significant differences when comparing the most common resistance patterns and SCCmec type.

CONCLUSIONS

MRSA isolated from humans showed similar resistance to those isolated from pigs, excepting erythromycin, since all the workers' isolates were sensitive to this antibiotic. The evolution of new MRSA clones has emphasized the need for infection control practices in animals and humans in close contact.

Knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of Jordan. A pilot study

Factors associated with antibiotic use, resistance and safety have been well recognized worldwide in the literature. Nevertheless, only few studies have been conducted in Jordan in this area. The aim of this study was to assess knowledge, behavior and attitude toward antibiotics use among adult Jordanians. The study represents a cross sectional survey using an interviewer administered questionnaire. Data collected from a random sample of 1141 adult Jordanians, recruited at different settings, regarding their knowledge about the effectiveness of, resistance toward, and self medications with antibiotics against bacterial, viral and parasitic diseases. 67.1% believed that antibiotics treat common cold and cough. 28.1% misused antibiotics as analgesics. 11.9% of females showed inadequate knowledge about the safe use of antibiotics during pregnancy and nursing. 28.5% kept antibiotics at home for emergency use and 55.6% use them as prophylaxis against infections. 49.0% use left-over antibiotics without physicians' consultation while 51.8% use antibiotics based on a relative advice. 22.9% of physicians prescribe antibiotics over the phone and >50.0% routinely prescribe antibiotics to treat common cold symptoms. Our findings indicated that young adults showed unsatisfactory knowledge of proper antibiotic use. Therefore, there is an urge for educational programs using all media means.

A point prevalence survey of antibiotic use in four acute-care teaching hospitals utilizing the European Surveillance of Antimicrobial Consumption (ESAC) audit tool

The objective of this research was to assess current patterns of hospital antibiotic prescribing in Northern Ireland and to determine targets for improving the quality of antibiotic prescribing. A point prevalence survey was conducted in four acute teaching hospitals. The most commonly used antibiotics were combinations of penicillins including β-lactamase inhibitors (33·6%), metronidazole (9·1%), and macrolides (8·1%). The indication for treatment was recorded in 84·3% of the prescribing episodes. A small fraction (3·9%) of the surgical prophylactic antibiotic prescriptions was for >24 h. The results showed that overall 52·4% of the prescribed antibiotics were in compliance with the hospital antibiotic guidelines. The findings identified the following indicators as targets for quality improvement: indication recorded in patient notes, the duration of surgical prophylaxis and compliance with hospital antibiotic guidelines. The results strongly suggest that antibiotic use could be improved by taking steps to address the identified targets for quality improvement.

Impact of an intervention designed to improve the documentation of the reassessment of antibiotic therapies in an intensive care unit

OBJECTIVES

The study objectives were: (i) to design an intervention to improve the written documentation of empiric antibiotic prescriptions' reassessment; (ii) and to assess the impact of this intervention on the quality of prescriptions.

PATIENTS AND METHODS

A prospective before and after 7-month intervention study in a medical ICU in a French teaching hospital, using interrupted time-series analysis. The intervention was made to improve the documentation of four process measures in medical records: antibiotic plan, reviewing the diagnosis, adapting to positive microbiological results, and IV-per os switch.

RESULTS

One hundred and fourteen antibiotic prescriptions were assessed, 62 before and 52 after the intervention. The reassessment of antibiotic prescriptions was more often documented in the ICU after the intervention (P=0.03 for sudden change). The prevalence of appropriate antibiotic prescriptions was not statistically different before and after the intervention, either for sudden change and/or linear trend.

CONCLUSION

A better documentation of antibiotic prescriptions' reassessment was achieved in this ICU, but it did not improve the quality of antibiotic prescriptions.

Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit

OBJECTIVES

The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation.

DESIGN

We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist.

RESULTS

Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18).

CONCLUSIONS

Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.

A point prevalence survey of antibiotic prescriptions: benchmarking and patterns of use

AIM

The aim of the study was to assess current patterns of antibiotic prescribing and the impact of a hospital antibiotic policy on these practices.

METHODS

The study involved collecting information regarding hospitalized patients utilizing the ESAC audit tool.

RESULTS

In the study site hospital, the use of the restricted agents was low whilst the use of the non-restricted agents was high. Compliance with the hospital antibiotic guidelines was 70%.

DISCUSSION

The findings identified monitoring non-restricted antibiotics and compliance with guidelines as targets for quality improvements in our hospital. Point prevalence surveys may offer a simple method of monitoring antibiotic policies, thus, informing antibiotic stewardship.

Conserving antibiotics for the future: new ways to use old and new drugs from a pharmacokinetic and pharmacodynamic perspective

There is a growing need to optimize the use of old and new antibiotics to treat serious as well as less serious infections. The topic of how to use pharmacokinetic and pharmacodynamic (PK/PD) knowledge to conserve antibiotics for the future was elaborated on in a workshop of the conference (The conference "The Global Need for Effective Antibiotics - moving towards concerted action", ReAct, Uppsala, Sweden, 2010). The optimization of dosing regimens is accomplished by choosing the dose and schedule that results in the antimicrobial exposure that will achieve the microbiological and clinical outcome desired while simultaneously suppressing emergence of resistance. PK/PD of antimicrobial agents describe how the therapeutic drug effect is dependent on the potency of a drug against a microorganism and the exposure (the concentration of antimicrobial available for effect over time). The description and modeling of these relationships quantitatively then allow for a rational approach to dose optimization and several strategies to that purpose are described. These strategies include not only the dosing regimen itself but also the duration of therapy, preventing collateral damage through inappropriate use and the application of PK/PD in drug development. Furthermore, PK/PD relationships of older antibiotics need to be urgently established. The need for global harmonization of breakpoints is also suggested and would add efficacy to antibiotic therapy. For each of the strategies, a number of priority actions are provided.

Strategies of initiation and streamlining of antibiotic therapy in 41 French intensive care units

INTRODUCTION

Few studies have addressed the decision-making process of antibiotic therapy (AT) in intensive care unit (ICU) patients.

METHODS

In a prospective observational study, all consecutive patients admitted over a one-month period (2004) to 41 French surgical (n = 22) or medical/medico-surgical ICUs (n = 19) in 29 teaching university and 12 non-teaching hospitals were screened daily for AT until ICU discharge. We assessed the modalities of initiating AT, reasons for changes and factors associated with in ICU mortality including a specific analysis of a new AT administered on suspicion of a new infection.

RESULTS

A total of 1,043 patients (61% of the cohort) received antibiotics during their ICU stay. Thirty percent (509) of them received new AT mostly for suspected diagnosis of pneumonia (47%), bacteremia (24%), or intra-abdominal (21%) infections. New AT was prescribed on day shifts (45%) and out-of-hours (55%), mainly by a single senior physician (78%) or by a team decision (17%). This new AT was mainly started at the time of suspicion of infection (71%) and on the results of Gram-stained direct examination (21%). Susceptibility testing was performed in 261 (51%) patients with a new AT. This new AT was judged inappropriate in 58 of these 261 (22%) patients. In ICUs with written protocols for empiric AT (n = 25), new AT prescribed before the availability of culture results (P = 0.003) and out-of-hours (P = 0.04) was more frequently observed than in ICUs without protocols but the appropriateness of AT was not different. In multivariate analysis, the predictive factors of mortality for patients with new AT were absence of protocols for empiric AT (adjusted odds ratio (OR) = 1.64, 95% confidence interval (95%CI): 1.01 to 2.69), age ≥60 (OR = 1.97, 95% CI: 1.19 to 3.26), SAPS II score >38 (OR = 2.78, 95% CI: 1.60 to 4.84), rapidly fatal underlying diseases (OR = 2.91, 95% CI: 1.52 to 5.56), SOFA score ≥6 (OR = 4.48, 95% CI: 2.46 to 8.18).

CONCLUSIONS

More than 60% of patients received AT during their ICU stay. Half of them received new AT, frequently initiated out-of-hours. In ICUs with written protocols, empiric AT was initiated more rapidly at the time of suspicion of infection and out-of-hours. These results encourage the establishment of local recommendations for empiric AT.

Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey

Background

Unnecessary or inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance, drug toxicity, increased morbidity and health care costs. Antimicrobial use has been reported to be incorrect or not indicated in 9–64% of inpatients. We studied the quality of antimicrobial therapy and prophylaxis in hospitalized patients at a tertiary care hospital to plan interventions to improve the quality of antimicrobial prescription.

Methodology/Principal Findings

Experienced infectious diseases (ID) fellows performed audits of antimicrobial use at regular intervals among all patients—with or without antimicrobials—hospitalized in predefined surgical, medical, haemato-oncological, or intensive care units. Data were collected from medical and nursing patient charts with a standardized questionnaire. Appropriateness of antimicrobial use was evaluated using a modified algorithm developed by Gyssens et al.; the assessment was double-checked by a senior ID specialist.

We evaluated 1577 patients of whom 700 (44.4%) had antimicrobials, receiving a total of 1270 prescriptions. 958 (75.4%) prescriptions were for therapy and 312 (24.6%) for prophylaxis. 37.0% of therapeutic and 16.6% of prophylactic prescriptions were found to be inappropriate. Most frequent characteristics of inappropriate treatments included: No indication (17.5%); incorrect choice of antimicrobials (7.6%); incorrect application of drugs (9.3%); and divergence from institutional guidelines (8%). Characteristics of inappropriate prophylaxes were: No indication (9%); incorrect choice of antimicrobials (1%); duration too long or other inappropriate use (6.7%). Patterns of inappropriate antimicrobial varied widely in the different hospital units; empirical prescriptions were more frequently incorrect than prescriptions based on available microbiological results.

Conclusions/Significance

Audits of individual patient care provide important data to identify local problems in antimicrobial prescription practice. In our study, antimicrobial prescriptions without indication, and divergence from institutional guidelines were frequent errors. Based on these results, we will tailor education, amend institutional guidelines and further develop the infectious diseases consultation service.

Blood samples drawn for culture as a surrogate marker for case-mix adjustment of hospital antibiotic use

Hospital antibiotic consumption is generally adjusted to occupancy. This study hypothesised that the number of blood culture samples could be a surrogate marker for case-mix adjustment. Antibiotic consumption was compared over 16 consecutive trimesters in one medical ward in terms of patient-days or blood culture samples. Compared with patient-days, measurement adjusted to blood culture samples detected three trimesters with an unusually high consumption, and one trimester with consumption falsely classified as high because of a high incidence of infections. Blood culture numbers enabled easy and accurate identification of periods with a drift in antibiotic consumption ina medical ward.

A new antimicrobial susceptibility testing method of Escherichia coli against ampicillin by MSPQC

A new antimicrobial susceptibility testing method by multi-channel series piezoelectric quartz crystal (MSPQC) was proposed. This method was used to test susceptibility of clinical Escherichia coli isolates against ampicillin. Both the minimum inhibitory concentrations (MICs) and interpretive categorization of clinical E. coli isolates were determined by proposed method. Comparing tests were run at the same time by the agar dilution method and the disk diffusion method. The experimental results showed that MSPQC method had a good agreement with the reference methods. Compared with those methods, the MSPQC method is simple, rapid, and convenient to perform. It can offer both a minimum inhibitory concentration (MIC) and an interpretive category result.

Healthcare Epidemiology: Does Antibiotic Selection Impact Patient Outcome?

Inadequate antibiotic therapy, generally defined as microbiologically ineffective anti-infective therapy against the causative pathogen, can influence patient outcome. However, the detrimental effects of inadequate antibiotic therapy seem to become weaker in the most severely ill patients with short life expectancies. In addition to severity of illness, other methodological issues should be carefully examined in studies assessing the excess mortality due to inadequate therapy. To adjust for confounding as much as possible in order to obtain an unbiased estimate of the magnitude of the effect of inadequate therapy is a key methodological challenge for future research. With regard to the choice of antibiotic agents, beta-lactam and aminoglycoside combination therapy does not seem to improve clinical outcome in most cases of sepsis caused by gram-negative bacteria, including Pseudomonas aeruginosa bacteremia. A potential benefit of combination therapy in the treatment of severe pneumococcal sepsis has been suggested in several observational studies, but recently published data have disputed this hypothesis. Finally, better risk scores and laboratory tools are urgently needed to improve the adequacy of empirical antibiotic therapy and patient outcomes.

Quantification and evaluation of antimicrobial drug use in group treatments for fattening pigs in Belgium

To control the emergence of antimicrobial resistance, knowledge of antimicrobial drug consumption is essential. Because consumption data are not available in Belgium, a study was conducted between March and October 2003 to investigate the antimicrobial drug consumption in pigs, using the treatment incidence based on the animal daily dose pig (ADDpig), the treatment incidence based on the used daily dose pig (UDDpig) (number of ADDpig or UDDpig/1,000 pigs at risk/day), and the ratio UDDpig/ADDpig. The sampling frame consisted of 821 pig herds that (a) used a closed or semi-closed production system, (b) were located in the most dense pig areas of Belgium, and (c) had at least 150 sows and 600 fattening pigs each. Of 50 randomly selected herds, all group treatments with antimicrobial drugs, applied to fattening pigs that were within 2 weeks of slaughter (median age 187 days), were collected retrospectively. The treatment incidence based on ADDpig for all oral and injectable antimicrobial drugs was 178.1 per 1,000 pigs at risk per day. The treatment incidence based on UDDpig shows that in reality fewer pigs were treated, namely 170.3 per 1,000 pigs at risk per day. Proportionally, the most often applied oral antimicrobial drugs were: doxycycline, amoxicillin, combination trimethoprim-sulphonamides and polymyxin E. The most often applied injectable antimicrobial drugs were long-acting amoxicillin and ceftiofur. The distribution of the UDDpig/ADDpig ratio per antimicrobial drug shows that 50-75% of the oral formulations were underdosed. Injectable formulations were almost always overdosed (>90%).

Limited effect of patient and disease characteristics on compliance with hospital antimicrobial guidelines

OBJECTIVE

Physicians frequently deviate from guidelines that promote prudent use of antimicrobials. We explored to what extent patient and disease characteristics were associated with compliance with guideline recommendations for three common infections.

METHODS

In a 1-year prospective observational study, 1,125 antimicrobial prescriptions were analysed for compliance with university hospital guidelines.

RESULTS

Compliance varied significantly between and within the groups of infections studied. Compliance was much higher for lower respiratory tract infections (LRTIs; 79%) than for sepsis (53%) and urinary tract infections (UTIs; 40%). Only predisposing illnesses and active malignancies were associated with more compliant prescribing, whereas alcohol/ intravenous drug abuse and serum creatinine levels >130 micromol/l were associated with less compliant prescribing. Availability of culture results had no impact on compliance with guidelines for sepsis but was associated with more compliance in UTIs and less in LRTIs. Narrowing initial broad-spectrum antimicrobial therapy to cultured pathogens was seldom practised. Most noncompliant prescribing concerned a too broad spectrum of activity when compared with guideline-recommended therapy.

CONCLUSION

Patient characteristics had only a limited impact on compliant prescribing for a variety of reasons. Physicians seemed to practise defensive prescribing behaviour, favouring treatment success in current patients over loss of effectiveness due to resistance in future patients.

Reliability of assessment of adherence to an antimicrobial treatment guideline

Assessment procedures for adherence to a guideline must be reliable and credible. The aim of this study was to explore the reliability of assessment of adherence, taking account of the professional backgrounds of the observers. A secondary analysis explored the impact of case characteristics on assessment. Six observers (two hospital pharmacists, two internists and two clinical microbiologists) assessed a random sample of 22 prescriptions made to infectious disease cases admitted to a department of internal medicine between February and August 2001. Agreement between observers with regard to adherence of these prescriptions to guideline recommendations concerning drug choice, duration of treatment, dosage and route of administration was measured using Cohen's kappa. Case characteristics were compared between cases where observers agreed and disagreed with two-sided Fisher's exact test. Agreement between all professionals was moderate for drug choice (0.59), fair for duration of therapy (0.36), moderate for dosage (0.48), and fair for route of administration (0.37). Agreement on drug choice was good within (0.75 and 0.83) and between (0.74) the internists and the hospital pharmacists, but was less within (0.31) the clinical microbiologists and between the clinical microbiologists and the internists (0.44) and the hospital pharmacists (0.42). Within the clinical microbiologists, agreement was good for dosage (0.79) and route of administration (0.66). There was frequent disagreement between observers regarding cases with combination therapy and non-immunocompromised patients. Despite the small number of cases, our results suggest that internists and hospital pharmacists can reliably be used to assess adherence for drug choice. The level of agreement seems to be affected by combination therapy and the immune status of the patient.

Antimicrobial prescribing at a university hospital: justified or ‘just in case’. Testing a new scoring system as a key quality indicator

OBJECTIVE

To evaluate the quality of antimicrobial drug prescribing at a university hospital in the Department of Medicine, by using a new scoring system as a quality indicator.

METHODS

DESIGN

a prospective, longitudinal survey, during a 21-week period. The necessity of antimicrobial treatment of all in-patients at the Department of Medicine, to whom new antimicrobials were prescribed, was assessed by using a scoring system based on the presence of signs and symptoms of an infection. If the sum's total score was 3 or more, the antimicrobial treatment was deemed justifiable; if the score was less than 3, the antimicrobial treatment was regarded as questionable.

SETTING

Department of Medicine (279 hospital-beds) at the University Hospital Center Rijeka, a 1200-patient-bed teaching hospital in Croatia.

RESULTS

Antimicrobials were prescribed to 15% of the total patients. They were given as a treatment to 89% of the patients, and in 67% of the cases, this treatment was administered empirically. According to the scoring system, 29% of the patients did not have a justified indication for antimicrobial treatment.

CONCLUSION

The proposed quality indicator (scoring system) that we used is a simple method for the quality assessment of antimicrobial use. It has indicated areas that require in-depth analysis.

Rational antibiotic use and academic staff

This study was devised to determine the knowledge, attitude and behaviour of an educated group of people towards antibiotic use and self-medication with antibiotics. Of 1380 members of academic staff (excluding those from the Faculty of Medicine) of Ege University, 602 were chosen by systematic sampling methods. Two groups were formed. Group A included academic staff from the Faculties of Dentistry and Pharmacy and Group B, members of all other faculties. The mean age was 37.4+/-11.0 and 47.0% were females. The mean antibiotic knowledge score was 7.16+/-3.32. Self-medication with antibiotics was admitted by 45.8% of the total samle and 15.6% of the respondents used antibiotics until their symptoms disappeared regardless of the period of prescription. In Group A 48.8% and in Group B 80.7% of the respondents believed that antibiotics could be used for common cold. It is concluded that priority should be given to knowledge-based behaviour education programmes for the more highly educated community; there must also be restriction on the sale of antibiotics without prescription.

A survey of group-level antibiotic prescriptions in pig production in France

There is world-wide concern that antimicrobial use in food-producing animals might contribute to antimicrobial resistance both in animals and in humans. The relationship between antimicrobial use and resistance is likely to be related to frequency of prescription of the compound, dose and duration of treatment. Routine collection of that information is not possible today in France. A postal survey of French pig veterinarians therefore was carried out in October 2000. The questionnaire focused on the last antibiotic group-level prescription made; data were collected on the type of animals, presumptive clinical diagnosis and drug prescription. The list frame was defined using a veterinary yearbook. All practitioners with mention of pig in the treated species or with employment in intensive animal production were sent the questionnaire. Out of the 431 selected practitioners, 303 responded to the self-administered questionnaire (overall return proportion 70%). 159 prescriptions were received and analysed (response proportion 37%). Their repartitions according to indications and active compounds were summarised. Mean prescribed daily doses and mean treatment length were calculated for four antibiotics: amoxicillin, colistin, oxytetracycline, tylosin. Prescribed daily dose were in the range of dosages used and recommended in Europe. High variations were encountered in treatment length: from 3 to 21 days.

Antibiotic policies and control of resistance

PURPOSE OF THE REVIEW

The current worldwide pandemic of antibiotic resistance shows no signs of abating. It is clear that it is driven mainly by heavy and often inappropriate antibiotic use. Although control measures are widely practised, it is important that we assess their efficacy critically in order to concentrate expensive control efforts where they will be most effective. The past year has seen much activity in this area, with evidence-based assessments of the literature according to strict guidelines, as well as progress in basic science studies of mechanisms of resistance, and their causes and relations to pathogenicity and adaptability.

RECENT FINDINGS

The present review summarizes current developments in the causes of antibiotic resistance, the classification of antibiotic stewardship and control measures, the evidence base for their efficacy, current problems in hospital practice, the adaptability of bacteria, the content of antibiotic policies and anticipated activities.

SUMMARY

The conclusions from the published literature are that much of it that pertains to changing prescribing practices does not stand up to modern evidence-based analysis concepts. Nevertheless, we can learn from experience in changing other areas of medical practice. We must be pragmatic and must not expect to change the world, but rather take it step by step, recognizing barriers and measuring outcomes and quality indicators. Studies into the molecular basis of resistance confirm the superb genetic adaptability of micro-organisms. They will always be several steps ahead of us. Nevertheless, we are learning how to modify our prescribing habits to minimize resistance, not only by using antibiotics less frequently but also by altering dosing schedules in various ways.