Changes in antibiotic-prescribing practices and carriage of penicillin-resistant Streptococcus pneumoniae: A controlled intervention trial in rural Alaska

Analysis of multiple bacterial species and antibiotic classes reveals large variation in the association between seasonal antibiotic use and resistance

Understanding how antibiotic use drives resistance is crucial for guiding effective strategies to limit the spread of resistance, but the use-resistance relationship across pathogens and antibiotics remains unclear. We applied sinusoidal models to evaluate the seasonal use-resistance relationship across 3 species (Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae) and 5 antibiotic classes (penicillins, macrolides, quinolones, tetracyclines, and nitrofurans) in Boston, Massachusetts. Outpatient use of all 5 classes and resistance in inpatient and outpatient isolates in 9 of 15 species-antibiotic combinations showed statistically significant amplitudes of seasonality (false discovery rate (FDR) < 0.05). While seasonal peaks in use varied by class, resistance in all 9 species-antibiotic combinations peaked in the winter and spring. The correlations between seasonal use and resistance thus varied widely, with resistance to all antibiotic classes being most positively correlated with use of the winter peaking classes (penicillins and macrolides). These findings challenge the simple model of antibiotic use independently selecting for resistance and suggest that stewardship strategies will not be equally effective across all species and antibiotics. Rather, seasonal selection for resistance across multiple antibiotic classes may be dominated by use of the most highly prescribed antibiotic classes, penicillins and macrolides.

Antibiotic use in pregnancy: knowledge, attitudes and practices among pregnant women in Cape Town, South Africa

OBJECTIVES

To establish the knowledge, attitudes and practices (KAP) regarding antibiotic use and self-medication among pregnant women.

METHODS

We conducted a KAP survey of 301 pregnant women hospitalized at a tertiary hospital obstetric service in Cape Town, South Africa in November and December 2017, using an interviewer-administered 12 item questionnaire. We stratified analysis of attitudes and practices by participants' mean knowledge score (K-score) group (<6 versus ≥6 out of 7 questions). Multivariate models were built to identify independent predictors of antibiotic self-medication and K-score.

RESULTS

The mean age of pregnant women was 29 (SD 6.1) years, 44/247 (17.8%) were nulliparous, 69/247 (27.9%) were HIV-infected, 228/247 (92.3%) had completed secondary school and 78/247 (31.6%) reported a monthly household income in the lowest category of ≤50-100 US dollars (USD). The mean K-score was 6.1 (SD 1.02) out of 7 questions. Sixteen percent of the cohort reported antibiotic self-medication, with higher rates among pregnant women with K-score <6 [18/48 (37.5%) versus 32/253 (12.6%); P<0.001]. The monthly household income category of >500 USD (the highest category) was the only predictor of antibiotic self-medication behaviour [adjusted OR=6.4 (95% CI 1.2-35.2), P=0.03].

CONCLUSIONS

Higher antibiotic knowledge scores are associated with lower rates of antibiotic self-medication, whereas higher household income is correlated with increasing self-medication behaviours. Education of pregnant women regarding the potential dangers of antibiotic self-medication and stricter enforcement of existing South African antibiotic prescribing and dispensing regulations are needed.

Mapping the Role of AcrAB-TolC Efflux Pumps in the Evolution of Antibiotic Resistance Reveals Near-MIC Treatments Facilitate Resistance Acquisition

Antibiotic resistance has become a major public health concern as bacteria evolve to evade drugs, leading to recurring infections and a decrease in antibiotic efficacy. Systematic efforts have revealed mechanisms involved in resistance. Yet, in many cases, how these specific mechanisms accelerate or slow the evolution of resistance remains unclear. Here, we conducted a systematic study of the impact of the AcrAB-TolC efflux pump on the evolution of antibiotic resistance. We mapped how population growth rate and resistance change over time as a function of both the antibiotic concentration and the parent strain's genetic background. We compared the wild-type strain to a strain overexpressing AcrAB-TolC pumps and a strain lacking functional pumps. In all cases, resistance emerged when cultures were treated with chloramphenicol concentrations near the MIC of their respective parent strain. The genetic background of the parent strain also influenced resistance acquisition. The wild-type strain evolved resistance within 24 h through mutations in the acrAB operon and its associated regulators. Meanwhile, the strain overexpressing AcrAB-TolC evolved resistance more slowly than the wild-type strain; this strain achieved resistance in part through point mutations in acrB and the acrAB promoter. Surprisingly, the strain without functional AcrAB-TolC efflux pumps still gained resistance, which it achieved through upregulation of redundant efflux pumps. Overall, our results suggest that treatment conditions just above the MIC pose the largest risk for the evolution of resistance and that AcrAB-TolC efflux pumps impact the pathway by which chloramphenicol resistance is achieved.IMPORTANCE Combatting the rise of antibiotic resistance is a significant challenge. Efflux pumps are an important contributor to drug resistance; they exist across many cell types and can export numerous classes of antibiotics. Cells can regulate pump expression to maintain low intracellular drug concentrations. Here, we explored how resistance emerged depending on the antibiotic concentration, as well as the presence of efflux pumps and their regulators. We found that treatments near antibiotic concentrations that inhibit the parent strain's growth were most likely to promote resistance. While wild-type, pump overexpression, and pump knockout strains were all able to evolve resistance, they differed in the absolute level of resistance evolved, the speed at which they achieved resistance, and the genetic pathways involved. These results indicate that specific treatment regimens may be especially problematic for the evolution of resistance and that the strain background can influence how resistance is achieved.

The role of "spillover" in antibiotic resistance

Antibiotic use is a key driver of antibiotic resistance. Understanding the quantitative association between antibiotic use and resulting resistance is important for predicting future rates of antibiotic resistance and for designing antibiotic stewardship policy. However, the use-resistance association is complicated by "spillover," in which one population's level of antibiotic use affects another population's level of resistance via the transmission of bacteria between those populations. Spillover is known to have effects at the level of families and hospitals, but it is unclear if spillover is relevant at larger scales. We used mathematical modeling and analysis of observational data to address this question. First, we used dynamical models of antibiotic resistance to predict the effects of spillover. Whereas populations completely isolated from one another do not experience any spillover, we found that if even 1% of interactions are between populations, then spillover may have large consequences: The effect of a change in antibiotic use in one population on antibiotic resistance in that population could be reduced by as much as 50%. Then, we quantified spillover in observational antibiotic use and resistance data from US states and European countries for three pathogen-antibiotic combinations, finding that increased interactions between populations were associated with smaller differences in antibiotic resistance between those populations. Thus, spillover may have an important impact at the level of states and countries, which has ramifications for predicting the future of antibiotic resistance, designing antibiotic resistance stewardship policy, and interpreting stewardship interventions.

A scoping review to assess the impact of public education campaigns to affect behavior change pertaining to antimicrobial resistance

BACKGROUND

Years of global antibiotic misuse has led to the progression of antimicrobial resistance (AMR), posing a direct threat to public health. To impact AMR and maintain antimicrobial viability, educational interventions toward fostering positive AMR behavior change have been employed with some success.

METHODS

This scoping review sought to identify research-supporting use of public educational AMR campaigns, and their efficacy toward informing positive AMR behaviors to inform current debate. To enable credible and reflexive examination of a wide variety of literature, Arksey and O'Malley's (2005) methodological framework was used.

RESULTS

Three primary themes were identified: (1) behavior change and theoretical underpinnings, (2) intervention paradigm, and (3) educational engagement. From 94 abstracts identified, 31 articles were chosen for review. More attention is required to identify elements of intervention design that inform and sustain behavior change, and the impact of how an intervention is delivered and targeted is needed to limit assumptions of population homogeneity, which potentially limits intervention efficacy. Moreover, research on the impact of hospital-based inpatient interventions is needed.

CONCLUSIONS

The existing body of research fails to provide robust evidence to support sound evidential interventions supported by theoretical justifications. Furthermore, interventions to ensure long-term sustained behavior change are unclear and not addressed.

Communication interventions to promote the public's awareness of antibiotics: a systematic review

Background

Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public.

Methods

We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes.

Results

Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful.

Conclusions

Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7258-3) contains supplementary material, which is available to authorized users.

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map

BACKGROUND

Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.

METHODS AND FINDINGS

Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.

CONCLUSIONS

To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.

PROTOCOL REGISTRATION

PROSPERO CRD42017067514.

Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis

BACKGROUND

Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs).

OBJECTIVE

To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs.

DESIGN

Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data.

SUBJECTS

Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider.

INTERVENTIONS

(1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues.

MAIN MEASURES

Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios.

KEY RESULTS

Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events.

CONCLUSIONS

Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.

The distribution of antibiotic use and its association with antibiotic resistance

Antibiotic use is a primary driver of antibiotic resistance. However, antibiotic use can be distributed in different ways in a population, and the association between the distribution of use and antibiotic resistance has not been explored. Here, we tested the hypothesis that repeated use of antibiotics has a stronger association with population-wide antibiotic resistance than broadly-distributed, low-intensity use. First, we characterized the distribution of outpatient antibiotic use across US states, finding that antibiotic use is uneven and that repeated use of antibiotics makes up a minority of antibiotic use. Second, we compared antibiotic use with resistance for 72 pathogen-antibiotic combinations across states. Finally, having partitioned total use into extensive and intensive margins, we found that intense use had a weaker association with resistance than extensive use. If the use-resistance relationship is causal, these results suggest that reducing total use and selection intensity will require reducing broadly distributed, low-intensity use.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries.

Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs.

Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively.

Results: Knowledge improved in the intervention group for ARI aetiology by 28% (Δ_{Decrement control arm} 10%), antibiotic use for mild ARIs by 15% (Δ_{Decrement control arm} 13%) and for severe ARIs by 14% (Δ_{Improvement control arm} 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δ_{mean improvement} 1.17); less so in the control group (Δ_{mean improvement} 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (Δ_{Decrement control arm} 3%).

Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections

OBJECTIVES

Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes.

METHODS

This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic.

RESULTS

Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt.

CONCLUSIONS

Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.

Protocol for a randomised trial of higher versus lower intensity patient-provider communication interventions to reduce antibiotic misuse in two paediatric ambulatory clinics in the USA

INTRODUCTION

Children with acute respiratory tract infections (ARTIs) are prescribed up to 11.4 million unnecessary antibiotic prescriptions annually. Inadequate parent-provider communication is a chief contributor, yet efforts to reduce overprescribing have only indirectly targeted communication or been impractical. This paper describes our multisite, parallel group, cluster randomised trial comparing two feasible interventions for enhancing parent-provider communication on the rate of inappropriate antibiotic prescribing (primary outcome) and revisits, adverse drug reactions and parent-rated quality of shared decision-making, parent-provider communication and visit satisfaction (secondary outcomes).

METHODS/ANALYSIS

We will attempt to recruit all eligible paediatricians and nurse practitioners (currently 47) at an academic children's hospital and a private practice. Using a 1:1 randomisation, providers will be assigned to a higher intensity education and communication skills or lower intensity education-only intervention and trained accordingly. We will recruit 1600 eligible parent-child dyads. Parents of children ages 1-5 years who present with ARTI symptoms will be managed by providers trained in either the higher or lower intensity intervention. Before their consultation, all parents will complete a baseline survey and view a 90 s gain-framed antibiotic educational video. Parent-child dyads consulting with providers trained in the higher intensity intervention will, in addition, receive a gain-framed antibiotic educational brochure promoting cautious use of antibiotics and rate their interest in receiving an antibiotic which will be shared with their provider before the visit. All parents will complete a postconsultation survey and a 2-week follow-up phone survey. Due to the two-stage nested design (parents nested within providers and clinics), we will employ generalised linear mixed-effect regression models.

ETHICS/DISSEMINATION

Ethical approval was obtained from the Children's Mercy Hospital Pediatric Institutional Review Board (#16060466). Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03037112; Pre-results.

Mounting resistance of uropathogens to antimicrobial agents: A retrospective study in patients with chronic bacterial prostatitis relapse

Purpose

Despite recent progress in the management of chronic bacterial prostatitis (CBP), many cases relapse. Increased drug resistance patterns of responsible bacteria have been proposed as the most probable causative factor. Driven by the limited number of previous studies addressing this topic, we aimed to study whether antibiotic resistance increases in patients with CBP when relapse occurs. A secondary aim of this study was to determine the resistance patterns of responsible bacteria from patients with CBP.

Materials and Methods

The study material consisted of bacterial isolates from urine and/or prostatic secretions obtained from patients with CBP. Bacterial identification was performed by using the Vitek 2 Compact system and susceptibility testing was performed by disc diffusion and/or the Vitek 2 system. Interpretation of susceptibility results was based on Clinical and Laboratory Standards Institute guidelines.

Results

A total of 253 samples from patients diagnosed with CBP for the first time (group A) and 137 samples from relapsing patients with a history of CBP and previous antibiotic treatment (group B) were analyzed. A significant reduction in bacterial resistance to the less used antibiotics (TMP-SMX, tetracyclines, aminoglycosides, penicillins, and macrolides) was noted. An increase in resistance to quinolones of many bacteria that cause CBP was also noted with the increase in resistance of enterococcus strains being alarming.

Conclusions

Comparison of the resistance profile of CBP-responsible bacteria between samples from first-time-diagnosed patients and samples from relapsing patients revealed notable differences that could be attributed to previous antibiotic treatment.

Utilization, Spending, and Price Trends for Quinolones in the US Medicaid Programs: 25 Years' Experience 1991-2015

BACKGROUND

Given that the quinolones is one of the antibacterial classes most frequently used to treat patients with bacterial infections in the United States, any change in prescribing patterns of quinolones will impact Medicaid medical expenditures.

OBJECTIVES

This study was undertaken to examine trends in utilization, reimbursement, and prices of quinolone antibacterials for the US Medicaid population.

METHODS

The publicly available Medicaid State Drug Utilization outpatient pharmacy files were used for this study. Quarterly and annual prescription counts and reimbursement amounts were calculated for each of the quinolones reimbursed by Medicaid from quarter 1, 1991 through quarter 2, 2015. Average per-prescription reimbursement, as a proxy for drug price, was calculated as the drug reimbursement divided by the number of prescriptions.

RESULTS

The total annual number of quinolone prescriptions increased 402%, from 247,395 in the first quarter of 1991 to 1.2 million in the second quarter of 2015, peaking at 1.3 million in the first quarter of 2005. Similarly, the total reimbursement for quinolone agents increased by 245.5% over the same period. More than 80% of quinolone prescriptions reimbursed by Medicaid were for the second-generation agent, ciprofloxacin, and the third-generation agent, levofloxacin. The average payment per prescription for quinolones increased from US$43.8 in the first quarter of 1991 to US$87.6 in the second quarter of 2015.

CONCLUSIONS

A substantial rise in Medicaid expenditures on quinolones was observed during the 25-year study period, which was mainly because of rising utilization. Therefore, there is a need for additional research that has access to clinically relevant data with which to measure the rate of inappropriate quinolone use among the Medicaid population and associated clinical outcomes and healthcare costs.

Systematic review of public-targeted communication interventions to improve antibiotic use

Background

Excessive use of antibiotics accelerates the acquisition/spread of antimicrobial resistance. A systematic review was conducted to identify the components of successful communication interventions targeted at the general public to improve antibiotic use.

Methods

The databases MEDLINE, EMBASE, CINAHL, Web of Science and Cochrane Library were searched. Search terms were related to the population (public, community), intervention (campaign, mass media) and outcomes (antibiotic, antimicrobial resistance). References were screened for inclusion by one author with a random subset of 10% screened by a second author. No date restrictions were applied and only articles in the English language were considered. Studies had to have a control group or be an interrupted time-series. Outcomes had to measure change in antibiotic-related prescribing/consumption and/or the public's knowledge, attitudes or behaviour. Two reviewers assessed the quality of studies. Narrative synthesis was performed.

Results

Fourteen studies were included with an estimated 74-75 million participants. Most studies were conducted in the United States or Europe and targeted both the general public and clinicians. Twelve of the studies measured changes in antibiotic prescribing. There was quite strong ( P  < 0·05 to ≥ 0·01) to very strong ( P  < 0·001) evidence that interventions that targeted prescribing for RTIs were associated with decreases in antibiotic prescribing; the majority of these studies reported reductions of greater than -14% with the largest effect size reaching -30%.

Conclusion

Multi-faceted communication interventions that target both the general public and clinicians can reduce antibiotic prescribing in high-income countries but the sustainability of reductions in antibiotic prescribing is unclear.

Exploring the evidence base for national and regional policy interventions to combat resistance

The effectiveness of existing policies to control antimicrobial resistance is not yet fully understood. A strengthened evidence base is needed to inform effective policy interventions across countries with different income levels and the human health and animal sectors. We examine three policy domains-responsible use, surveillance, and infection prevention and control-and consider which will be the most effective at national and regional levels. Many complexities exist in the implementation of such policies across sectors and in varying political and regulatory environments. Therefore, we make recommendations for policy action, calling for comprehensive policy assessments, using standardised frameworks, of cost-effectiveness and generalisability. Such assessments are especially important in low-income and middle-income countries, and in the animal and environmental sectors. We also advocate a One Health approach that will enable the development of sensitive policies, accommodating the needs of each sector involved, and addressing concerns of specific countries and regions.

Impact of the Pneumococcal Conjugate Vaccine and Antibiotic Use on Nasopharyngeal Colonization by Antibiotic Nonsusceptible Streptococcus pneumoniae, Alaska, 2000[FIGURE DASH]2010

BACKGROUND

We describe the relative impact of the heptavalent pneumococcal conjugate vaccine (PCV7, introduced 2001) and antibiotic use on colonization by antibiotic-resistant pneumococci in urban Alaskan children during 2000-2010.

METHODS

We obtained nasopharyngeal swab specimens from a convenience sample of children aged <5 years at clinics annually during 2000-2004 and 2008-2010. PCV7 status and antibiotic use <90 days before enrollment were determined by interview/medical records review. Pneumococci were characterized by serotype and susceptibility to penicillin (PCN). Isolates with full PCN resistance (PCN-R) or intermediate PCN resistance (PCN-I) were classified as PCN-NS.

RESULTS

We recruited 3496 children (median, 452 per year). During 2000-2010, a range of 18-29% per year of children used PCN/amoxicillin (P value for trend = 0.09); the proportion age-appropriately vaccinated with PCV7 increased (0[FIGURE DASH]90%; P < 0.01). Among pneumococcal isolates, the PCV7-serotype proportion decreased (53-<1%; P < 0.01) and non[FIGURE DASH]PCV7-serotype proportion increased (43-95%; P < 0.01). PCN-R pneumococcal colonization prevalence decreased (23-9%; P < 0.01) and PCN-I pneumococcal colonization prevalence increased (13-24%; P < 0.01); overall PCN-NS pneumococcal colonization prevalence was unchanged. PCN-NS among colonizing PCV7-type and non[FIGURE DASH]PCV7-type pneumococci remained unchanged; a mean of 31% per year of PCV7-type and 10% per year of non[FIGURE DASH]PCV7-type isolates were PCN-R, and 10% per year of PCV7 and 20% per year of non[FIGURE DASH]PCV7-type isolates were PCN-I.

CONCLUSIONS

Overall, PCN-NS pneumococcal colonization remained unchanged during 2000-2010 because increased colonization by predominantly PCN-I non-PCV7 serotypes offset decreased colonization by predominantly PCN-R PCV7 serotypes. Proportion PCN-NS did not increase within colonizing pneumococcal serotype groups (PCV7 vs. non-PCV7) despite stable PCN use in our population.

Inappropriate Use of Antibiotics and Its Associated Factors among Urban and Rural Communities of Bahir Dar City Administration, Northwest Ethiopia

Background

Inappropriate use of antibiotics in the community plays a role in the emergence and spread of bacteria resistant to antibiotics which threatens human health significantly. The present study was designed to determine inappropriate use of antibiotics and its associated factors among urban and rural communities of Bahir Dar city administration.

Methods

A comparative cross sectional study design was conducted in urban and rural kebeles of Bahir Dar city administration from February 1 to March 28, 2014. A total of 1082 participants included in the study using a systematic random sampling technique. Data was collected using pre-tested and structured questionnaire. Data was coded and entered into SPSSS version 16 for statistical analysis. Bivariate and multivariate logistic regression model were used to identify factors associated with inappropriate use of antibiotics.

Results

Inappropriate use of antibiotics was 30.9% without significant difference between urban (33.1%) and rural (29.2%) communities. From the inappropriate antibiotic use practice, self-medication was 18.0% and the remaining (12.9%) was for family member medication. Respiratory tract symptoms (74.6%), diarrhea (74.4%), and physical injury/wound (64.3%) were the three main reasons that the communities had used antibiotics inappropriately. Factors associated with inappropriate use of antibiotics were low educational status, younger age, unsatisfaction with the health care services, engagement with a job, and low knowledge on the use of antibiotic preparations of human to animals.

Conclusions

Inappropriate use of antibiotic exists in the study area with no significant difference between urban and rural communities. The study indicated an insight on what factors that intervention should be made to reduce inappropriate use of antibiotics in the community. Interventions that consider age groups, educational status, common health problems and their jobs together with improvement of health care services should be areas of focus to reduce inappropriate use of antibiotics.

Comparative analysis of quinolone resistance in clinical isolates of Klebsiella pneumoniae and Escherichia coli from Chinese children and adults

The objective of this study was to compare quinolone resistance and gyrA mutations in clinical isolates of Klebsiella pneumoniae and Escherichia coli from Chinese adults who used quinolone in the preceding month and children without any known history of quinolone administration. The antimicrobial susceptibilities of 61 isolates from children and 79 isolates from adults were determined. The mutations in the quinolone resistance-determining regions in gyrA gene were detected by PCR and DNA sequencing. Fluoroquinolone resistance and types of gyrA mutations in isolates from children and adults were compared and statistically analyzed. No significant differences were detected in the resistance rates of ciprofloxacin and levofloxacin between children and adults among isolates of the two species (all P > 0.05). The double mutation Ser83→Leu + Asp87→Asn in the ciprofloxacin-resistant isolates occurred in 73.7% isolates from the children and 67.9% from the adults, respectively (P = 0.5444). Children with no known history of quinolone administration were found to carry fluoroquinolone-resistant Enterobacteriaceae isolates. The occurrence of ciprofloxacin resistance and the major types of gyrA mutations in the isolates from the children were similar to those from adults. The results indicate that precautions should be taken on environmental issues resulting from widespread transmission of quinolone resistance.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

PCV7-induced changes in pneumococcal carriage and invasive disease burden in Alaskan children

BACKGROUND

Changes in pneumococcal serotype-specific carriage and invasive pneumococcal disease (IPD) after the introduction of pneumococcal conjugate vaccine (PCV7) could inform serotype epidemiology patterns following the introduction of newer conjugate vaccines.

METHODS

We used data from statewide IPD surveillance and annual pneumococcal carriage studies in four regions of Alaska to calculate serotype-specific invasiveness ratios (IR; odds ratio of a carried serotype's likelihood to cause invasive disease compared to other serotypes) in children <5 years of age. We describe changes in carriage, disease burden, and invasiveness between two time periods, the pre-PCV7 period (1996-2000) and the late post-PCV7 period (2006-2009).

RESULTS

Incidence of IPD decreased from the pre- to post-vaccine period (95.7 vs. 57.2 cases per 100,000 children, P<0.001), with a 99% reduction in PCV7 disease. Carriage prevalence did not change between the two periods (49% vs. 50%), although PCV7 serotype carriage declined by 97%, and non-vaccine serotypes increased in prevalence. Alaska pre-vaccine IRs corresponded to pooled results from eight pre-vaccine comparator studies (Spearman's rho=0.44, P=0.002) and to the Alaska post-vaccine period (Spearman's rho=0.28, P=0.029). Relatively invasive serotypes (IR>1) caused 66% of IPD in both periods, although fewer serotypes with IR>1 remained in the post-vaccine (n=9) than the pre-vaccine period (n=13).

CONCLUSIONS

After PCV7 introduction, serotype IRs changed little, and four of the most invasive serotypes were nearly eliminated. If PCV13 use leads to a reduction of carriage and IPD for the 13 vaccine serotypes, the overall IPD rate should further decline.

NOTE

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Childhood infections, antibiotics, and resistance: what are parents saying now?

Parental misconceptions and even "demand" for unnecessary antibiotics were previously viewed as contributors to overuse of these agents. We conducted focus groups to explore the knowledge and attitudes surrounding common infections and antibiotic use in the current era of more judicious prescribing. Among diverse groups of parents, we found widespread use of home remedies and considerable concern regarding antibiotic resistance. Parents generally expressed the desire to use antibiotics only when necessary. There was appreciation of inherent error in the diagnosis of common infections, with most trust placed in providers with whom parents had long-standing relationships. While some parents had experience with "watchful waiting" for otitis media, there was little enthusiasm for this approach. While there may still be room for further education, it appears that parents have become more informed and sophisticated regarding appropriate uses of antibiotics. This has likely contributed to the declines seen in their use nationally.

Effectiveness of physician-targeted interventions to improve antibiotic use for respiratory tract infections

BACKGROUND

Antibiotic use and concomitant resistance are increasing. Literature reviews do not unambiguously indicate which interventions are most effective in improving antibiotic prescribing practice.

AIM

To assess the effectiveness of physician-targeted interventions aiming to improve antibiotic prescribing for respiratory tract infections (RTIs) in primary care, and to identify intervention features mostly contributing to intervention success.

DESIGN AND SETTING

Analysis of a set of physician-targeted interventions in primary care.

METHOD

A literature search (1990-2009) for studies describing the effectiveness of interventions aiming to optimise antibiotic prescription for RTIs by primary care physicians. Intervention features were extracted and effectiveness sizes were calculated. Association between intervention features and intervention success was analysed in multivariate regression analysis.

RESULTS

This study included 58 studies, describing 87 interventions of which 60% significantly improved antibiotic prescribing; interventions aiming to decrease overall antibiotic prescription were more frequently effective than interventions aiming to increase first choice prescription. On average, antibiotic prescription was reduced by 11.6%, and first choice prescription increased by 9.6%. Multiple interventions containing at least 'educational material for the physician' were most often effective. No significant added value was found for interventions containing patient-directed elements. Communication skills training and near-patient testing sorted the largest intervention effects.

CONCLUSION

This review emphasises the importance of physician education in optimising antibiotic use. Further research should focus on how to provide physicians with the relevant knowledge and tools, and when to supplement education with additional intervention elements. Feasibility should be included in this process.

A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers

Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.

Factors affecting caregivers' use of antibiotics available without a prescription in Peru

OBJECTIVE

To determine factors that affect caregivers' decisions about antibiotic use in children in settings where antibiotics are available without prescription.

METHODS

In a house-to-house survey, 1200 caregivers in 3 periurban districts of Lima, Peru, were asked about antibiotic use in young children.

RESULTS

In this sample, 87.2% of children aged <5 years had received an antibiotic drug in their lives; 70.3% had received antibiotics before 1 year of age, and 98.8% of those had been prescribed by a physician. Given hypothetical cases of common cold and nondysenteric diarrhea, caregivers would seek medical advice in 76.4% and 87.1%, respectively, and 84.6% of caregivers said they respected medical decisions even if an antibiotic was not prescribed. Caregivers with high school-level education accepted 80% more medical decisions of not using an antibiotic and used fewer pharmacist-recommended antibiotics. For each additional year of life, the risk of self-medicated antibiotic use and the use of pharmacist-recommended antibiotics increased in 30%. (OR: 1.3, 95% CI: 1.1-1.4, P = .001 and OR: 1.3, 95% CI: 1.2-1.5, P < .001, respectively). Caregivers respected a medical decision of not prescribing an antibiotic 5 times more when physicians had explained the reason for their advice (OR: 5.0, 95% CI: 3.2-7.8, P < .001).

CONCLUSIONS

Prescribed antibiotic use in these young children is common. Even if they are available without prescription, caregivers usually comply with medical advice and follow physicians' recommendations when antibiotics are not prescribed. Improving physician prescribing habits could reduce irrational antibiotic use, decreasing future caregiver-driven misuse.

Epidemiology of pneumococcal serotype 6A and 6C among invasive and carriage isolates from Alaska, 1986-2009

We investigated serotype 6A/6C invasive pneumococcal disease (IPD) incidence, genetic diversity, and carriage before and after 7-valent pneumococcal conjugate vaccine (PCV7) introduction in Alaska. IPD cases (1986-2009) were identified through population-based laboratory surveillance. Isolates were initially serotyped by conventional methods, and 6C isolates were differentiated from 6A by polymerase chain reaction. Among invasive and carriage isolates initially typed as 6A, 35% and 50% were identified as 6C, respectively. IPD rates caused by serotype 6A or 6C among children <5 years did not change from the pre- to post-PCV7 period (P = 0.71 and P = 0.09, respectively). Multilocus sequence typing of IPD isolates revealed 28 sequence types. The proportion of serotype 6A carriage isolates decreased from 7.4% pre-PCV7 to 1.8% (P < 0.001) during 2008-2009; the proportion of serotype 6C carriage isolates increased from 3.0% to 8.4% (P = 0.004) among children <5 years. Continued surveillance is warranted to monitor changes in serotype distribution and prevalence.

Reduction of fluoroquinolone use is associated with a decrease in methicillin-resistant Staphylococcus aureus and fluoroquinolone-resistant Pseudomonas aeruginosa isolation rates: a 10 year study

OBJECTIVES

High rates of methicillin-resistant Staphylococcus aureus (MRSA) and fluoroquinolone-resistant Pseudomonas aeruginosa may be related, in part, to the overuse of fluoroquinolones. The objective was to analyse and correlate long-term surveillance data on MRSA and fluoroquinolone-resistant P. aeruginosa rates and antibiotic consumption after implementation of an institution-wide programme to reduce fluoroquinolone use.

METHODS

An interrupted time series/quasi-experimental study of monthly fluoroquinolone use and MRSA and fluoroquinolone-resistant P. aeruginosa isolation rates was carried out in a tertiary hospital during three periods: pre-intervention (January 2000-August 2005), intervention (September 2005-March 2006), and post-intervention (March 2006-March 2010). The effect of the intervention on the consumption of fluoroquinolones and bacterial resistance was assessed using segmented regression analyses.

RESULTS

Mean monthly fluoroquinolone consumption dropped by 29.1 defined daily doses per 1000 patient-days (DDD/1000 PD) (95% CI 13.1-45.9; P = 0.0005) from a mean of 148.2 to 119.1 DDD/1000 PD during the intervention period. A sustained and significant decrease in fluoroquinolone consumption of -0.95 DDD/1000 PD/month was also observed during the post-intervention period (P = 0.0002). During the post-intervention period the rate of fluoroquinolone-resistant P. aeruginosa continuously decreased, from a mean of 42% to 26%, with a constant relative change rate of -13%/year (95% CI -19 to -5, P = 0.001). A decrease in the MRSA rate was observed during the intervention period, from a mean resistance rate of 27% to 21% (P < 0.0001).

CONCLUSIONS

We showed the sustained impact of a fluoroquinolone control programme on the reduction of fluoroquinolone use with a significant decrease in fluoroquinolone-resistant P. aeruginosa and MRSA rates over 4 years.

Serotyping of Streptococcus pneumoniae isolates from nasopharyngeal samples: use of an algorithm combining microbiologic, serologic, and sequential multiplex PCR techniques

We evaluated nasopharyngeal carriage of Streptococcus pneumoniae (pneumococci) in nine Alaskan communities and used an algorithm combining microbiologic, serologic, and sequential multiplex PCR (MP-PCR) techniques to serotype the isolates. After microbiological identification as pneumococci, isolates (n = 1,135) were serotyped using latex agglutination and Quellung tests (LA/Q) as well as a series of six sequential MP-PCR assays. Results from the two methods agreed for 94% (1,064/1,135) of samples. Eighty-six percent (61/71) of the discordant results were resolved. Discordant results occurred because (i) the MP-PCR gel was misread (31/61 [51%]), (ii) the LA/Q agglutination was misinterpreted (13/61 [21%]), (iii) two serotypes or sets of serotypes were identified by MP-PCR and only one of the two was identified by LA/Q (9/61 [15%]), (iv) different serotypes or sets of serotypes were identified by LA/Q and MP-PCR and both were correct (7/61 [11%]), and (v) the capsular polysaccharide locus (cps) did not amplify during the initial MP-PCR but was present upon retesting (1/61 [2%]). Overall, isolation of pneumococci followed by MP-PCR quickly and accurately identified pneumococcal serotypes in >97% of samples and made available isolates for additional tests such as antimicrobial susceptibility. Misinterpretation of the MP-PCR gel was identified as the main source of discordance. Increasing the number of MP-PCRs from six to seven and reducing the number of serotypes in each reaction may reduce this error. This method may be of use to laboratories characterizing large numbers of S. pneumoniae samples, especially when antimicrobial susceptibility data are needed.

Trends in antimicrobial prescribing rates for Alaska Native and American Indian persons <18 years of age residing in the Anchorage region

OBJECTIVES

In the U.S., the total number of antimicrobials prescribed in ambulatory care declined between 1989 and 2000; however, antimicrobial resistance increased among many pathogens. We evaluated antimicrobial prescribing patterns from 1992 to 2004 in Alaska Native/American Indian (AI/AN) persons

STUDY DESIGN

Retrospective study based on medical records.

METHODS

Medical records were used to obtain data on oral antibiotics prescribed for ambulatory and emergency-room visits. Antimicrobial prescribing rates were calculated per population and per ambulatory-clinic visit.

RESULTS

The total number of antimicrobial courses prescribed increased 94% from 4,929 (1992) to 9,561 (2004). However, the total number of ambulatory-clinic visits also increased (79%) from 49,008 (1992) to 87,486 (2004), while the population of AI/AN persons <18 in Anchorage region rose 14%. The population-based rate of antimicrobial prescriptions (per 1,000 persons) rose from 309 (1992) to 524 (2004 (p<0.001). The visit-based annual rate (per 1,000 visits) remained stable from 101 (1992) to 109 (2004) (=0.651). Overall, visit-based prescriptions rates in AI/AN persons were lower than previously reported among children in the U.S. (range 250-340). Penicillins comprised >50% of antimicrobials presribed from 1992 to 2004. Visit-based prescribing rates from 1992 to 2004 changed: penicillin, +27% (p=0.210): cephalosporins, +33% (p=0.23); trimethoprim-sulfamethexazole, -48% (p<0.001).

CONCLUSIONS

Visit -based antimicrobial prescribing rates in the Anchorage region for AI/AN children receiving care in the AI/AN health system have been stable over a 13-year period. Although a trend in decreased antibiotic prescribing has been seen in the general U.S. population, visit-based prescribing rates in the Anchorage region for AI/AN children have remained below those in previous studies in the U.S.

Factors affecting the reversal of antimicrobial-drug resistance

The persistence or loss of acquired antimicrobial-drug resistance in bacterial populations previously exposed to drug-selective pressure depends on several biological processes. We review mechanisms promoting or preventing the loss of resistance, including rates of reacquisition, effects of resistance traits on bacterial fitness, linked selection, and segregational stability of resistance determinants. As a case study, we discuss the persistence of glycopeptide-resistant enterococci in Norwegian and Danish poultry farms 12 years after the ban of the animal growth promoter avoparcin. We conclude that complete eradication of antimicrobial resistance in bacterial populations following relaxed drug-selective pressures is not straightforward. Resistance determinants may persist at low, but detectable, levels for many years in the absence of the corresponding drugs.

Sustainability for behaviour change in the fight against antibiotic resistance: a social marketing framework

Antibiotic resistance is one of today's most urgent public health problems, threatening to undermine the effectiveness of infectious disease treatment in every country of the world. Specific individual behaviours such as not taking the entire antibiotic regimen and skipping doses contribute to resistance development as does the taking of antibiotics for colds and other illnesses that antibiotics cannot treat. Antibiotic resistance is as much a societal problem as it is an individual one; if mass behaviour change across the population does not occur, the problem of resistance cannot be mitigated at community levels. The problem is one that potentially can be solved if both providers and patients become sufficiently aware of the issue and if they engage in appropriate behaviours. Although a number of initiatives have been implemented in various parts of the world to elicit behaviour change, results have been mixed, and there is little evidence that trial programmes with positive outcomes serve as models of sustainability. In recent years, several scholars have suggested social marketing as the framework for behaviour change that has the greatest chance of sustained success, but the antibiotic resistance literature provides no specifics for how the principles of social marketing should be applied. This paper provides an overview of previous communication-based initiatives and offers a detailed approach to social marketing to guide future efforts.

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis

BACKGROUND

Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses for which antibiotics are often inappropriately prescribed.

RESEARCH DESIGN AND METHODS

We searched the Cochrane Collaboration's Effective Practice and Organisation of Care database, supplemented by MEDLINE and manual review of article bibliographies. We included randomized trials, controlled before-after studies, and interrupted time series. Two independent reviewers abstracted all data, and disagreements were resolved by consensus and discussion with a third reviewer. The primary outcome was the absolute reduction in the proportion of patients receiving antibiotics.

RESULTS

Forty-three studies reporting 55 separate trials met inclusion criteria. Most studies (N = 38) addressed prescribing for acute respiratory infections (ARIs). Among the 30 trials eligible for quantitative analysis, the median reduction in the proportion of subjects receiving antibiotics was 9.7% [interquartile range (IQR), 6.6-13.7%] over 6 months median follow-up. No single QI strategy or combination of strategies was clearly superior. However, active clinician education strategies trended toward greater effectiveness than passive strategies (P = 0.096). Compared with studies targeting specific conditions or patient populations, broad-based interventions extrapolated to larger community-level impacts on total antibiotic use, with savings of 17-117 prescriptions per 1000 person-years. Study methodologic quality was fair.

CONCLUSIONS

QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains. Strategies using active clinician education and targeting management of all ARIs (rather than single conditions in single age groups) may yield larger reductions in community-level antibiotic use.

Seasonality of antibiotic-resistant streptococcus pneumoniae that causes acute otitis media: a clue for an antibiotic-restriction policy?

BACKGROUND

It is unclear whether reducing antibiotic prescriptions can reduce rates of resistance once resistance becomes prevalent. We attempted to determine whether reduced antibiotic consumption, which is observed yearly in children during the warm season, is associated with a reduction in antibiotic resistance in pneumococcal acute otitis media (AOM).

METHODS

Antibiotic prescriptions and resistance were measured prospectively during 1999-2003 in 2 demographically distinct populations: Jewish and Bedouin children (aged <5 years) in southern Israel. Associations were assessed using seasonally clustered logistic regression models.

RESULTS

The study included 236,466 prescriptions and 3609 pneumococcal isolates. Prescription rates decreased during the warm months by 36% and 15% in Jewish and Bedouin children, respectively (P < .001 for the season). Among Jewish children, higher resistance rates were observed during the cold than the warm months (P < .001 for each antibiotic). This difference remained significant after adjustment for age, ethnic group, study year, history of antibiotic use, and serotype. The difference was not observed in Bedouin children.

CONCLUSIONS

Rapid seasonal decline in resistant AOM-causing pneumococci occurred only in Jewish children, among whom a marked prescribing seasonality was noted, and not in Bedouin children, among whom prescription was less seasonal. The rapid seasonal decrease in resistance associated with markedly reduced antibiotic use suggests that drug-resistant pneumococci may pay a fitness cost.

Prevalence and risk factors for nasopharyngeal carriage of Streptococcus pneumoniae among adolescents

Data on the prevalence of pneumococcal nasopharyngeal carriage and its risk factors among adolescents are scarce. The aim of this study was to provide such information. A cross-sectional, population-based prospective study was conducted. Participants were 1013 adolescents (age range 10-19 years) randomly recruited in 22 public schools. Those schools were randomly chosen among 307 public schools from 11 Sanitary Districts of Salvador, Brazil. Nasopharyngeal samples were assessed by standard procedures to recover and identify Streptococcus pneumoniae. Data on potential risk factors were gathered by confidential interview based on a standardized questionnaire. Pneumococci were recovered from 8.2 % [83/1013, 95 % confidence interval (CI) 6.6-10.0]. By stepwise logistic regression, pneumococcal colonization was independently associated with younger age [odds ratio (OR) 0.85, 95 % CI 0.77-0.94, P=0.001], being male (OR 1.78, 95 % CI 1.11-2.85, P=0.02), exposure to passive smoke in the household (OR 1.76, 95 % CI 1.10-2.79, P=0.02), having an upper respiratory infection during recruitment (OR 2.67, 95 % CI 1.67-4.28, P<0.001) and having a history involving an episode of acute asthma during the last year (OR 2.89, 95 % CI 1.18-7.08, P=0.03). The estimated probability of pneumococcal colonization decreased with age (chi(2) for trend=8.52, P=0.003). These findings provide tools for increasing the use of prevention strategies for pneumococcal diseases, such as pneumococcal vaccination among asthmatic patients and public health measures to stop smoking.

Age inconsistency in the American Academy of Pediatrics guidelines for acute otitis media

OBJECTIVE

The American Academy of Pediatrics acute otitis media guidelines could reduce antibiotic use. The objective was to compare strategies for diagnosing and treating otitis: (1) a commonly used, 2-criteria strategy, (2) the guidelines' 3-criteria algorithm, and (3) initially watching without antibiotics.

METHODS

A decision analysis was performed with literature-based parameter. The target population was children presenting to primary care physicians with possible otitis media. Main outcomes were antibiotic use, sick days, mild adverse drug events, and number needed to treat/avoided sick day.

RESULTS

For children 2 to <6 months of age, compared with the 2-criteria strategy, guideline use predicted 21% less antibiotic use, 13% more sick days, and 23% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.2 children per avoided sick day. For children 6 to <24 months of age, guideline use, compared with the 2-criteria strategy, predicted 26% less antibiotic use, 14% more sick days, and 28% fewer adverse drug events; the number needed to treat for the 2-criteria strategy versus the American Academy of Pediatrics strategy was 1.4 children per avoided sick day. For children >2 years of age, guideline use, compared with the 2-criteria strategy, predicted 67% less antibiotic use, 4% more sick days, and 68% fewer adverse drug events. The number needed to treat for the guideline strategy versus the watch strategy was 6.3 children per avoided sick day; that for the 2-criteria strategy versus the guideline strategy was 12.3. Guideline use for children <2 years implies that our number needed to treat to avoid a sick day is <1.4; for children >2, guideline use implies we are willing to treat at least 6.3 children to avoid a sick day. Thus, the guidelines imply a greater willingness to treat older children, compared with younger children.

CONCLUSIONS

The American Academy of Pediatrics guidelines are inconsistent in their outcomes across age groups. Guideline implementation under age 2 reduces antibiotic use but at a relatively heavy cost of sick days and parental missed work days. This trade-off may be particularly unfavorable for working parents, who might reasonably prefer greater antibiotic use.

Valuing reduced antibiotic use for pediatric acute otitis media

OBJECTIVE

The 2004 American Academy of Pediatrics acute otitis media guidelines urge parents to weigh the benefits of reduced antibiotic use, adverse drug events, and future resistance versus risks of extra costs and sick days resulting from guideline use. The value of decreased antibiotic resistance has not been quantified. The objective was to perform cost-utility analysis, estimating the resistance value of implementing the guidelines for acute otitis media treatment for children <2 years of age. Outcomes were described with a common denominator and the value of avoiding resistance was estimated using a parental perspective.

METHODS

Decision analysis results were used for outcome probabilities. Published utilities were used to describe outcomes in quality-adjusted life-day units. The minimum resistance benefit value, where the benefits of the American Academy of Pediatrics guidelines would at least balance their costs, was defined as the guidelines' incremental costs minus their other benefits.

RESULTS

For a child 2 to <6 months of age presenting to a primary care physician with possible otitis media, parents would need to value the resistance benefit at 0.77 quality-adjusted life-days per antibiotic prescription avoided for the guidelines' benefits to balance their costs. For the 6- to <24-month-old group, results were 0.67 quality-adjusted life-days per prescription avoided. Results were sensitive to the dollar cost utility; when willingness to pay ranged from $20,000 to $200,000 per quality-adjusted life-year, results ranged from 0.36 and 0.30 quality-adjusted life-days up to 4.10 and 3.57 quality-adjusted life-days for the 2- to <6-month-old and 6- to <24-month-old groups, respectively. Costs were driven by missed parent work days.

CONCLUSIONS

From a societal perspective, trading 0.30 to 4 quality-adjusted life-days to avoid 1 antibiotic course might be desirable; from a parental perspective, this may not be as desirable. Parent demand for antibiotics may be rational when driven by the value of parent time. Other approaches that have the potential to reduce antibiotic use, such as wider use of influenza vaccine and improved rapid viral diagnostic techniques, might be more successful.

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts

OBJECTIVES

Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.

METHODS

We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.

RESULTS

The data include 223,135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.

CONCLUSIONS

A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

The role of telemedicine in fostering health-care innovations to address problems of access, specialty shortages and changing patient care needs

The integration of advanced technologies into health-care services promises to aid society in its transition to a coordinated, systems approach which is focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality and patient safety. By incorporating such technologies, clinicians will be able to manage the growing volumes of medical information, research and decision support analytical tools. The deployment of advanced technologies will minimize the barriers of distance and geography to enhance access and facilitate the delivery of integrated health care. This will support and enhance the goals of the US federal Healthy People 2010 initiative.

Impact of pneumococcal conjugate vaccine and of reduction of antibiotic use on nasopharyngeal carriage of nonsusceptible pneumococci in children with acute otitis media

BACKGROUND

Penicillin resistance among pneumococci has increased in the past 15 years. The implementation of widespread vaccination with the heptavalent pneumococcal conjugate vaccine (PCV7) and the reduction of inappropriate antibiotic use could help reduce antibiotic resistance.

METHODS

Between September 2001 and June 2004, 89 pediatricians distributed throughout France took part in this prospective study. We obtained 1906 nasopharyngeal swabs for culture from children aged 6 to 24 months with acute otitis media (AOM). At the same time as PCV7 was introduced into the routine immunization schedule, a plan to promote judicious antibiotic use was established. We recorded the frequency of antibiotic use, as well as the dates of immunization with PCV7.

RESULTS

The proportion of PCV7-vaccinated children (> or =1 dose) increased from 8.2% (year 1) to 61.4% (year 3). The proportion of children who received antibiotics within 3 months before enrollment decreased from 51.8% in year 1 to 40.9% in year 3 (P < 0.001). Overall pneumococcal carriage and carriage of PCV7 serotypes decreased during the 3-year period by 16% (P < 0.001) and 35% (P < 0.001), respectively. Rates of highly penicillin resistant strains (PRP) decreased yearly: 15.4%, 10.6%, 6.7% (P < 0.001), respectively. Risks for PRP carriage were 4.2% for immunized children who had not received antibiotics, 8.6% for those vaccinated who also had received antibiotics, 10.3% for unimmunized children who had not received antibiotics, and 16.2% for unimmunized children who had received antibiotics (P < 0.001).

CONCLUSION

Implementation of PCV7, combined with a reduction in antibiotic use, in a country with a high prevalence of antibiotic-resistant pneumococci appears to have a strong impact on the carriage of penicillin nonsusceptible pneumococci in children with AOM.

Macrolide and ketolide resistance with Streptococcus pneumoniae

Antimicrobial agents in the macrolide family have long been considered drugs of potential utility in the management of infections caused by Streptococcus pneumoniae. However, with the emergence of macrolide resistance, the clinical value of macrolides in pneumococcal infections is threatened. In part, as a consequence of the development of macrolide resistance, recently the first agent in the ketolide antimicrobial class, telithromycin, was developed and introduced into clinical practice. The ketolides are macrolide antimicrobials whose chemistry has been modified so as avoid the effects of the most common mechanisms of macrolide resistance with S pneumoniae. This discussion reviews the current state of resistance to macrolides and ketolides with S pneumoniae in North America.