Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for Europe

Retrospective antimicrobial consumption surveillance at health facility level in Dodoma Region, Tanzania

INTRODUCTION

Antimicrobial resistance (AMR) is a major threat in sub-Saharan Africa (SSA), but assessments of antimicrobial consumption (AMC) are limited. This study aimed to investigate regional AMC and resistance patterns in a representative area of Tanzania and to introduce a method for determining AMC in low-resource settings.

DESIGN AND METHODS

We conducted a retrospective study using prescription data collected over 5 years (2013-2017) from multiple hospitals and selected primary health facilities in the Dodoma Region of Tanzania. The study employed the WHO's Anatomical Therapeutic Chemical (ATC) classification and Daily Defined Dose (DDD) methodology to quantify antimicrobial use. Outpatient prescription records that met our inclusion criteria were analysed, while incomplete records were excluded. Sensitivity testing for frequently prescribed antimicrobials was performed against representative gram-negative and gram-positive bacteria, with resistance expressed as minimum inhibitory concentrations and resistance percentages.

SETTING AND PARTICIPANTS

This study was conducted across several high-volume healthcare facilities in the Dodoma Region, encompassing both hospital and primary care settings. The dataset comprises outpatient prescription records from these facilities, representing a significant proportion of the regional healthcare usage. The selected facilities were chosen based on their substantial catchment populations to maximise data volume and relevance.

OUTCOME MEASURES

The primary outcome measure was the DDD per 1000 inhabitants per day (DID) for various antimicrobial classes. Secondary outcomes included the prevalence of specific drugs, such as amoxicillin and erythromycin, and their corresponding resistance profiles. Resistance data were quantitatively analysed, with particular attention given to penicillinase-sensitive penicillins and their resistance rates among gram-negative and Gram-positive bacteria.

RESULTS

Analysis revealed that single penicillins, particularly amoxicillin, dominated prescriptions, accounting for 25% to 60% of hospitals and 13% to 29% of primary health centres. Erythromycin was prescribed in 9.4% to 25.1% of cases across facilities. The overall AMC in the region ranged from 36.7 to 50.2 DID during the study period, with consumption patterns showing an initial increase of 4.3% from 2013 to 2014, a subsequent 29.0% decrease from 2014 to 2015, followed by a 34.1% increase from 2015 to 2016 and a further 37.9% increase from 2016 to 2017. Resistance testing demonstrated that penicillinase-sensitive penicillins exhibited an average resistance rate of 87.3%, with gram-negative and gram-positive bacteria showing resistance levels of 90.1% (±8%) and 83.6% (±8%), respectively, indicating a statistically significant association (p<0.05) between high consumption and elevated resistance.

CONCLUSION

Our findings reveal that AMC in the Dodoma Region is high and is linked to significant resistance against commonly used agents. This study presents a robust method for monitoring AMC and resistance in a resource-efficient manner, offering potential applicability in similar settings across SSA. The data, though representing only a fraction of total antimicrobial use, underscore the urgent need for targeted antimicrobial stewardship interventions, particularly at the primary healthcare level. Future research should further investigate demographic influences and evaluate intervention strategies to mitigate AMR effectively.

Navigating Antimicrobials and Combating Antimicrobial Resistance: Challenges, Impacts, and Strategies for Global Action

Antimicrobial resistance (AMR) is one of the biggest problems facing the scientific and medical communities. According to WHO, this growing issue might make once-effective antibiotics obsolete and pose a substantial risk to public health. Estimates indicate that multimillion deaths were either directly or indirectly caused by AMR, making it one of the most substantial risks to public health and development in the world. The issue of AMR is primarily caused by healthcare workers' excessive and inappropriate use of antimicrobial agents. Dentists are believed to prescribe a considerable portion of all antibiotics globally. The emergence of AMR, its causes, and its effects on human health are examined in this article, with special attention to dental offices and medical facilities. It draws attention to the rising issue of antibiotic overprescription and abuse, particularly in low- and middle-income countries, where improper antibiotic use is an everyday practice around the globe. The article discusses the role of antimicrobial stewardship programs and the importance of implementing precise, evidence-based practices in preventing AMR. Since antibiotic abuse in livestock greatly accelerates the spread of resistance, the role of antibiotics in animal agriculture is also investigated. To address AMR, the paper highlights the necessity of a global, coordinated response that bolsters surveillance systems, cuts back on needless antibiotic use, and expands access to alternative treatments. Recent research has called into question the efficacy of preventive antibiotic medication in these situations. According to other researchers, it might not help avoid surgical site infections. However, other experts say disrupting deeper tissues and local mucosal defenses during an intraoral surgical operation may raise the risk of infection even when antibiotics are used.

A model-based evaluation of the pharmacokinetics-pharmacodynamics (PKPD) of avibactam in combination with ceftazidime

Background

The emergence of β-lactamase-producing bacteria limits the effectiveness of β-lactam (BL) antibiotics, and the combination with a β-lactamase inhibitor (BLI) aims to counteract this resistance. However, existing guidelines primarily focus on optimizing the dosing of BLs and do not adequately address the interaction between BLs and BLIs, leading to uncertain pharmacokinetic/pharmacodynamic (PK/PD) targets and potentially suboptimal dosing strategies.

Objectives

To investigate optimal PK/PD targets and dosing strategies for avibactam (BLI) combined with ceftazidime (BL) using mechanism-based PKPD models.

Methods

PK models for ceftazidime and avibactam were integrated with mechanism-based PKPD models for Gram-negative bacteria. Simulations explored dose regimens in mice and humans, evaluating PK/PD indices and computing the PTA for diverse dosing strategies and infusion modes.

Results

fAUC/MICCAZ/AVI was the most predictive index for avibactam against Enterobacteriaceae in both mice and humans, regardless of infusion mode. Against Pseudomonas aeruginosa, fT > CT predicted efficacy in mice, while fAUC/MICCAZ/AVI and fCmax/MICCAZ/AVI were more predictive in humans, particularly for continuous infusion regimens. Higher PTAs were achieved with increased avibactam doses relative to ceftazidime, particularly with 1:1 and 2:1 ceftazidime:avibactam ratios. Continuous infusion improved PTA against P. aeruginosa but had limited impact on Enterobacteriaceae.

Conclusion

The PK/PD indices predictive of avibactam efficacy varied by species (mice and humans), bacterial strains, and mode of infusion. Dosing simulations suggest that increasing avibactam relative to ceftazidime and using continuous infusion regimens may enhance bacterial killing. These findings highlight the importance of refining dosing strategies for both components of the combination therapy.

Public knowledge, attitudes, and practices regarding antibiotics use and resistance in Montenegro

A drug consumption monitoring revealed that Montenegro is one of the major consumers of antimicrobial drugs in Europe. The aim of this study is to obtain the first data on the knowledge, attitudes, and practices of the general population in Montenegro regarding antibiotics use. This cross-sectional study was designed according to the methodology of Eurobarometer survey on antimicrobial resistance, created by the European Commission. The standardized questionnaire was conducted in Podgorica, in October-November 2022. A total of 532 participants completed the questionnaire. More than a half of responders (60.9%) have received antibiotics within the last 12 months and among them 33.4% was missing a medical prescription, nor the antibiotic was administered by a medical practitioner. The rest of the responders mostly had some antibiotics left over from a previous course (13.0%), had taken it from a pharmacy (11.4%), or elsewhere without a prescription. The most frequent reasons for antimicrobial therapy were "cold" (22.5%), "sore throat" (21.0%), "cough" (19.4%), and "COVID-19" (coronavirus disease 2019) (17.9%). Throat swab, blood test, urine test, or other test that could identify the cause of the illness preceded antimicrobial therapy in 46.3% participants. Only one-half of the participants were convinced that antibiotics are ineffective in viral infection treatment. This study is the first report on public knowledge, attitudes and practices regarding antibiotics use and resistance in Montenegro and it highlights the need for the knowledge improvement among general population, better regulations for antibiotics procurement and a campaign regarding appropriate antibiotics use among youth.

Serotypes distribution and antibiotic susceptibility of Streptococcus pneumoniae strains: five-year surveillance results of post-PCV-13

BACKGROUND

Approximately 100 capsular serotypes of S. pneumonia have been identified according to the composition of their capsular polysaccharides, currently available vaccines do not cover many of these. Pneumococcal vaccination serotype coverage is essential for preventing noninvasive and invasive illnesses as well as asymptomatic carriage. We aimed to determine the serotype distribution and antimicrobial susceptibility pattern of pneumococcal clinical isolates in this study. We also analyzed the serotype coverage rates of PCV13, which is applied in the NIP, and PCV-15 and PCV20, which have been introduced recently.

METHODS

This study is a retrospective surveillance of pneumococcal infections including invasive pneumococcal isolates (IPIs) and non-invasive pneumococcal isolates (non-IPIs).

RESULTS

A total of 420 isolates from 356 different patients aged 0-89 years were enrolled in the study. A total of 420 pneumococcal isolates were serotyped and 26 different serotypes were detected. Serotype 19 F was the most prevalent serotype (n = 96, 22.8%), followed by 6 A/B (n = 55, 13.1%), 23 F (n = 49, 11.6%), 3 (n = 22, 5.2%) and 19 A (n = 16, 3.8%).

CONCLUSIONS

Surveillance studies of pneumococcal diseases are critical to investigating current serotype distributions, antibiotic resistance status, and frequency of IPD cases. Considering the increasing antibiotic resistance rates of S. pneumoniae, it is necessary to provide protective immunization by switching to more comprehensive PCV vaccines rather than treatment.

CLINICAL TRIAL NUMBER

Not applicable.

Fluoroquinolone Resistance in Drug-Resistant Tuberculosis, Kharkiv, Ukraine, 2019-2023

Rifampin-resistant Mycobacterium tuberculosis was identified by the World Health Organization as a pathogen of public health critical importance. During 2014-2023, an increase in fluoroquinolone resistance in rifampin-resistant M. tuberculosis from Kharkiv, Ukraine, was observed. Efforts to mitigate factors contributing to resistance should be prioritized to prevent further escalation of that threat.

National trends in Azithromycin consumption during 2017-2023 in Kazakhstan: impact of the COVID-19 pandemic and the imperative for enhanced clinical guidelines

Antibiotic resistance (AMR) has reached critical levels globally, especially in developing economies like Kazakhstan, largely due to improper antibiotic use. The aim of this study was to examine seven years of azithromycin sales data in Kazakhstan to uncover consumption patterns during the COVID-19 pandemic and develop effective strategies to combat AMR. This study analyzes two data sets: one from a comprehensive review of documents regulating azithromycin use in Kazakhstan. The second data set consists of a pharmaco-epidemiological analysis of azithromycin consumption from procurement data provided by Vi-ORTIS. Azithromycin consumption (ATC group J01FA10) from 2017 to 2023 was measured in DDD/1000 inhabitants/day (DID) using the ATC/DDD methodology. Azithromycin is extensively used in adult and pediatric care in Kazakhstan. Its consumption, measured in DDD per 1,000 inhabitants, surged in 2020 with the COVID-19 outbreak. The steady annual increase in "Watch" antibiotics, including azithromycin, should alarm Kazakhstan's healthcare system. This trend highlights the need for stronger stewardship programs, targeted interventions, and comprehensive monitoring to prevent antibiotic overuse and misuse. Addressing this is crucial to maintaining antibiotic effectiveness and safeguarding public health.

Evaluation of Liposome-Encapsulated Vancomycin Against Methicillin-Resistant Staphylococcus aureus

Background/Objectives: Methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern due to its resistance to conventional antibiotics. This study evaluated the efficacy of liposome-encapsulated vancomycin against MRSA using phospholipids extracted from egg yolk. Liposomes were prepared via the freeze-thaw method, yielding vesicles with an average diameter of 157.01 ± 33.04 nm and a polydispersity index (PDI) of 0.0442, indicating uniformity and stability. Antibacterial activity was assessed using the microdilution method. Liposome-encapsulated vancomycin demonstrated complete bacterial growth inhibition (100%) against MRSA ATCC 2758 at dilutions of 101 and 102, compared to only 50% inhibition by free vancomycin at 101. At higher dilutions (103), liposome-encapsulated vancomycin maintained 70% inhibition, whereas free vancomycin was ineffective. In vivo studies using a murine wound infection model revealed that wounds treated with liposome-encapsulated vancomycin achieved superior healing, with complete tissue regeneration observed by day 14. Histological analysis showed reduced inflammation and enhanced tissue recovery in liposome-encapsulated vancomycin-treated groups, compared to fibrosis and persistent necrosis in free vancomycin-treated groups. By enabling sustained drug release and improved bioavailability, liposomal formulations minimized required dosages and systemic toxicity, reducing the risk of resistance development. This study highlights the clinical potential of liposome-encapsulated vancomycin as a scalable, cost-effective treatment for MRSA, particularly in resource-limited settings.

Antibiotic use in different hospital administrative categories: an overview of 10 years of a statewide surveillance program in Brazil

Objective

The present study aimed to describe ICU antibiotic use based on data reported from 2009 to 2018 to the Nosocomial Surveillance System (NSS) of the State Health Department in the State of Sao Paulo, Brazil.

Design

Ecological study.

Setting

Data obtained from hospitals located in the state of São Paulo, Brazil from 2009 to 2018.

Participants

Intensive care units located at participant hospitals.

Methods

Data on healthcare-associated infections, antibiotic usage, and bacterial identification were collected and reported monthly by hospitals. Antibiotic consumption was quantified as defined daily doses (DDD) per 1000 patient-days. The relationship between antibiotic use and bacterial resistance, categorized by hospital type and ICU complexity, was analyzed using statistical methods to assess correlations and significance.

Results

Our findings reveal an escalating trend in antibiotic consumption over the study period, with a notable increase from 588.16 DDD per 1000 patient-days in the initial year to 943.12 DDD/1000 patient-days in the final year (p < 0.01). Cephalosporins emerged as the most frequently utilized class, accounting for 33.9% of total antibiotic consumption. Public hospitals exhibited significantly higher antibiotic use compared to private and philanthropic institutions, with a mean of 889.11 DDD/1000 patient-days in public hospitals compared to 849.07 DDD/1000 patient-days in private hospitals and 785.12 DDD/1000 patient-days in philanthropic hospitals (p < 0.05).

Conclusions

The study provides critical insights into antibiotic use and resistance in different hospital settings, emphasizing the importance of tailored antimicrobial stewardship strategies.

Sludge biolysis pretreatment to reduce antibiotic resistance genes (ARGs): Insight into the relationship between potential ARGs hosts and BALOs' preferred prey

As an important reservoir of antibiotic resistance genes (ARGs), the sludge discharged from wastewater treatment plants is the key intermediate for ARG transport into the environment. Bdellovibrio-and-like organisms (BALOs) are predatory bacteria that are expected to attack antibiotic-resistant bacteria (ARB). In this study, the screened BALOs (C3 & D15) were mixed with the sludge for biolysis to achieve the satisfying removal efficiencies of six tet genes, two sul genes, and one mobile genetic element (intl 1). Among them, tet(Q) demonstrated the highest reduction rate in relative abundance at 87.3 ± 1.0 %, while tet(X) displayed the lowest of 11.7 ± 0.2 %. The microorganisms, including Longilinea, Methanobacterium, Acetobacterium, Sulfurimonas, allobaculum, Gaiella, AAP99, Ellin6067, Rhodoferax, Ferruginibacter and Thermomonas, were expected to play a dual role in the reduction of ARGs by serving as ARB and BALOs' preferred prey. Meanwhile, BALOs consortium improved ARGs reduction efficiency via the expansion of the prey profile. Additionally, BALOs decreased the relative abundance of not only pathogens (Shinella, Rickettsia, Burkholderia, Acinetobacter, Aeromonas, Clostridium, Klebsiella and Pseudomonas), but also the ARGs' host pathogens (Mycobacterium, Plesiocystis, Burkholderia, and Bacteroides). Therefore, the application of BALOs for sludge biolysis are promising to decrease the sludge's public health risks via limiting the spread of ARGs and pathogens into the environment.

Antimicrobial prescribing in referral hospitals in Timor-Leste: results of the first two national point prevalence surveys, 2020-21

Objectives

To describe antimicrobial use (AMU) in patients admitted to hospitals in Timor-Leste.

Methods

In 2020 and 2021, we undertook antimicrobial prescribing point prevalence surveys across all six hospitals in Timor-Leste (one national and five municipal) to describe AMU and appropriateness in admitted patients.

Results

In 2020, 291/394 (73.9%) surveyed patients had been prescribed antimicrobials, compared with 260/403 (64.5%) in 2021 (P = 0.004). Most (309/551; 56.1%) were prescribed one antimicrobial, and 179/551 (32.5%) were prescribed two. The most commonly prescribed antibiotics were ceftriaxone (38.5% in 2020, 41.5% in 2021) and ampicillin (35.7% in 2020, 32.3% in 2021), followed by gentamicin, metronidazole and cloxacillin. Reserve antibiotics like meropenem and vancomycin were minimally used. Of all antimicrobial prescriptions, 70.8% were deemed appropriate in 2020 and 69.1% in 2021. Antimicrobial prescriptions for surgical and post-partum prophylaxis were frequently deemed inappropriate [37/50 (74.0%) and 39/44 (88.6%) prescriptions, respectively].

Conclusions

Most patients admitted to hospital in Timor-Leste are prescribed antimicrobials, and approximately one-third of these prescriptions are inappropriate. However, this was in the context of limited local guideline availability at the time of surveys and limited microbiological culture capacity outside of the capital, Dili. Improved microbiological guidance, iterative guideline revisions based on local antimicrobial resistance (AMR) surveillance data, and enhanced stewardship activities including further point prevalence studies, could improve antimicrobial use, optimize patient outcomes and reduce AMR in Timor-Leste.

Mapping the path to excellence: Evaluation of the diagnostic and treatment tools for invasive fungal infections in the balkans

BACKGROUND

In the Balkans, rising concerns about invasive fungal infections over the past decade stem from various factors. Primarily, there has been a notable uptick in immunocompromised individuals, including those with chronic illnesses like immunological and hematological diseases. Thus, it is essential to assess the region's laboratory capabilities and the availability of antifungals. This evaluation is vital for gauging the preparedness to diagnose and treat fungal infections effectively, thus minimizing their public health impact.

METHODS

Data were collected via an online questionnaire targeting healthcare professionals specializing in relevant fields across diverse healthcare settings in Balkan countries. The survey covered various aspects, including diagnostic methods, imaging techniques, and available antifungal armamentarium.

RESULTS

Responses were obtained from 50 institutions across the Balkans. While conventional diagnostic methods like microscopy (96 %) and culture (100 %) diagnostics were widely available, access to newer diagnostic tools such as molecular assays (61 %) were limited, often relying on outsourced services. Imaging modalities like ultrasound (100 %) and CT scans (93 %) were universally accessible. A variety of antifungal drugs were available, including amphotericin B formulations (80 %), echinocandins (79 %), and triazoles (100 %). However, access to newer agents like posaconazole (62 %) and isavuconazole (45 %) was inconsistent. Therapeutic drug monitoring (53 %) services were also limited.

CONCLUSION

The study underscores the need for equitable access to diagnostic facilities and antifungal treatments across healthcare settings in the Balkan geographic region. Improving access to molecular diagnostic tools and essential antifungal drugs, as well as implementing therapeutic drug monitoring, would optimize the management of fungal infections in the region.

Causative Microorganisms in Community-Acquired Urinary Tract Infections and Risk Factors for the Development of Infection with Extended-Spectrum β-Lactamase-Producing Species

Objective

This study aimed to determine the microorganisms grown in the urine cultures of patients followed up with the diagnosis of community-acquired urinary tract infection (CA-UTI), their antibiotic susceptibility, and the risk factors that cause extended-spectrum β-lactamase (ESBL) production in microorganisms.

Materials and Methods

Patients diagnosed with CA-UTI in the Yıldırım Beyazıt University City Hospital Infectious Diseases and Clinical Microbiology Clinic between February 2019 and February 2020 were prospectively analyzed. The microorganisms grown in the urine cultures and antibiotic susceptibility rates were examined. The clinical and demographic characteristics of the patients were compared in terms of the isolated agent producing ESBL.

Results

Escherichia coli (63.8%) and Klebsiella pneumoniae (22.0%) were the most common microorganisms detected in the urine cultures; the rate of those producing ESBL was 46.6%. Antibiotics with high resistance rates were ampicillin (74.2%), cefuroxime (49.6%), and ceftriaxone (49%). Male gender, complicating factors, immunosuppression, kidney transplantation and history of antibiotic use were determined as significant risk factors for ESBL production. Male gender, immunosuppression, and history of antibiotic use were also independent risk factors. ROC analysis of risk factors showed ESBL-producing bacteria were isolated at a high rate in patients having ≥3 risk factors.

Conclusion

The resistance rates in our study are quite high. Male gender, history of antibiotic use and immunosuppression status were found to be independent risk factors for ESBL positivity in patients with CA-UTI, and the more risk factors a patient has, the higher the risk of ESBL positivity.

The antibiotic knowledge, attitudes and behaviours of patients purchasing antibiotics with prescription in Russia: a qualitative, comparative analysis

Objectives

The study aimed to investigate behaviour, knowledge and practices towards antibiotic (AB) use among patients who purchased ABs with a prescription across Russia.

Methods

Semi-structured interviews conducted in all eight Federal Districts, Moscow and Saint Petersburg in 2022 by 21 researchers trained specifically for this study. Data were analysed using a directed content analysis approach.

Results

In total, 151 respondents were interviewed. Respiratory symptoms were the most common reason for AB prescription. The majority of patients discussed their complaints with family members or friends before consulting the physician and occasionally looked for information on antimicrobial treatment on the internet. The decision to use an AB was usually made by the physician, although patients often anticipated its prescription. Respondents typically chose to go to the nearest drug store to pick up the medicines, not seeking any recommendation from the local pharmacists. The level of knowledge about the effects of ABs was generally low. In most cases, patients were not aware of antimicrobial resistance and rarely recalled any information campaigns targeting prudent AB use. Respondents admitted COVID-19 had an impact on their behaviour: they have become more caring towards their health, but less likely to seek medical care because of the risk of infection.

Conclusions

Our findings, in particular low awareness of the population about the effects of ABs and antimicrobial resistance, peculiarities of attitudes and behaviour (significant influence of the environment, tendency to self-diagnose, fairly high level of trust in doctors etc.) can be useful for the development of effective initiatives aiming for prudent AB use.

Strategies to Name Metallo-β-Lactamases and Number Their Amino Acid Residues

Metallo-β-lactamases (MBLs), also known as class B β-lactamases (BBLs), are Zn(II)-containing enzymes able to inactivate a broad range of β-lactams, the most commonly used antibiotics, including life-saving carbapenems. They have been known for about six decades, yet they have only gained much attention as a clinical problem for about three decades. The naming conventions of these enzymes have changed over time and followed various strategies, sometimes leading to confusion. We are summarizing the naming strategies of the currently known MBLs. These enzymes are quite diverse on the amino acid sequence level but structurally similar. Problems trying to describe conserved residues, such as Zn(II) ligands and other catalytically important residues, which have different numbers in different sequences, have led to the establishment of a standard numbering scheme for BBLs. While well intended, the standard numbering scheme is not trivial and has not been applied consistently. We revisit this standard numbering scheme and suggest some strategies for how its implementation could be made more accessible to researchers. Standard numbering facilitates the comparison of different enzymes as well as their interaction with novel antibiotics and BBL inhibitors.

The role of major and minor determinants in penicillin allergy testing: Time to revisit an old friend?

Background

Skin testing is an important step in evaluation of penicillin allergic reactions. It includes testing to the following: amoxicillin, benzyl penicillin, and products generated in vivo after penicillin administration, the major determinant hapten penicilloyl-polylysine (PPL) and the minor determinant mixture (MDM). Although PPL and MDM are available as a commercial kit, their supply and cost remain problematic.

Objective

We aimed to evaluate the performance and utility of PPL and MDM in penicillin allergy testing.

Methods

A retrospective audit over a 5-year period was undertaken for those with penicillin testing in a tertiary immunology unit.

Results

In all, 214 patients were identified. Of those patients, 151 (70.6%) were female and the average age was 58 years. Unspecified penicillin was the most common index drug (n = 127 [59.3%]), followed by amoxicillin (n =3 [24.8%]) and amoxicillin-clavulanic acid (n = 21 [9.7%]). The result of skin testing was positive in 23 patients (10.7%); skin prick testing was positive in 10 patients (4.7%), and intradermal testing (IDT) was positive in 13 patients (6.1%), the majority of whom had identified amoxicillin or amoxicillin-clavulanic acid as the index drug (n = 22 [95.7%]). The result of testing to PPL and/or MDM was positive with IDT only (n=5 [23.8%]). PPL and MDM positivity coexisted with a positive reaction to amoxicillin IDT in 2 patients, 1 of whom passed an amoxicillin challenge. Additionally, 2 positive tests to PPL were present with a negative result for MDM; of these 2 positive results, 1 was positive to amoxicillin IDT. In only 1 case were the results of testing for MDM and PPL both positive, with negative results to all native β-lactams tested; the patient tolerated an amoxicillin challenge. Overall, the negative predictive value for both skin prick testing and IDT was 89.5%.

Conclusion

Benzyl penicillin and amoxicillin alone may be sufficient for in vivo testing in suspected individuals with penicillin allergy.

Rational Drug and Antibiotic Use Status, E-Health Literacy in Syrian Immigrants and Related Factors: A Cross-Sectional Study

Rational drug use is a pivotal concept linked with morbidity and mortality. Immigration plays a significant role as a determinant affecting individuals' health-related attitudes, behaviors, and the pursuit of health services. Within this context, the study was initiated to assess the factors influencing health literacy and rational drug use among Syrian immigrants in Istanbul. A cross-sectional study was undertaken on 542 Syrian adults utilizing a three-part questionnaire encompassing sociodemographics, rational drug use, and the e-health literacy scale (eHEALS). With an average age of 39.19 ± 13.10 years, a majority of participants believed medications should solely be doctor-prescribed (97%) and opposed keeping antibiotics at home (93.7%). Yet, 62.5% thought excessive herbal medicine use was harmless. The mean eHEALS score stood at 20.57 ± 7.26, and factors like age, marital status, income, and duration of stay in Turkey influenced e-health literacy. Associations were seen between low e-health literacy and being female, being older, having a lower education level, and regular medication use. Syrian immigrants displayed proper knowledge concerning antibiotics yet exhibited gaps in their understanding of general drug usage, treatment adherence, and herbal medicines. Approximately 80.3% had limited health literacy, pointing to the need for targeted interventions for enhanced health and societal assimilation.

Community-acquired antimicrobial resistance among Syrian refugees and the local population in Türkiye

BACKGROUND

The long-standing antimicrobial resistance (AMR) pandemic has proven difficult to resolve and is becoming more complex, especially in the context of increasing forced migration, with little evidence around patterns of AMR in migrant communities. This study aimed to determine the frequency in the carriage of common types of antimicrobial-resistant bacteria between Syrian refugees and the local communities in Türkiye: extended-spectrum β-lactamase (ESBL), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).

METHODS

We collected nasal swabs and stool samples from the study participants, the local community members, and refugees, between September 2020 and March 2021. We screened clinical samples for the presence of ESBL, MRSA and VRE. Antimicrobial-resistant bacterial isolates were tested by phenotypic analysis to determine the AMR status.

RESULTS

The study included a total of 3960 participants: 1453 individuals in the local community (36.2%) and 2525 Syrian refugees (63.8%). Overall, a significantly greater proportion of refugees (6.7%) carried MRSA compared to the local community (3.2%) (P < 0.001). The ESBL-positivity rate was 17.9% in Syrian refugees and 14.3% in the local community (P = 0.041). Carbapenemase activity was detected in three isolates from Syrian refugees. No VRE was detected in Syrian refugees or the local community.

CONCLUSIONS

This large, community-based study on the frequency and the distribution of AMR among Syrian refugees and the local population is the first study in Türkiye.

Safety evaluation of enterococci isolated from raw milk and artisanal cheeses made in Slovenia and Serbia

Enterococci represent a significant part of the non-starter LAB microbiota of artisanal cheeses produced mainly from raw milk. Common approaches to safety evaluation of enterococci isolates include assessment of antimicrobial resistance and virulence potential. Hence, a collection of 47 (n = 22, Serbia; n = 25, Slovenia) dairy enterococcal isolates, of which E. faecalis (n = 28), E. faecium (n = 11), E. durans (n = 5), E. casseliflavus (n = 2), and E. gallinarum (n = 1), was analyzed. The susceptibility to 12 antimicrobials was tested using a broth microdilution method, and the presence of the selected antimicrobial resistance and virulence genes was investigated using PCR. Isolates were resistant to tetracycline (TET) (25.5%), erythromycin (ERY) (17.0%), gentamycin and chloramphenicol (CHL) (∼6%). No resistance to ampicillin (AMP), ciprofloxacin (CIP), daptomycin (DAP), linezolid (LZD), teicoplanin (TEI), tigecycline (TGC) and vancomycin (VAN) was detected. Among all the resistance determinants analyzed, ermB gene was detected most frequently. All 10 virulence genes analyzed were detected with a distribution of cpd (72.3%), cob and ccf (70.2%), gelE (68.1%), hyl (59.6%), agg (53.2%) and esp (46.8%). The genes encoding cytolysin (cylA, cylM and cylB) were amplified to a lesser extent (21.3%, 21.3% and 12.8%, respectively). However, due to the limited number of enterococci isolates analyzed in the present study, further studies are still required in order to better document the safety status of dairy enterococci.

A model of antibiotic resistance genes accumulation through lifetime exposure from food intake and antibiotic treatment

Antimicrobial resistant bacterial infections represent one of the most serious contemporary global healthcare crises. Acquisition and spread of resistant infections can occur through community, hospitals, food, water or endogenous bacteria. Global efforts to reduce resistance have typically focussed on antibiotic use, hygiene and sanitation and drug discovery. However, resistance in endogenous infections, e.g. many urinary tract infections, can result from life-long acquisition and persistence of resistance genes in commensal microbial flora of individual patients, which is not normally considered. Here, using individual based Monte Carlo models calibrated using antibiotic use data and human gut resistomes, we show that the long-term increase in resistance in human gut microbiomes can be substantially lowered by reducing exposure to resistance genes found food and water, alongside reduced medical antibiotic use. Reduced dietary exposure is especially important during patient antibiotic treatment because of increased selection for resistance gene retention; inappropriate use of antibiotics can be directly harmful to the patient being treated for the same reason. We conclude that a holistic approach to antimicrobial resistance that additionally incorporates food production and dietary considerations will be more effective in reducing resistant infections than a purely medical-based approach.

Trends and seasonal variation of antibiotic consumption by community residents in Hefei, China, 2012-2016

OBJECTIVES

The aim of this study was to evaluate the trends and seasonal variations of antibiotic consumption by community residents in Hefei, China, over a 5-year period.

STUDY DESIGN

This was an ecological study.

METHODS

Data on antibiotic consumption by community residents in Hefei between 2012 and 2016 were collected from the Hefei Center for Disease Control and Prevention. Statistical analysis was carried out using Microsoft Excel 2021, SPSS 26.0 and R4.1.3. An interrupted time series (ITS) analysis was modelled to assess the impact of policies on antibiotic consumption trends.

RESULTS

Amoxicillin and cephalosporins accounted for 63.64% and 30.48%, respectively, of the total defined daily dose per 1000 inhabitant-days (DID) of antibiotics in 2016. The total consumption of antibiotics decreased from 6.92 DID in 2012 to 5.61 DID in 2016 (P_trend = 0.017). Seasonal analysis showed an average of 34.24% antibiotic consumption in the winter over the 5 years. The equation constructed by the ITS analysis was Y = 5.530 + 0.323X1 - 7.574X2 - 0.323X3 + ε.

CONCLUSION

Between 2012 and 2016, overall antibiotic consumption by community residents in Hefei decreased significantly. The impact of antibiotic policies, implemented between 2011 and 2013, started to appear in 2014 when the consumption of antibiotics decreased. This study has important policy implications for the use of antibiotics at the community level. Further studies on the trends of antibiotic consumption are required, and strategies should be designed to promote appropriate use of antibiotics.

11-Year Trend in Antibiotic Consumption in a South-Eastern European Country; the Situation in Albania and the Implications for the Future

There are growing concerns with rising antimicrobial resistance (AMR) across countries. These concerns are enhanced by the increasing and inappropriate utilization of 'Watch' antibiotics with their greater resistance potential, AMR is further exacerbated by the increasing use of antibiotics to treat patients with COVID-19 despite little evidence of bacterial infections. Currently, little is known about antibiotic utilization patterns in Albania in recent years, including the pandemic years, the influence of an ageing population, as well as increasing GDP and greater healthcare governance. Consequently, total utilization patterns in the country were tracked from 2011 to 2021 alongside key indicators. Key indicators included total utilization as well as changes in the use of 'Watch' antibiotics. Antibiotic consumption fell from 27.4 DIDs (defined daily doses per 1000 inhabitants per day) in 2011 to 18.8 DIDs in 2019, which was assisted by an ageing population and improved infrastructures. However, there was an appreciable increase in the use of 'Watch' antibiotics during the study period. Their utilization rose from 10% of the total utilization among the top 10 most utilized antibiotics (DID basis) in 2011 to 70% by 2019. Antibiotic utilization subsequently rose after the pandemic to 25.1 DIDs in 2021, reversing previous downward trends. Alongside this, there was increasing use of 'Watch' antibiotics, which accounted for 82% (DID basis) of the top 10 antibiotics in 2021. In conclusion, educational activities and antimicrobial stewardship programs are urgently needed in Albania to reduce inappropriate utilization, including 'Watch' antibiotics, and hence AMR.

Antibiotic Utilization during COVID-19: Are We Over-Prescribing?

The aims of this study were to analyze the utilization of antibiotics before (2018, 2019) and during the COVID-19 pandemic (2020) and the practice of prescribing antibiotics in outpatient settings for COVID-19 patients during the 2020-2022 period. The Anatomical Therapeutic Chemical Classification/Defined Daily Dose methodology was used for the analysis of outpatient antibiotic utilization in the Republic of Srpska. The data was expressed in DDD/1000 inhabitants/day. The rate of antibiotics prescribed to COVID-19 outpatients was analyzed using medical record data from 16,565 patients registered with B34.2, U07.1, and U07.2 World Health Organization International Classification of Diseases 10th revision codes. During 2020, outpatient antibiotic utilization increased by 53.80% compared to 2019. At least one antibiotic was prescribed for 91.04%, 83.05%, and 73.52% of COVID-19 outpatients during 2020, 2021, and the first half of 2022, respectively. On a monthly basis, at least one antibiotic was prescribed for more than 55% of COVID-19 outpatients. The three most commonly prescribed antibiotics were azithromycin, amoxicillin/clavulanic acid, and doxycycline. The trend of repurposing antibiotics for COVID-19 and other diseases treatment might be a double-edged sword. The long-term effect of this practice might be an increase in antimicrobial resistance and a loss of antibiotic effectiveness.

Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province

BACKGROUND

Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example.

METHODS

Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results.

RESULTS

Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs.

CONCLUSIONS

The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.

Is There a Relationship between Antimicrobial Use and Antibiotic Resistance of the Most Common Mastitis Pathogens in Dairy Cows?

Antimicrobials have had an important impact on animal health and production performance. However, non-prudent antimicrobial use (AMU) in food producing animals is considered to contribute to the emergence of antimicrobial resistance (AMR), with a potential impact on both animal and public health. Considering the global importance of AMR, and the threats and challenges posed by mastitis and mastitis therapy in livestock production, the main objective of this study was to quantify AMU on three dairy farms in Serbia and to examine whether there is an association between AMU and the emergence of antimicrobial resistance of mastitis-associated pathogens. Antimicrobial susceptibility testing was performed by the disk diffusion method using causative agents isolated from the milk samples of 247 dairy cows. AMU data were obtained for a one-year period (May 2021 to May 2022) based on antibiotic prescriptions listed in electronic databases kept by farm veterinarians. To estimate antimicrobial drug exposure at the farm level, the veterinary drug Defined Daily Dose was calculated by multiplying the total amount of antibiotic used on the farms during the study period by the quantity of antibiotic in the administered drug and number of original drug packages used. The results on the association between the use of common antibiotics in mastitis treatment and AMR of isolated mastitis-associated pathogens confirm a pattern that could raise awareness of the importance of this aspect of good veterinary and clinical practice to combat the global threat of AMR.

Computational and data mining studies to understand the distribution and dynamics of Temoneria (TEM) β-lactamase and their interaction with β-lactam and β-lactamase inhibitors

β-lactams are large group of antibiotics widely used to suppress the bacterial growth by inhibiting cell wall synthesis. Bacterial resistance against β-lactam antibiotics is primarily mediated through the production of Temoneria (TEM) β-lactamase (BLs), with almost 474 variants identified in Lactamase Engineering Database (LacED). The present study aims to develop a model to track the evolution of TEM BLs and their interactions with β-lactam and BLs inhibitors through data mining and computational approaches. Further, the model will be used to predict the effective combinations of β-lactam and BLs inhibitors to treat the bacterial infection harbouring emerging variants of β-lactamase. The molecular docking study results demonstrated that most TEM mutants recorded the least binding energy to penicillin and cephalosporin (I/II/III/IV/V generations) class of antibiotics. On the contrary, the same mutants recorded higher binding energy to carbapenem and Monobactam class of antibiotics. Among the BLs inhibitors, tazobactam recorded the least binding energy against most of the TEM mutants, indicating that it can lower the catalytic activity of TEM BLs, thereby potentiating antibiotic action. Similarly, data mining work has assisted us in creating a database of TEM mutants that has comprehensive data on mutations, bacterial diversity, Km, MIC, and IRT types. It has been noted that earlier released antibiotics like amoxicillin and ampicillin had lower Km and higher MIC values, which indicates the prevalence of bacterial resistance. By analysing the differential binding energy (ΔBE) of the selected TEM mutants against β-lactam and BLs inhibitors, the most effective combination of β-lactam (carbapenem and monobactam class of antibiotics) and BLs inhibitors (tazobactam) was identified, to cure bacterial diseases/infections and to prevent similar antibiotic resistance outbreaks. Therefore, our study opens a new avenue in developing strategies to manage antibiotic resistance in bacteria.

Hydroxypyrone derivatives in drug discovery: from chelation therapy to rational design of metalloenzyme inhibitors

The versatile structural motif of hydroxypyrone is found in natural products and can be easily converted into hydroxypyridone and hydroxythiopyridone analogues. The favourable toxicity profile and ease of functionalization to access a vast library of compounds make them an ideal structural scaffold for drug design and discovery. This versatile scaffold possesses excellent metal chelating properties that can be exploited for chelation therapy in clinics. Deferiprone [1,2-dimethyl-3-hydroxy-4(1H)-one] was the first orally active chelator to treat iron overload in thalassemia major. Metal complexes of hydroxy-(thio)pyr(id)ones have been investigated as magnetic resonance imaging contrast agents, and anticancer and antidiabetic agents. In recent years, this compound class has demonstrated potential in discovering and developing metalloenzyme inhibitors. This review article summarizes recent literature on hydroxy-(thio)pyr(id)ones as inhibitors for metalloenzymes such as histone deacetylases, tyrosinase and metallo-β-lactamase. Different approaches to the design of hydroxy-(thio)pyr(id)ones and their biological properties against selected metalloenzymes are discussed.

Risk Factors for Severe Cutaneous Anthrax in a Retrospective Case Series and Use of a Clinical Algorithm to Identify Likely Meningitis and Evaluate Treatment Outcomes, Kyrgyz Republic, 2005-2012

BACKGROUND

US Centers for Disease Control and Prevention guidelines currently recommend triple-therapy antimicrobial treatment for anthrax meningitis. In the Kyrgyz Republic, a country with endemic anthrax, cutaneous anthrax patients are routinely hospitalized and treated successfully with only monotherapy or dual therapy. Clinical algorithms have been developed to identify patients with likely anthrax meningitis based on signs and symptoms alone. We sought to retrospectively identify likely meningitis patients in the Kyrgyz Republic using a clinical algorithm and evaluate risk factors and their outcomes by type of treatment.

METHODS

We conducted a retrospective chart review of cutaneous anthrax patients in the Kyrgyz Republic from 2005 through 2012. Using previous methods, we developed a highly specific algorithm to categorize patients by meningitis status. We then evaluated patient risk factors, treatments, and outcomes by disease severity and meningitis status.

RESULTS

We categorized 37 of 230 cutaneous anthrax patients as likely having meningitis. All 37 likely meningitis patients survived, receiving only mono- or dual-therapy antimicrobials. We identified underlying medical conditions, such as obesity, hypertension, and chronic obstructive pulmonary disease, and tobacco and alcohol use, as potential risk factors for severe anthrax and anthrax meningitis.

CONCLUSIONS

Based on our analyses, treatment of anthrax meningitis may not require 3 antimicrobials, which could impact future anthrax treatment recommendations. In addition, chronic comorbidities may increase risk for severe anthrax and anthrax meningitis. Future research should further investigate potential risk factors for severe anthrax and their impact on laboratory-confirmed meningitis and evaluate mono- and dual-therapy antimicrobial regimens for anthrax meningitis.

Usage of Surgical Antibiotic Prophylaxis in Routine Otolaryngologic Surgeries in Turkey

Introduction:  Inappropriate antibiotic use in the world leads to an increase in both health care costs and antibiotic resistance. Surgical antibiotic prophylaxis (SAP) is used by most surgeons, especially in the postoperative period. Objective  The aim of the study is to determine the approach of ear, nose, and throat (ENT) specialists to surgical antibiotic prophylaxis in routine surgeries, and to raise awareness regarding inappropriate antibiotic use. Methods  ENT specialists from all over Turkey participated in the study by filling out a data collecting form. The form consisted of 6 questions and was sent to specialists via email. Routine ENT operations such as adenoidectomy, tonsillectomy, adenotonsillectomy, ventilation tube application, septoplasty, rhinoplasty, septorhinoplasty (noncomplicated), tympanoplasty, and simple mastoidectomy were chosen for the study. Data were analyzed statistically. Results  The form results of 110 ENT specialists were evaluated. The rate of participants who used and did not use SAP was 77.3% and 22.7%, respectively. The SAP usage rates of septoplasty, rhinoplasty, and septorhinoplasty operations were 84.7%, 81.2%, and 75.3%, respectively. For tympanoplasty and ventilation tube application operations, the rates were 82.4% and 24.7%, respectively. Finallly, the SAP usage rates of adenoidectomy, tonsillectomy, and adenotonsillectomy were 57.6%, 75.3%, and 72.9%, respectively. Conclusion  Otolaryngological surgeries are often classified as clean or clean-contaminated surgeries. In most studies in the literature, it is reported that SAP use is unnecessary in routine otolaryngological surgery. Providing inservice training, regularly updating the prophylaxis guidelines and sharing these guidelines with surgeons may prevent inappropriate SAP use.

Has the COVID-19 pandemic wiped out the seasonality of outpatient antibiotic use and influenza activity? A time-series analysis from 2014 to 2021

OBJECTIVE

To assess the influence of the emergence of severe acute respiratory syndrome coronavirus 2 and the implementation of public health measures on the seasonality of outpatient antibiotic use and their possible association with the incidence of influenza.

METHODS

We performed a time-series ecological study in 1516 primary care centres of Andalusia, Spain, comparing the coronavirus disease 2019 period (April 2020 to March 2021) with the 6 previous years. We assessed the number of packs and defined daily doses per 1000 inhabitants of antibacterials and key antibiotics commonly used for acute respiratory tract infections and the number of influenza-positive cases per 100 000 inhabitants. We calculated the correlation between variables and analyzed the seasonal patterns and differences in quarterly antibiotic use.

RESULTS

For all quarters, a significant correlation was observed between influenza activity and antibiotic use (Spearman's r = 0.94; p < 0.001). Before the pandemic period, both variables presented similar seasonal patterns. After the start of the pandemic, influenza activity was suppressed and the pattern of antibiotic use flattened into a straight line (R² = 0.96; p = 0.022) with a quarterly change of 3.9% (p = 0.007). Total antibiotic use and antibiotics used for treating acute respiratory tract infections showed significant reductions in all quarters compared to the previous year (p < 0.01).

DISCUSSION

The coronavirus disease 2019 pandemic has strongly influenced the seasonality of antibiotic use in primary care. The decline in respiratory viruses, among which the influenza virus is a major player that may act as a proxy for general prevalence, is proposed as a reason for the flattening of the seasonal fluctuations of outpatient antibiotic use in our region.

Adsorption of a wide variety of antibiotics on graphene-based nanomaterials: A modelling study

The knowledge on the sorption behaviour of antibiotics on nanomaterials is limited, especially regarding the reaction mechanism on the surface of carbon nanomaterials, which may determine both the adsorptive capacity and regeneration efficiency of graphene adsorbers. In this work, we used molecular modelling to generate the most comprehensive (to date) adsorption dataset for pristine and functionalised graphene interacting with 8 β-lactams, 3 macrolide, 12 quinolone, 4 tetracycline, 15 sulphonamide, trimethoprim, 2 lincosamide, 2 phenicole and 4 nitroimidazole antibiotics, and their transformation products in water and n-octanol. Results show that various non-covalent interactions that operate simultaneously, including van der Waals dispersion forces, π-interactions, hydrophobic interaction and hydrogen bonding, facilitate adsorption. The molecular properties of antibiotics and graphene/graphene oxide, as well as the composition of the background solution regulate the magnitude of these interactions. Our findings demonstrate that the most efficient method for the removal of antibiotics from aquatic environments is the use of graphene at environmental pH. The subsequent regeneration of the sorbent is best achieved through washing with slightly basic (pH 8-10) non-polar solvents. The obtained theoretical insights expand and complement experimental observations and provide important information that can contribute to further exploration into the adsorbent properties of graphene-based materials, and towards the development of predictive adsorption models.

Good versus poor prescribers: the comparison of prescribing competencies in primary care

Aim:

To compare the competencies of primary care physicians (PCPs) with poor and good prescribing performance in frequently encountered indications.

Background:

Primary care centers are one of the mostly visited health facilities by the population for different health issues.

Methods:

In this cross-sectional study, we analyzed 6 125 487 prescriptions generated by 1431 PCPs which were selected by systematic sampling in 2016 in Istanbul. We defined PCPs as poor prescriber (n = 227) or good prescriber (n = 210) in terms of their prescribing performance per WHO/INRUD criteria. We compared solo diagnosis prescriptions of these two groups in ‘percentage of prescriptions in compliance with clinical guidelines’ and also rational prescribing indicators.

Findings:

Poor prescribers and good prescribers significantly differed in each of the prescribing indicators for their all solo diagnosis prescriptions. Hypertension had the highest difference of the average cost per encounter (Δ = 284.2%) between poor prescribers (US$43.99 ± 63.05) and good prescribers (US$11.45 ± 45.0), whereas headache had the highest difference between the groups in the percentage encounters with an antibiotic (14.9% vs. 1.5%). Detailed analysis of the prescribing performances showed significantly higher values of each WHO/INRUD indicators for all examined diagnoses. We found significantly higher percentages of guideline-compliant drugs in good prescribers compared to that in poor prescribers in hypertension (40.8% vs 34.8%), tonsillopharyngitis (57.9% vs 50.7%), and acute sinusitis (46.4% vs 43.6%).

Conclusion:

This study shows that the prescribing performances of PCPs are not rational enough in terms of drug selection and prescription content. Furthermore, even the physicians who have good prescribing practice appear as not satisfactorily rational in compliance with current pharmacotherapy competencies.

The Effect of Antimicrobial Policy Implementation on Carbapenem Resistance: A University Hospital Experience

Objective: The resistance of Gram-negative bacteria to antibiotics is a global issue that leads to increased mortality and treatment costs. The aim of this study is to see how a newly formed carbapenem control team affected the prevalence of carbapenem-resistant Gram-negative rods and antibiotic consumption expenses in 2017 compared to the year before. Methods: The rate of carbapenem antibiotic usage in Intensive Care Units and Bone Marrow Transplantation services, as well as the findings of culture materials obtained from various body parts of the same patients, between January 1, 2016, and December 31, 2017 were assessed. Results: While there was an ordinary restriction on carbapenem consumption in 2016, carbapenem consumption has been more restricted in 2017. The carbapenem-resistant Gram-negative bacteria patterns of culture materials are examined and compared with Defined Daily Dose data of carbapenems. After the restriction, a significant decrease in the consumption of carbapenems was detected. The decline in carbapenem-resistant Gram-negative bacteria and decreasing antibiotic consumption were found to have a moderately positive correlation (r=0.641, p=0.02). A 60.9% decrease was observed in carbapenem costs after carbapenem restriction, on the other hand, an increase in other unrestricted antibiotics was apparent. Conclusion: Antimicrobial restriction policies can help minimize the rate of carbapenem-resistant Gram-negative rods, which is a serious problem in healthcare. We demonstrated that a decrease in carbapenem-resistant Gram-negative rods isolation rates can lead to a decrease in healthcare-associated infections. Although there is no decrease in the direct antibiotics cost, a drop in carbapenem-resistant may lower the expenses of drastic consequences of infections with carbapenem-resistant and its cost. we can conclude that the Antibiotic Control Policy should be modified based on this new information.

A Qualitative Analysis of the Culture of Antibiotic Use for Upper Respiratory Tract Infections Among Patients in Northwest Russia

Introduction: Due to the globally persistent threat of Antimicrobial Resistance (AMR), the purpose of this study was to gain an in-depth understanding of the antibiotic (AB) practices, knowledge and attitudes among patients residing in five regions in the northwest part of Russia. Given the high prevalence, this study focused on ABs for Upper Respiratory Tract Infections (URTI).

Methods: The qualitative, semi-structured interviews followed a guide organized by major themes such as common symptoms, consultations with doctors and external influences in decision-making. Patient participants were recruited via convenience sampling. Fifty-five interviews were conducted among patients using ABs for URTIs purchased with or without prescription. Data was analyzed using a direct content analysis and validation rounds were conducted between interviewers and data analyzers.

Results: Self-medication with ABs seemed a common practice across all five Russian regions; in some cases, patients tried to persuade pharmacists into selling them ABs without prescription. Factors, such as time spent going to the doctor, need of a sick leave or self-persuasion, influenced the decisions of whether or not to seek the doctor for symptoms of URTIs. Knowledge of ABs and AMR was generally low; however, some patients with seemingly good knowledge practiced self-medication from time to time. Family members and friends were often involved in decisions about how to handle symptoms of URTIs, especially among those patients using ABs without prescription. Few patients had noticed ABs awareness campaigns, and very few reported having learned something important from them.

Conclusion: Despite enforced regulation of AB use in Russia, self-medication still exists. Knowledge is not always linked to appropriate use of AB, and the few campaigns conducted were not always noticed.

Perspectives of physicians and pharmacists on rational use of antibiotics in Turkey and among Turkish migrants in Germany, Sweden and the Netherlands: a qualitative study

Background

Antimicrobial resistance may result from inappropriate use of antibiotics in health care. Turkey is one of the countries with the highest antibiotic consumption in the world. Considering the role of transnational ties between Turkish migrants and their social contacts in Turkey, the attitudes and behaviors relating to rational antibiotic use in Turkey can also affect the use of antibiotics by Turkish migrants residing abroad. This study explores physicians’ and pharmacists’ experiences and perspectives on rational antibiotic use among Turkish adults in Turkey and among Turkish migrants in Germany, Sweden, and the Netherlands, three European countries with large populations of Turkish migrants.

Methods

Following a qualitative study design using convenience and snowball sampling, in-depth interviews with 21 family physicians and 24 pharmacists were conducted in the aforementioned countries. We transcribed all interviews verbatim and performed content analysis separately in the countries, followed by translation, pooling and joint interpretation of the findings.

Results

Physicians and pharmacists encountered irrational use of antibiotics among their patients in Turkey. Physicians interviewed in the three European countries explained that Turkish migrants differ from non-migrants with respect to their attitudes towards antibiotics, for example by more often expecting to be prescribed antibiotics. All physicians and pharmacists in the selected countries reported to inform their patients on how to use antibiotics upon prescription; however, Turkish migrants’ poor language proficiency was considered as a substantial communication barrier by the physicians and pharmacists interviewed in the European countries.

Conclusions

The study illustrated some aspects of irrational antibiotic use among the population in Turkey and Turkish migrants in selected European countries. It emphasized the need for closer community participation, adequate information campaigns, as well as in-service training of health care providers in Turkey. The strategies and interventions on rational antibiotic use should also be supported and encouraged by health care providers, who need to reach out to people with various cultural backgrounds.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01636-8.

Contribution of Governance and Socioeconomic Factors to the P. aeruginosa MDR in Europe

This work aims to explain the behavior of the multi-drug resistance (MDR) percentage of Pseudomonas aeruginosa in Europe, through multivariate statistical analysis and machine learning validation, using data from the European Antimicrobial Resistance Surveillance System, the World Health Organization, and the World Bank. We ran a multidimensional data panel regression analysis and used machine learning techniques to validate a pooling panel data case. The results of our analysis showed that the most important variables explaining the MDR phenomena across European countries are governance variables, such as corruption control and the rule of law. The models proposed in this study showed the complexity of the antibiotic drugs resistance problem. The efforts controlling MDR P. aeruginosa, as a well-known Healthcare-Associated Infection (HCAI), should be focused on solving national governance problems that impact resource distribution, in addition to individual guidelines, such as promoting the appropriate use of antibiotics.

Administration of Systemic Antibiotics for Dental Treatment in Kosovo Major Dental Clinics: A National Survey

OBJECTIVE

 Antibiotics misuse and a high level of antibiotics resistance is observed worldwide, but particularly in developing countries. Kosovo in the last decade is facing challenges regarding antimicrobial resistance. The purpose of the present study was to investigate patterns of antibiotics prescriptions of dentists in Kosovo's major dental clinics.

MATERIALS AND METHODS

 For Kosovo's prescribing pattern, data collection was obtained from 10 Regional Dental Clinics and a Tertiary Health Center regarding patients who were prescribed antibiotics in the years 2015 to 2019. Data analysis was performed by using descriptive statistics and was processed by using MS Excel.

RESULTS

 Most prescribed antibiotic during the observed period from 2015 to 2019 in Kosovo was amoxicillin, although a drastic increase of amoxicillin with clavulanic acid-as a broad-spectrum antibiotic-is observed. The trend of antibiotics use in tertiary health institutions is in an overall decrease in Kosovo with an exception in the year 2017. Despite this overall decrease, inconsistency in prescribing is observed when the pattern is analyzed for each region separately. The highest number of patients in health care dental clinics received antibiotics for maxilla-related health conditions and the lowest number of them for oncologic ones.

CONCLUSION

 The patterns of antibiotics prescriptions by dental practitioners in Kosovo during the years 2015 to 2019 are fluctuating. Compared with the global health care standards, the irrational use of antibiotics in dental health care clinics in Kosovo still exist and this issue should be further addressed by respective actors.

Increasing rates of extended-spectrum B-lactamase-producing Escherichia coli and Klebsiella pneumoniae in uncomplicated and complicated acute pyelonephritis and evaluation of empirical treatments based on culture results

Increasing rates of extended-spectrum beta-lactamase (ESBL) producing E. coli and K. pneumoniae over time made empirical treatment complicated. Knowing local antimicrobial resistance patterns of common pathogens can make it easier to decide on empirical antibiotics. We aimed to investigate the prevalence and risk factors of ESBL positivity of E. coli and K. pneumoniae strains in uncomplicated and complicated pyelonephritis acquired in community and healthcare associations and to evaluate the appropriateness of empirical treatment. Adult patients hospitalized with diagnosis of community-acquired or healthcare-associated uncomplicated/complicated pyelonephritis initiated empirical antimicrobial therapy were included in the study. Appropriateness of empirical treatment at 48-72 h based on culture results and treatment modifications were evaluated. A total of 369 uncomplicated (94) and complicated (275) episodes of pyelonephritis were evaluated. The most common agents were E. coli (71.0%) and K. pneumoniae (17.7%), and the ESBL-production rate was 64.4%, and higher in healthcare-associated pyelonephritis (P 0.013). Being of healthcare-associated infection, previous antibiotic use, and presence of urinary catheters were independent risk factors for ESBL-producing E. coli and K. pneumoniae (P 0.009, < 0.001, and 0.024, respectively). The treatment inappropriateness was mostly associated with use of ceftriaxone (56.3%) (P < 0.001). Treatment has escalated in 41.5% of ceftriaxone-initiated patients, in only 8.8% and 9.5% ertapenem and piperacillin-tazobactam-initiated patients, respectively. ESBL-production rates are quite high even in community-acquired infections. The use of broad-spectrum antibiotics covering ESBL-producing pathogens to increase the appropriateness of empirical treatment and then narrowing treatment based on culture results appears a better and life-saving choice.

Evaluation of parental knowledge, attitudes and practices regarding antibiotic use in acute upper respiratory tract infections in children under 18 years of age: a cross-sectional study in Turkey

Background

Upper respiratory tract infections (URTIs) are common in children. Antibiotics still continue to be prescribed although most URTIs are of viral origin. This is inappropriate use and this unnecessary administration contributes or may cause antibiotic resistance. The problem of unnecessary antibiotic use among children is a concern for antibiotic resistance in low- and middle-income developing countries. This study aims to evaluate the knowledge and attitudes of parents of children with upper respiratory tract infections regarding antibiotic use and their antibiotic administration practices in a tertiary care hospital in Turkey.

Methods

Our study is a cross-sectional survey study. It was carried out between 14 December 2020 and 1 April 2021 for parents over 18 years of age with a child under 18 years’ old who applied to the general pediatrics outpatient clinics of Gazi University Faculty of Medicine Hospital Department of Pediatrics.

Results

Five hundred fifty-four parents responded to the questionnaire (93.2% rate of response). A total of 15.7% of parents stated to use antibiotics in any child with fever. 37% of parents believed that antibiotics could cure infections caused by viruses. 6.3% of parents declared that they put pressure on pediatricians to prescribe antibiotics. While 28% of the parents who thought that the use of inappropriate antibiotics would not change the effect and resistance of the treatment, 41% thought that new antibiotics could be developed continuously. 85.6% of the parents stated that they never gave their children non-prescription antibiotics when they had a high fever. 80.9% of them declared that they never used past antibiotics in the presence of a new infection.

Conclusion

According to the results of our study of parents’ lack of knowledge about antibiotics in Turkey, though generally it shows proper attitude and practices. It shows that some of the restrictions imposed by the National Action Plan are partially working. However, it is still necessary to continue to inform parents, pediatricians and pharmacists about the use of antibiotics, and to be more sensitive about the prescribing of antibiotics, and if necessary, sanctions should be imposed by the state in order to prevent unnecessary antibiotic prescriptions.

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.

Trends in antimicrobial consumption in Bhutan

Introduction

Antimicrobial use has been recognized as one of the main drivers of antimicrobial resistanceand it is, therefore, crucial to monitor the consumption and use of antimicrobials. This study was conducted to determine the consumption of antimicrobials in terms of defined daily doses (DDDs) per 1000 inhabitants per day (DIDs) at both national and dzongkhag levels in Bhutan, and to investigate trends from 2017 to 2019.

Methods

A retrospective analysis of antimicrobial consumption in healthcare facilities in Bhutan from 2017 to 2019 was undertaken using the national records of annual distribution of medicines. World Health Organization Anatomical Therapeutic Chemical (ATC) Classification System/DDD methodology was used for data collection and analysis.

Results

In 2019, the consumption of antimicrobials (ATC subgroup J01) for systemic use in healthcare facilities in Bhutan was 16.29 DIDs, compared with 14.39 DIDs in 2018 and 13.27 DIDs in 2017. The most commonly used subgroup of antimicrobials was the penicillin group of beta-lactams (J01C).

Conclusion

Antimicrobial consumption in Bhutan was found to be lower than the European Union and European Economic Area average, and lower compared with most Eastern European countries and some countries in the Western Pacific region. However, overall consumption in Bhutan increased steadily over the 3-year study period. This should be monitored carefully, and appropriate interventions to optimize antimicrobial use should be put in place in the near future.

Antimicrobial Susceptibility Profile of Several Bacteria Species Identified in the Peritoneal Exudate of Cows Affected by Parietal Fibrinous Peritonitis after Caesarean Section

The aim of this study was to identify the species and antimicrobial susceptibility of bacteria involved in parietal fibrinous peritonitis (PFP). We studied 156 peritoneal fluid samples from cows presenting PFP after caesarean section. Bacteria were cultured in selective media and their antimicrobial susceptibility was tested by disk diffusion assay. Bacteria were isolated in the majority (129/156; 83%) of samples. The majority (82/129; 63%) of positive samples contained one dominant species, while two or more species were cultured in 47/129 (36%) samples. Trueperella pyogenes (T. Pyogenes) (107 strains) was the most identified species, followed by Escherichia coli (E. coli) (38 strains), Proteus mirabilis (P. mirabilis) (6 strains), and Clostridium perfringens (C. perfringens) (6 strains). Several other species were sporadically identified. Antimicrobial susceptibility was tested in 59/185 strains, predominantly E. coli (38 strains) and P. mirabilis (6 strains). Antibiotic resistance, including resistance to molecules of critical importance, was commonly observed; strains were classified as weakly drug resistant (22/59; 37%), multidrug resistant (24/59; 41%), extensively drug resistant (12/59; 20%), or pan-drug resistant (1/59; 2%). In conclusion, extensive antibiotic resistance in the isolated germs might contribute to treatment failure. Ideally, antimicrobial therapy of PFP should be based upon bacterial culture and susceptibility testing.

Experiences From an Implementation Model of ARI Diagnostic Device in Pneumonia Case Management Among Under-5 Children in Peripheral Healthcare Centers in India

OBJECTIVES

To address pneumonia, a major killer of under-5 children in India, a multimodal pulse oximeter was implemented in Health and Wellness Centers. Given the evidence of pulse oximetry in effective pneumonia management and taking into account the inadequate skills of front-line healthcare workers in case management, the device was introduced to help them readily diagnose and treat a child and to examine usability of the device.

DESIGN

The implementation was integrated with the routine OPD of primary health centers for 15 months after healthcare workers were provided with an abridged IMNCI training. Monthly facility data was collected to examine case management with the diagnostic device. Feedback on usefulness of the device was obtained.

SETTING

Health and Wellness Centers (19) of 7 states were selected in consultation with state National Health Mission based on patient footfall.

PARTICIPANTS

Under-5 children presenting with ARI symptoms at the OPD.

RESULTS

Of 4846 children, 0.1% were diagnosed with severe pneumonia and 23% were diagnosed with pneumonia. As per device readings, correct referrals were made of 77.6% of cases of severe pneumonia, and 81% of pneumonia cases were correctly given antibiotics. The Pulse oximeter was highly acceptable among health workers as it helped in timely classification and treatment of pneumonia. It had no maintenance issue and battery was long-lasting.

CONCLUSION

Pulse oximeter implementation was doable and acceptable among health workers. Together with IMNCI training, PO in primary care settings is a feasible approach to provide equitable care to under-5 children.

Healthcare-associated infections over an eight year period in a large university hospital in Sicily (Italy, 2011-2018)

Background

Up to 7% of hospitalised patients acquire at least one healthcare-associated infection (HAI). The aim of the present study was to quantify the burden of HAIs in an Italian hospital, identifying involved risk factors.

Methods

Prevalence point study carried out from 2011 to 2018. For each recruited patient, a data entry form was compiled including information on demographics, hospital admission, risk factors, antimicrobial treatment, and infection if present.

Results

A total of 2844 patients were included and 218 (7.03%) reported an infection. HAI prevalence rates showed a significant increase (average annual per cent change (AAPC) +33.9%; p=0.018) from 2011 to 2014 whereas from 2014 to 2018 a gradual decline was observed (AAPC -6.15%; p=0.35). Urinary tract infection was the most common HAI (25.2%) and a total of 166 (76.1%) pathogens were isolated from 218 infections. Enterococcus and Klebsiella species were the most prevalent pathogens, causing 15.1% and 14.5% of HAIs, respectively. A significant higher risk of HAIs was found in patients exposed to central catheter (adjusted odds ratio (adj-OR)=5.40), peripheral catheter (adj-OR=1.89), urinary catheter (adj-OR=1.46), National Healthcare Safety Network surgical intervention (adj-OR=1.48), ultimately fatal disease (adj-OR=2.19) or rapidly fatal disease (adj-OR=2.09) and in patients with longer hospital stay (adj-OR=1.01).

Conclusion

Intervention programmes based on guidelines dissemination and personnel training can contribute to reduce the impact of HAI. Moreover, McCabe score can be a very powerful and efficient predictor of risk for HAI. Finally, an unexpected very high burden of disease due to Enterobacteriaceae and Gram positive cocci that could be related to the frequent use of carbapenems and third generation cephalosporins in this hospital was found.

Metagenomic Analysis Reveals the Fate of Antibiotic Resistance Genes in a Full-Scale Wastewater Treatment Plant in Egypt

Wastewater treatment plants (WWTPs) are recognized as hotspots for the dissemination of antibiotic resistance genes (ARGs) and antibiotic-resistant bacteria (ARBs) in the environment. Our study utilized a high-throughput sequencing-based metagenomic analysis approach to compare the ARG abundance profiles of the raw sewage, treated effluent and activated sludge samples from a full-scale WWTP in Egypt. In addition, the difference in microbial community composition due to the treatment process was assessed. As a result, 578 ARG subtypes (resistance genes) belonging to 18 ARG types (antibiotic resistance classes) were identified. ARGs encoding for resistance against multidrug, aminoglycoside, bacitracin, beta-lactam, sulfonamide, and tetracycline antibiotics were the most abundant types. The total removal efficiency percentage of ARGs in the WWTP was found to be 98% however, the ARG persistence results indicated that around 68% of the ARGs in the influent could be found in the treated effluent. This finding suggests that the treated wastewater poses a potential risk for the ARG dissemination in bacterial communities of the receiving water bodies via horizontal gene transfer (HGT). The community composition at phylum level showed that Proteobacteria, Bacteroidetes, Firmicutes, and Actinobacteria were the most abundant phyla in all datasets. Although the relative abundance of several pathogenic bacteria in the influent declined to less than 1% in the effluent, the taxonomic assignments at species level for the effluent and sludge metagenomes demonstrated that clinically important pathogens such as Escherichia coli, Klebsiella pneumonia, and Aeromonas caviae were present. Overall, the results of this study would hopefully enhance our knowledge about the abundance profiles of ARGs and their fate in different wastewater treatment compartments that have never been examined before.

The adsorption-desorption characteristics and degradation kinetics of ceftiofur in different agricultural soils

Cephalosporins are one of the most widely used antibiotics. When cephalosporins are discharged into the environment, they not only induce the production of antibiotic resistant genes (ARGs) and antibiotic resistant bacteria (ARBs) but also cause toxic effects on animals and plants. Due to their complicated environmental behavior and lack of relevant data, the environmental behavior remains unclear. In this study, the adsorption-desorption and degradation characteristics of the third-generation cephalosporin drug ceftiofur (CEF) were investigated in three agricultural soils (sandy loam, loam and clay). According to the relevant parameters of the Freundlich adsorption isotherm (the K_f range was 57.63-122.44 μg^1-1/n L^1/n kg^-1), CEF was adsorbed moderately in the soils and had the potential to migrate into groundwater. CEF exhibited low persistence in the soils and faster degradation than other antibiotics, such as tetracyclines and fluoroquinolones. The degradation half-lives (DT50) of CEF in soils ranged from 0.76 days to 4.31 days. Adding feces, increasing the water content, providing light and increasing the temperature significantly accelerated the degradation of CEF in soils. The DT50 values of CEF in soils were significantly prolonged when the soils were sterilized, indicating that both physical degradation and biodegradation played important roles in the degradation of CEF in soils. The DT50 values of CEF in soils were significantly prolonged at high concentrations, indicating that the degradability of CEF in soils was affected by the initial concentration. No significant differences were observed in the DT50 values for the different soil types (p > 0.05). This study provides useful information about the environmental behavior of CEF and improves the environmental risk assessment of CEF.

Community Use of Antibiotics in Turkey: The Role of Knowledge, Beliefs, Attitudes, and Health Anxiety

Turkey has been among the leading countries in antibiotic consumption. As a result of the 4-year National Action Plan for Rational Drug Use, antibiotic prescriptions had declined from 34.9% in 2011 to 24.6% in 2018. However, self-medication with antibiotics without prescription is common, which is not reflected in official statistics. The present study aims at investigating antibiotic use in the community and the factors related to it. A web-based survey was conducted among 945 Turkish-speaking respondents (61.3% female). The questionnaire included questions about antibiotic use for different illnesses, ways to obtain and handle leftover antibiotics, knowledge, beliefs of the antibiotic effectiveness, attitudes, health anxiety, and background factors. According to the results, 34.2% of the sample had self-medicated themselves with antibiotics without a valid prescription. The most common way to self-medicate was to use leftover antibiotics. While 80.4% knew that antibiotics are used to treat bacterial infections, 51.4% thought that antibiotics are effective for viral diseases. The most important predictor of antibiotic use frequency was the belief in their efficiency for various illnesses and symptoms, followed by negative attitudes to antibiotics, health anxiety, knowledge level, positive attitudes, and health status. The results underline the importance of targeting misbeliefs about antibiotics in future campaigns.

Antibiotic use and resistance in Belgium: the impact of two decades of multi-faceted campaigning

Objective: To present an overview of almost two decades of multi-faceted campaigning by the Belgian Antibiotic Policy Coordination Committee (BAPCOC) and partners, and its impact on public and prescribers' awareness, outpatient antibiotic use, its cost and antimicrobial resistance in Belgium.Methods: Awareness of both public and prescribers was assessed through pre- and post-campaign interviews and surveys. Outpatient antibiotic use was evaluated using national reimbursement data expressed in number of defined daily doses and packages (a good proxy for treatments) per 1000 inhabitants per day (DID and PID, respectively) from July 1997 to June 2018. Its cost was studied using the same data expressed in number of euros per 1000 inhabitants per day. Antimicrobial resistance was evaluated between 1986 and 2017 using national data on the proportion of Streptococcus pneumoniae isolates not susceptible to penicillins, macrolides and tetracyclines.Results: Antibiotic awareness improved significantly, with general practitioners preferred by 87.5% of respondents as source of information. The Belgian outpatient antibiotic use has decreased by 12.8% in DID and by 42.8% in PID in the 2017-2018 winter compared to the winter before the start of its public awareness campaigns (1999-2000). This evolution coincided with decreasing costs for antibiotics and decreasing antimicrobial resistance. Despite multi-faceted campaigning, outpatient antibiotic use and use of broad-spectrum antibiotics, especially fluoroquinolones and amoxicillin with clavulanic acid, are still high in Belgium.Conclusion: Almost two decades of multi-faceted campaigning coincide with improvements in antibiotic awareness among the public and prescribers, outpatient antibiotic use and resistance. Nevertheless, additional efforts are needed to reach the targets set in BAPCOC's national action plan 2014-2019. Therefore, a new national action plan was developed for 2020-2024 using a One Health approach.