Let the games begin: the race to optimise antibiotic use

Over prescription of antibiotics in children with acute upper respiratory tract infections: A study on the knowledge, attitude and practices of non-specialized physicians in Egypt

BACKGROUND

Antimicrobial resistance (AMR) is currently one of the global public health threats. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR. Upper respiratory tract infections (URIs) are one of the most common conditions treated by antibiotics, even if unnecessary as in cases of viral infections and self-limited conditions which represent the most cases of URIs. Investigating physicians' knowledge, attitudes, and practice regarding antibiotic prescriptions in children with acute URIs may reflect the problem of antibiotic over prescription. This study aims to assess the problem in our community and provide information for further planning of appropriate interventions to optimize antibiotic prescriptions.

METHODS

This is a cross-sectional study for all non-specialized physicians dealing with acute upper respiratory tract infections (URIs) in pediatrics sittings in Assiut district, Egypt. We used a self-administered questionnaire to assess physicians' knowledge, attitudes, and practice. In addition, four clinical vignettes addressing different URI scenarios were included in the questionnaire to assess the patterns of antibiotic prescriptions in common cases.

RESULTS

Our study included 153 physicians whose mean age was 32.2 ± 8.7, most of whom were pediatric residents in different health institutes in Assiut district. They had good knowledge as out of the 17 knowledge questions,the mean number of correct answers was 12.4 ± 2.9. Regarding their attitudes, mean attitude scores for inappropriate antibiotic prescribing were low. However, of those scores, the responsibility of others had the highest score (3.8 ± 0.61). Prescribing practice in special conditions of URIs showed that 80% of participants prescribed antibiotics if fever continued for more than five days and 61.4% if the child had a yellowish or greenish nasal discharge. Among 612 clinical vignettes, 326 contained antibiotic prescriptions (53.3%), and appropriate antibiotic prescriptions represented only 8.3% overall.

CONCLUSIONS

Physicians dealing with acute URIs in outpatients' clinics in the Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. Although the percentage of inappropriate prescriptions in clinical vignettes in high, more research is required to investigate the factors of antibiotic inappropriate prescribing practice and non-adherence to guidelines. Also, it is essential to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems.

Knowledge, attitudes and perceptions of antibiotic use and resistance among patients in South Africa: A cross-sectional study

Background

Antibiotic resistance (ABR) is a global health crisis. We conducted a cross-sectional survey to describe South African patients' (n = 782) ABR knowledge, attitudes and perceptions (KAP), differences in KAP between public (n = 379, 48%) and private (n = 403, 52%) practice respondents and associations between attitudes, perceptions and knowledge scores.

Methods

Knowledge scores (15 questions) were placed into low (0% - 53%) and high (> 54%) categories (below and above overall mean). Comparisons were conducted using chi-squared and t-tests.

Results

Of all respondents, 72% believed it was the human body that becomes resistant to antibiotics, 66% stated that antibiotics are good for treating viruses and 25% of patients believed that people should be given antibiotics on demand. Mean knowledge scores were lower in public sector respondents (public 45%, s.d. 15%; private 60%, s.d. 30%; p ≤ 0.001). Public practice patients with high knowledge scores were more likely to report both negative KAP (antibiotic prescriptions justify doctors' visits, scientists will discover new antibiotics) and protective KAP (finishing a course of antibiotics, antibiotics do not treat all illnesses). Private practice patients with high knowledge scores were marginally less likely to report negative KAP (wanting antibiotics after long illnesses or when very sick) and more likely to report protective KAP (antibiotics have side effects and are a strong treatment).

Conclusion

Our study shows differences in KAP by practice type and that greater knowledge increases the likelihood of protective attitudes, perceptions and behaviours.

Cost-effectiveness analysis of a multi-dimensional intervention to reduce inappropriate antibiotic prescribing for children with upper respiratory tract infections in China

BACKGROUND

We developed a multifaceted intervention to reduce antibiotic prescription rate for children with upper respiratory tract infections (URTIs) among primary care doctors in township hospitals in China. The intervention achieved a 29% (95% CI 16-42) absolute risk reduction in antibiotic prescribing. This study was to assess the cost-effectiveness of our intervention at reducing antibiotic prescribing in rural primary care facilities as measured by the intervention's effect on the antibiotic prescription rates for childhood URTIs.

METHODS

We took a healthcare provider perspective, measuring costs of consultation (time cost of doctor), prescription monitoring process and peer-review meetings (time cost of participants) and medication costs. Costs on provider side were collected through a bespoke questionnaire from all 25 township hospitals in December 2016, while medication costs were collected prospectively in the trial. Incremental cost-effectiveness ratios were calculated by dividing the mean difference in cost of the two trial arms by the mean difference in antibiotic prescribing rate.

RESULTS

This showed an incremental cost of $0.03 per percentage point reduction in antibiotic prescribing. In addition to this incremental cost, the cost of implementing the intervention, including training and materials delivered by township hospitals, was $390.65 (SD $145.68) per healthcare facility.

CONCLUSIONS

This study shows that a multifaceted intervention programme, when embedded into routine practice, is very cost-effective at reducing antibiotic prescribing in primary care facilities and has the potential of scale up in similar resource limited settings.

Knowledge and awareness of the general public and perception of pharmacists about antibiotic resistance

Background

Antibiotic resistance (AR) continues to be a serious problem. Many factors contribute to AR, including inappropriate use of antibiotics, in which both healthcare professionals and patients play a contributing role. This study aimed to assess the awareness and knowledge of antibiotic usage and AR among the general public (in affluent and deprived areas) and community pharmacists’ (CPs’) in Greater London.

Methods

A cross-sectional survey involving members of the public was conducted between July 2014 and February 2015. Stage one involved members of the public (N = 384) residing in affluent areas of London. The second stage targeted public (N = 384) in deprived areas of London. In addition, CPs (N = 240) across the same areas were also surveyed. Data analysis was performed using Microsoft Excel and SPSS Software packages.

Results

Response rate: 36% (n = 139/384) and 57% (n = 220/384) and 25% (n = 60/240) of public residing in affluent areas, deprived areas and of CPs respectively was achieved. Definitive trends in knowledge of how antibiotics work could not be drawn to distinguish between affluent and deprived areas. However, public respondents residing in affluent areas possessed better understanding of AR and prudent use of antibiotics, and this was statistically significant in both cases (p < 0.05). Exposure to an antibiotic campaign (32% in affluent areas, 17% in deprived areas) did not raise public respondents’ knowledge on AR and only partially raised their general knowledge on antibiotics usage. Only 20% of public residing in deprived areas received counselling from a CP, among them 74% had an antibiotic prescribed on at least one previous occasion. Those who received counselling displayed better knowledge about concordance/adherence with respect to antibiotic usage (p < 0.05) whereas exposure to an antibiotic campaign made no significant impact on knowledge about concordance/adherence.

Conclusion

The study highlights that there has been no change in the status quo with respect to awareness of antibiotic usage and AR even after the implementation of several awareness campaigns in England. Those who benefited from CP counselling showed a significant better knowledge towards prudent antibiotic usage which stresses the importance of CPs’ counselling on antibiotic prescription.

A computational protocol for the discovery of lead molecules targeting DNA unique to pathogens

With the rapid emergence of drug resistant pathogens, it has become imperative to develop alternative medications as well as find new drug targets to overcome this crisis. Hence, this has become prime focus of several academic laboratories and pharmaceutical companies. Here, we report a computational protocol for identifying unique DNA sequence(s) in the pathogen which is absent in human and related non-pathogenic strains of the microbe. In order to use the unique sequence as drug target, the protocol, in the second step, uses virtual screening against a million compound library to identify candidate small molecules which can bind to these unique DNA targets in the pathogen only. Theoretically the molecules identified after screening should not bind to human DNA. This methodology is demonstrated on Mycobacterium tuberculosis H37Rv, wherein a new octamer sequence present only in H37Rv has been identified and a few candidate small molecules as potential drug have been proposed. Being fast and cost effective, this protocol could be of importance in generating new potential drug candidates against infectious organisms for further experimental studies. This methodology is freely available at http://www.scfbio-iitd.res.in/PSDDF/.

Measuring antibiotic consumption in low-income countries: a systematic review and integrative approach

Antibiotic resistance is a global issue. Risk factors specific to low-income countries (LICs), including non-prescribed antibiotic use, place them at risk for the emergence of resistance and make them important targets for reducing the burden of resistance worldwide. Responding to this threat in LICs means first having access to appropriate antibiotic consumption data. A PubMed search was conducted for studies examining antibiotic consumption in the community in LICs. For the articles included in the analysis, the methodologies used, type of data gathered and methodological appropriateness in responding to specific LIC data needs were noted. Of the 487 articles identified by the search strategy, 27 were retained for final analysis. Four main investigative methods were identified, including pharmacy/hospital document reviews, the simulated client method, observed prescribing encounters/patient exit interviews and community surveys. Observed encounters and exit interviews are well adapted to answering a number of important questions surrounding antibiotic consumption but may include bias and miss some sources of non-prescribed antibiotics. Community surveys are the only approach able to fully account for non-prescribed antibiotics and should be used as the first step in an integrative approach towards antibiotic consumption measurement and monitoring in LICs. Antibiotic consumption data needed for programmes to control use must take into account the LIC context. An integrated and adaptive approach beginning with community surveys responds to the various data needs and difficulties of LIC contexts and may help facilitate the investigation and optimisation of antibiotic consumption in these settings.