Perceptions and attitudes regarding antibiotic resistance in Germany: a cross-sectoral survey amongst physicians, veterinarians, farmers and the general public

Perceptions of antibiotic resistance among hospital healthcare professionals in high-income countries: A systematic review of causes, consequences, and solutions

OBJECTIVE

Antibiotic resistance (ABR) is a major threat to public health. Hospital healthcare professionals are important stakeholders in curbing ABR. To be able to encourage healthcare professionals to act against ABR, information on their perceptions is needed. Yet, summary evidence on how healthcare professionals perceive ABR causes, consequences, and solutions is outdated. This review aims to elucidate these perceptions.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL for literature published until July 6th, 2022, and used Web of Science and Scopus to identify reports citing included studies. Reports of quantitative original research from high-income countries were included if they investigated hospital healthcare professionals' perceptions about ABR. Descriptive data and data on perceptions about causes, consequences, and solutions regarding ABR were extracted. PROSPERO registration: CRD42022359249.

RESULTS

The database search and citation tracking yielded 13,551 and 694 papers respectively. Forty-eight reports from 46 studies were included in the review. These studies were performed between 1999 and 2023 and included between 8 and 1362 participants. Healthcare professionals perceived ABR as a problem that is more severe nationally than locally and they primarily recognize ABR as a distant and abstract problem. Studies mostly concurred on prescribing behavior as a cause and a solution for ABR, while external causes and solutions (e.g., in agriculture) elicited less agreement.

CONCLUSIONS

Studies with a primary focus on the perceptions of healthcare professionals about ABR are limited. Healthcare professionals perceive prescribing behavior as a major cause of ABR and a focus area for ABR solutions.

Transdisciplinary stakeholder understandings of antimicrobial resistance: An integrative approach in Aotearoa New Zealand

OBJECTIVE

Antimicrobial resistance (AMR) is a complex public health issue, with a range of influences across human, animal, and environmental health. Given the complexity of the problem, the diversity of stakeholders, and the failure of current policies to curb AMR worldwide, integrative approaches are needed to identify effective actions. Underpinned by systems thinking and One Health principles, this qualitative study explored how diverse AMR experts in Aotearoa New Zealand perceive the main drivers and effects of AMR.

METHODS

Semi-structured interviews with clinical, academic, policy, community, and industry representatives were designed to elicit mental models of the causes and outcomes of AMR across dimensions.

RESULTS

Thematic analysis revealed contrasting understandings of AMR causes across four domains: food-producing animals (livestock), healthcare, community, and environment. AMR was often framed as a problem of individual behaviour, despite many implicit references to underlying structural economic influences. The politics of collaboration was a further major underlying theme. The interviews highlighted fundamental connections between AMR and other complex issues, including poverty and environmental pollution.

IMPLICATIONS FOR PUBLIC HEALTH

This study brings together the understandings of AMR of transdisciplinary stakeholders, providing some immediate insights for policy makers and setting the foundation for developing a collaborative system model of AMR as a basis for decision-making.

Consumer Preferences and Attitudes towards Antibiotic Use in Food Animals

Antimicrobial resistance (AMR) is one of the major challenges faced by society, with the real threat of the failure of many medical procedures. Antibiotics are also used in livestock production and provide a potential pathway to increasing AMR. The central challenge involves ensuring animal health and welfare while securing the long-term effectiveness of antibiotics. This paper reports the results of a survey of 5693 respondents from the customer panels of four major UK supermarkets regarding preferences and attitudes towards antibiotic use in food animals, and their perspectives on how the balance between animal welfare and human benefit can be achieved. The results of these surveys are consistent with those from other countries that found that consumers generally have limited knowledge about antibiotic use in agriculture and AMR, with around 50% responding "don't know" to many questions. There was agreement about the benefits of antibiotics outweighing harm, with 40% agreeing that, overall, the use of antibiotics to treat disease in farm animals delivers more benefit than harm. However, 44% neither agreed nor disagreed, indicating a high level of uncertainty and a situation that is potentially unstable. The seriousness of the AMR challenge is such that continued action for the more discriminating use of antibiotics must continue.

Appropriate antibiotic use and antimicrobial resistance: knowledge, attitudes and behaviour of medical students and their needs and preferences for learning

BACKGROUND

The impact of an appropriate use of antibiotics on the prevention of antimicrobial resistance (AMR) has been demonstrated. Surveys have shown, however, that medical students do not feel sufficiently trained to use antibiotics wisely. The aims of our study were (1) to describe what medical students currently know about appropriate antibiotic use, and (2) to identify students' learning preferences as a basis for developing student-centred teaching modules to convey the basics of AMR prevention.

METHODS

We performed an online survey at Charité Universitätsmedizin Berlin and the Julius-Maximilians-University Würzburg on the knowledge, attitudes, and behaviour (KAB) of medical students concerning AMR, antibiotic treatment options, and their perceptions of AMR topics addressed in the medical curriculum. Participants were able to fill out an online questionnaire between December 2019 and February 2020. In addition, we conducted focus group discussions with lecturers and medical students in winter 2019/2020 to identify AMR-related learning needs and preferences. Data were analysed descriptively.

RESULTS

Overall, 356 students (response rate 5.1%) participated in the KAB survey. Of these, 192 (54%) strongly agreed that the topic of AMR is relevant to students' clinical practice and 48% (171/355) stated that their future antibiotic prescription behaviour will have an influence on AMR development in their region. Participating students seemed to be interested in the topic of AMR and antibiotic therapy. But even of them, only 46% answered the question about the length of antibiotic use for community-acquired pneumonia correctly and 57% the question about the appropriate use of antibiotics in Staphylococcus aureus infections. Focus group discussions with students (n = 7) and lecturers (n = 9) identified a lack of competence in the responsible use of antibiotics and the prevention of AMR. Respondents stated that the teaching formats and AMR-related content should emphasize clinical applications, interaction with peers/clinicians, and repeated formative feedback from instructors.

CONCLUSIONS

Our results show that even medical students who were interested in the AMR problem were not able to use antibiotics appropriately due to gaps in knowledge and a lack of clinical skills. Based on the insights gained in the learning preferences of students and their content priorities, improved student-centred teaching materials should be developed.

Antibiotic prescription patterns and non-clinical factors influencing antibiotic use by Ecuadorian veterinarians working on cattle and poultry farms: A cross-sectional study

Understanding antibiotic prescription patterns and non-clinical factors influencing antibiotic use is essential for implementing strategies to promote appropriate antibiotic use. There is, however, limited research exploring these issues with Ecuadorian veterinarians. Therefore, a questionnaire was developed and applied cross-sectionally to veterinarians (n = 173) from two professional organizations to explore the antibiotic prescription patterns and non-clinical factors (e.g., attitudes and perceptions) influencing antibiotic use, and to identify strategies to reduce antibiotic use. The response rate was 78.4%. Responses were compared between veterinarians working mainly on cattle and poultry farms using Mann-Whitney U tests. The most important attitudes, beliefs and perceptions towards antimicrobial resistance (AMR) and antibiotic use were identified with the Relative Importance Index (RII). Veterinarians showed high awareness of AMR and its implications for public health, as well as the necessity of reducing antibiotic use. However, some veterinarians appear to underestimate the potential contribution of veterinary antibiotic use on AMR in humans. Veterinarians self-reported high prescription (> 20%) of antibiotics for cattle and poultry that are critically important for human medicine, such as 3rd and 4th generation cephalosporins, polymyxins and quinolones. Further, antibiotic therapy was not tailored to disease type. Cattle and poultry veterinarians perceived similar barriers to increasing antibiotic stewardship including: poor biosecurity measures, animal confinement, low feed quality, farmers' behaviors (such as stopping antibiotic treatment, storing antibiotics on farms, buying antibiotics in veterinary supply stores), and sales agents' roles as non-professional prescribers of antibiotics. Overall, veterinarians were broadly supportive (>90%) of most strategies to promote appropriate antibiotic use. They saw more merit in improving biosecurity of farms and implementing educational programs for farmers and veterinarians. This study provides insight into the complexity of antibiotic use on Ecuadorian farms and the need for holistic strategies in a One Health context, to achieve antibiotic stewardship.

Tackling AMR from a multidisciplinary perspective: a primer from education and psychology

Antimicrobial resistance (AMR) is currently one of the most concerning threats in public health. The efforts to tackle the problem require a global One Health approach, using multidisciplinary approaches and a thorough understanding of the topic both by the general public and the experts. Currently, the lack of a shared mental model of the problem, the absence of a sense of responsibility amongst the different actors and a deficient education on the topic burden the efforts to slow down the emergency and spread of antimicrobial resistant infections. We here propose a multidisciplinary approach to tackle the AMR problem, taking into consideration not only the input from the biological and medical sciences but also the input from the social sciences. Specifically, we suggest strategies from education and psychology to increase awareness about antimicrobial resistance and to implement more effective interventions. Finally, we advocate for a comprehensive and a solidaristic model as the only solution for a problem which knows no borders. As such, political will and international cooperation will be key to achieve the desired change in antibiotic resistance trend.

Awareness of inappropriate use related to antimicrobial resistance among medical doctors by country economic status: A systematic review

BACKGROUND

Antimicrobial resistance (AMR) is promoted by inappropriate use and is a greater burden for low to middle income countries (LMIC) than high income countries (HIC).

OBJECTIVE

This systematic review aimed to compare the awareness of inappropriate use related to AMR among medical doctors from LMIC and HIC using published knowledge, attitude and practice (KAP) studies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, sequential systematic literature search of PubMed and Web of Science databases for articles published since inception up to June 1, 2022 for KAP studies involving medical doctors. Using fifteen KAP items related to promoting AMR, data on proportion of participants responding affirmatively was extracted and reported using means, ranges and 95% confidence intervals (CI).

RESULTS

Forty-two studies met the inclusion criteria and involved 13,089 medical doctors from 11HIC and 21LMIC. All were cross-sectional studies, 71.4% involved non-probability sampling and 78.6% were of satisfactory quality. Knowledge items showed mean proportion of more medical doctors responding correctly. Similar affirmation trends were observed for attitude and prescribing practice items. Awareness appeared similar between medical doctors of the economic groups, except for a greater interest in training for LMIC (95.4%; 95%CI 93.0%, 97.9%) versus HIC (81.7%; 95%CI 65.6%, 97.9%). Countries with poor proportions were identified in both economic groups.

CONCLUSION

For identified studies, trends suggest good awareness among medical doctors of the known inappropriate use and perceived threat of AMR, as well as prescribing practices to reduce the risk of AMR. Trends were similar across HIC and LMIC; however, countries with evidence of poor awareness exist in both economic groups.

Veterinary Practitioners' Standpoints and Comprehension towards Antimicrobial Use-Are There Opportunities for Antimicrobial Stewardship Improvement?

The main subject of the research is the assessment of the knowledge, attitudes and behaviors of veterinarians regarding the use of antibiotics (AMU) and antimicrobial resistance (AMR) through a questionnaire conducted among veterinarians in the northern region of Serbia. A total of 62 respondents completed the questionnaire, which represents a response rate of 44.3%. Male veterinarians are less likely to be in the group of veterinarians with insufficient knowledge (p < 0.05). Veterinarians engaged in mixed practice (small and large animals) (p < 0.001) and veterinarians who have over 100 patients per month (p < 0.005) are also less likely to be in the group with insufficient knowledge of antimicrobial resistance. The proportion of those with insufficient knowledge is growing among veterinarians whose source is the Internet (p < 0.01), while the proportion of those with insufficient knowledge about antimicrobial resistance is declining among veterinarians whose source of information is continuous education (p < 0.05). The majority of the respondents (n = 59, 95.2%) completely agreed that AMR is a very big issue in the global health sector right now. Unfortunately, there are crucial gaps in the knowledge and attitudes of the surveyed participants. They do not appear to be aware of the importance of AMU in veterinary medicine and its influence on overall AMR, or the crucial part that non-prescribed antibiotics have in all of it. Positively, many veterinarians use good practice AMU guidelines in their everyday practice and in line with the global trend of AMU reduction, respondents have also decreased their AMU compared to the previous year.

What the public in England know about antibiotic use and resistance in 2020: a face-to-face questionnaire survey

OBJECTIVES

To describe public attitudes and knowledge around antibiotic activity, resistance and use.

DESIGN

Face-to-face household 18 question survey using computer-assisted data collection undertaken by Ipsos Market and Opinion Research International.

SETTING

Randomly selected households across England, January-February 2020.

PARTICIPANTS

2022 adults (aged 15+,) including 521 black, Asian and minority ethnic (BAME) participants, and 406 aged 15-25 years olds.

MAIN OUTCOME MEASURES

Responses to questions about antibiotic activity, resistance and expectations for antibiotics and trust in healthcare professionals. Analyses were weighted to obtain estimates representative of the population with multivariable analysis undertaken for questions with five or more significant univariate variables.

RESULTS

84% stated they would be pleased if their general practitioner (GP) said they did not need antibiotics. Trust in GPs to make antibiotic decisions remains high (89%) and has increased for nurses (76%) and pharmacists (71%). Only 21% would challenge an antibiotic decision; this was significantly greater in BAME participants (OR 2.5; 95% CI 1.89 to 3.35). 70% reported receiving advice when prescribed antibiotics. Belief in benefits of antibiotics for ear infections was very high (68%). Similar to 2017, 81% agreed that antibiotics work for bacterial, 28% cold and influenza viruses. 84% agreed antibiotic resistant bacteria (ARB) are increasing, only 50% agreed healthy people can carry ARB and 39% agreed there was nothing they personally could do about ARB. Social grade DE and BAME participants, and those with less education had significantly less understanding about antibiotics and resistance.

CONCLUSIONS

As trust in healthcare practitioners is high, we need to continue antibiotic education and other interventions at GP surgeries and community pharmacies but highlight that most ear infections are not benefitted by antibiotics. Targeted interventions are needed for socioeconomic DE, BAME groups and previous antibiotic users. We need to explore if increasing perceived personal responsibility for preventing ARB reduces antibiotic use.

Assessing Knowledge, Beliefs, and Behaviors around Antibiotic Usage and Antibiotic Resistance among UK Veterinary Students: A Multi-Site, Cross-Sectional Survey

Antimicrobial resistance (AMR) is a profound threat to human and animal health. Antimicrobial prescribing behaviours are influenced by psychological factors such as knowledge, beliefs, and emotions. As future antimicrobial prescribers, it is important to understand beliefs about AMR and stewardship among veterinary (vet) students. This cross-sectional online survey assessed vet students’ self-reported behavior, knowledge, and beliefs in specific relation to antibiotic resistance (ABR) and antibiotic usage. Participants were early years (first- and second-year; n = 460) and later-years (third- and fourth-year; n = 113) undergraduate vet students from three UK universities. Self-reported antibiotic-related behaviors were responsible among most students. Knowledge about ABR and stewardship was moderate among early years students and good among later years students. Vet students typically believed that vets had less responsibility for both causing and preventing ABR than other groups (animal owners, human medics, and the public). This study offers evidence that vet students (along with other groups) tend to lay greater responsibility for ABR/AMR outside of their own profession, which may impact their future prescribing behaviors. It is vital that AMR and antimicrobial stewardship are embedded across veterinary curricula, and that the One Health nature of the challenge posed by AMR is emphasized to encourage shared responsibility across all stakeholder groups, thereby helping to reduce ‘other-blaming’ for AMR.

Antimicrobial use in agriculture: critical review of the factors influencing behaviour

Antimicrobial resistance (AMR) is a global health emergency affecting humans and animals, diminishing the effectiveness of medication used to treat illness. The agri-food sector has attracted increased attention for imprudent antimicrobial use (AMU) and its contribution to AMR. Thus, ascertaining farmers' and veterinarians' behaviours surrounding AMU is essential to address imprudent AMU and generate behaviour change within the agri-food sector. Therefore, the aim of this critical review is to investigate, assess and collate the current body of evidence to identify psychosocial factors including knowledge, understanding, perceptions, attitudes and behaviours surrounding AMU. Database searches were limited to articles utilizing qualitative and quantitative methodologies, available in English with no restriction on publication year. Of the 1156 articles identified, 103 were retained for this review. Findings on the psychosocial aspects were thematically analysed. Five key themes emerged from the data: (i) knowledge and awareness of antimicrobials; (ii) attitudes towards antimicrobials; (iii) influential relationships; (iv) resources; and (v) factors influencing AMU. Results indicated that to overcome barriers experienced by key stakeholders, a carefully considered, evidence-based approach, incorporating behaviour change theory, is required when designing intricate interventions/strategies, in order to elicit successful and sustained AMU behaviour change.

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.

Examining the Effect of Context, Beliefs, and Values on UK Farm Veterinarians' Antimicrobial Prescribing: A Randomized Experimental Vignette and Cross-Sectional Survey

Antimicrobial resistance (AMR) is a pressing threat to public and animal health. There is evidence that antimicrobial prescribing and stewardship behaviors by veterinarians (vets) are influenced by non-clinical factors, such as psychological, social, and environmental factors. This study explored the role of context, beliefs, and values on vets' antimicrobial prescribing decisions. UK-based practicing farm vets (n = 97) were recruited to an online study. Using an experimental vignette methodology, vets were randomly assigned across four conditions, to examine the effects of different contexts (pressure on farm economics, the farmer, or the vet-farmer relationship, compared to a control condition) on vets' likelihood of prescribing antibiotics. Vets' beliefs about different groups' responsibility for causing and preventing AMR and vets' values were also measured. Key findings were that context alone, values, and beliefs about groups' responsibilities for causing AMR were not predictive of vets' likelihood of prescribing antibiotics. However, vets' beliefs about groups' responsibilities for preventing AMR were predictive of an increased likelihood of prescribing antibiotics, when vets were exposed to the experimental condition of the vignette in which the vet-farmer relationship was under pressure. Farm vets also believed that different groups have different levels of responsibility for causing and preventing AMR. Results should be interpreted cautiously, given the smaller than planned for sample size, and the possibility for both false negatives and false positives. Further research is needed to explore how these findings could inform antimicrobial stewardship interventions in veterinary medicine.

Evaluation of a multimodal intervention to promote rational antibiotic use in primary care

Background

Increasing antimicrobial resistance is a serious societal challenge affecting outpatient, inpatient and veterinary care. The German One-Health project, RAI (Rational use of Antibiotics via Information and Communication) addresses all three sectors. In the outpatient sector, General Practitioners (GPs) are the main prescribers of antibiotics and were therefore, targeted for this study. A multimodal intervention focusing on Acute Respiratory Tract infections (ARI) was designed and implemented. The aim of this study was to evaluate acceptance, rating and the self-reported impact of the intervention among GPs.

Methods

The intervention offered six tools: a GP training on rational antibiotic use, an app for self-monitoring, a leaflet and a set of posters (both for use as information materials in waiting rooms) and both digital and printed information prescriptions (material for ‘prescribing’ information instead of an antibiotic to the patient). The tools could be used according to individual preferences. The intervention was conducted between August 2016 and July 2017. Following the intervention, a three pages anonymous questionnaire was sent to all 271 participants. Items covered socio-demographic and professional background, use and judgement of the intervention tools (6 point Likert scale), impact of the intervention tools (4 point Likert scale).

Results

The response rate was 39% (n = 107). On average, respondents used 3.1 of the six available tools, with printed information prescriptions used most frequently (79%). Digital information prescriptions were used more frequently by men than by women (OR 2.8; 95% CI 1.16–7.24; p = 0.02). Eighty-seven percent of respondents stated that information prescriptions supported doctor-patient communication. In a comparison of the overall impression of the different intervention tools the GP training on rational antibiotic use was rated best (1.67 on a 6 point scale with 1 = highest, 6 = lowest) and most often noted as having had a “strong” or “very strong” impact on personal antibiotic prescribing behavior.

Conclusions

The multimodal intervention addressing education and communication was well accepted among GPs and could help in fostering rational use of antibiotics in primary care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00908-9.

Farmer perceptions of dairy farm antibiotic use and transport pathways as determinants of contaminant loads to the environment

Agricultural antibiotic contamination into milk and beef products has been considered extensively, but antibiotic transport into soil and water environments is less regulated and studied. Farmer perceptions of these transport processes are critical to understanding how antibiotics reach soils and surface waters and what management strategies can be implemented to reduce environmental antibiotic loads. We have conducted semi-structured interviews with twenty-seven dairy farmers in central New York to understand farmer perceptions of environmental transport of antibiotics and decisions that reduce environmental antibiotic loads. Interviews were qualitatively analyzed and coded using thematic analysis. We found that farmers extensively considered transport of antibiotics into milk and beef, while consideration of antibiotic transport into manure was less common, and no farmers discussed antibiotic transport from carcasses into soil from on-farm animal mortality. Farmers highlighted decisions that reduce antibiotic environmental loads through disease prevention actions, usage of non-antibiotic treatments, and culturing bacterial samples before antibiotic treatment. Farmers did not cite reduction of environmental antibiotic loads as a driver of their waste management decisions. Farmers perceived antibiotic usage was already minimized on farms in the region, suggesting future environmental antibiotic contamination mitigation strategies should focus on waste management pathways.

Survey of production animal veterinarians' prescription practices, factors influencing antimicrobial drug use, and perceptions of and attitudes toward antimicrobial resistance

OBJECTIVE

To assess production animal medicine veterinarians' prescription practices and identify factors influencing their use of antimicrobial drugs (AMDs) and their perceptions of and attitudes toward antimicrobial resistance (AMR).

SAMPLE

157 production animal veterinarians in the United States.

PROCEDURES

An online cross-sectional survey and digital diary were used to gather information regarding perceptions on AMD use and AMR and on treatment recommendations for production setting-specific disease scenarios. Results were compared across respondents grouped by their selected production setting scenarios and reported years as veterinarians.

RESULTS

The most commonly selected production setting disease scenarios were dairy cattle (96/157 [61.1%]), backgrounding cattle (32/157 [20.4%]), and feedlot cattle (20/157 [12.7%]). Because few respondents selected swine (5/157 [3.2%]) or poultry (4/157 [2.5%]) scenarios, those responses were excluded from statistical analysis of AMD prescription practices. Most remaining respondents (147/148 [99.3%]) reported that they would recommend AMD treatment for an individual ill animal; however, responses differed for respondents grouped by their selected production setting scenarios and reported years as veterinarians when asked about AMD treatment of an exposed group or high-risk disease-free group. Most respondents reported that government regulations influenced their AMD prescribing, that owner and producer compliance was a veterinary-related factor that contributed to AMR, and that environmental modifications to prevent disease could be effective to mitigate AMR.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of the present study helped fill important knowledge gaps pertaining to prescription practices and influencing factors for AMD use in production animal medicine and provided baseline information for future assessments. This information could be used to inform future interventions and training tools to mitigate the public health threat of AMR.

Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention

BACKGROUND

Antimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study "Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)" aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components.

METHODS

A mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data.

RESULTS

Uptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use.

CONCLUSIONS

The process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population.

TRIAL REGISTRATION

ISRCTN, ISRCTN15061174 . Registered 13 July 2018 - Retrospectively registered.

[Prescribing of antibiotics for respiratory tract infections in German outpatient pediatric care : Results of a survey of pediatricians and general practitioners]

BACKGROUND

Pediatric outpatients with respiratory tract infections (RTIs) comprise an important target population for antibiotic stewardship (ABS) intervention.

OBJECTIVES

The aim of this qualitative study was to determine which clinical and contextual factors have a significant impact on antibiotic therapy (ABT) in pediatric patients with RTIs.

MATERIALS AND METHODS

An online survey was developed and carried out in Germany in cooperation with the Federal Association of Pediatricians and the German Society for Pediatric Infectious Diseases. Pediatricians and general practitioners were invited to participate.

RESULTS

The survey yielded 555 complete response data sets. Diagnostic uncertainty, time constraints for repeated consultations, and fear of complications were identified by 50% of both medical specialties as contextual factors fostering ABT. The risk of serious complications (e.g., mastoiditis) was overestimated by the majority of participants. More than 40% of respondents lacked knowledge concerning official guidelines, and RTIs with fever lasting longer than three days appeared to be an important criterion for ABT for 30-40%. Fewer than 60% of physicians were using a point-of-care device to determine C‑reactive protein.

CONCLUSION

Although most participants acknowledged the growing prevalence of antibiotic-resistant pathogens as an important problem, this survey identifies targets for ABS in pediatric outpatients with RTIs. Ongoing education and training (e.g., better communication strategies in response to parental concerns) should become mandatory for those who prescribe ABT for children with RTIs.

Use of stewardship smartphone applications by physicians and prescribing of antimicrobials in hospitals: A systematic review

BACKGROUND

Antimicrobial stewardship (AMS) programs promote appropriate use of antimicrobials and reduce antimicrobial resistance. Technological developments have resulted in smartphone applications (apps) facilitating AMS. Yet, their impact is unclear.

OBJECTIVES

Systematically review AMS apps and their impact on prescribing by physicians treating in-hospital patients.

DATA SOURCES

EMBASE, MEDLINE (Ovid), Cochrane Central, Web of Science and Google Scholar.

STUDY ELIGIBILITY CRITERIA

Studies focusing on smartphone or tablet apps and antimicrobial therapy published from January 2008 until February 28th 2019 were included.

PARTICIPANTS

Physicians treating in-hospital patients.

INTERVENTIONS

AMS apps.

METHODS

Systematic review.

RESULTS

Thirteen studies met the eligibility criteria. None was a randomized controlled trial. Methodological study quality was considered low to moderate in all but three qualitative studies. The primary outcomes were process indicators, adherence to guidelines and user experience. Guidelines were more frequently accessed by app (53.0% - 89.6%) than by desktop in three studies. Adherence to guidelines increased (6.5% - 74.0%) significantly for several indications after app implementation in four studies. Most users considered app use easy (77.4%->90.0%) and useful (71.0%->90%) in three studies and preferred it over guideline access by web viewer or booklet in two studies. However, some physicians regarded app use adjacent to colleagues or patients unprofessional in three qualitative studies. Susceptibility to several antimicrobials changed significantly post-intervention (from 5% decrease to 10% - 14% increase) in one study.

CONCLUSIONS

Use of AMS apps seems to promote access to and knowledge of antimicrobial prescribing policy, and increase adherence to guidelines in hospitals. However, this has been assessed in a limited number of studies and for specific indications. Good quality studies are necessary to properly assess the impact of AMS apps on antimicrobial prescribing. To improve adherence to antimicrobial guidelines, use of AMS apps could be considered.

Knowledge, Attitudes and Practices of Veterinarians Towards Antimicrobial Resistance and Stewardship in Nigeria

Antimicrobial resistance (AMR) is a global health concern and the inappropriate use of antibiotics in animals and humans is considered a contributing factor. A cross-sectional survey to assess the knowledge, attitudes and practices of veterinarians regarding AMR and antimicrobial stewardship was conducted in Nigeria. A total of 241 respondents completed an online survey. Only 21% of respondents correctly defined the term antimicrobial stewardship and 59.8% were unaware of the guidelines provided by the Nigeria AMR National Action Plan. Over half (51%) of the respondents indicated that prophylactic antibiotic use was appropriate when farm biosecurity was poor. Only 20% of the respondents conducted antimicrobial susceptibility testing (AST) frequently, and the unavailability of veterinary laboratory services (82%) and the owner’s inability to pay (72%) were reported as key barriers to conducting AST. The study findings suggest strategies focusing on the following areas may be useful in improving appropriate antibiotic use and antimicrobial stewardship among veterinarians in Nigeria: increased awareness of responsible antimicrobial use among practicing and newly graduated veterinarians, increased dissemination of regularly updated antibiotic use guidelines, increased understanding of the role of good biosecurity and vaccination practices in disease prevention, and increased provision of laboratory services and AST at affordable costs.

Addressing Individual Values to Impact Prudent Antimicrobial Prescribing in Animal Agriculture

Antimicrobial resistance is a growing public health threat driven by antimicrobial use—both judicious and injudicious—in people and animals. In animal agriculture, antimicrobials are used to treat, control, and prevent disease in herds of animals. While such use generally occurs under the broad supervision of a veterinarian, individual animals are often treated by farm owners or managers. The decision to administer antimicrobials is therefore influenced not only by the clinical situation but also by the motivations and priorities of different individual actors. Many studies have examined the drivers of external forces such as costs, workload and time constraints, or social pressures on antimicrobial use by veterinarians and producers, but none have explored the role of individually held values in influencing decision-making related to antimicrobial use. Values are deeply held normative orientations that guide the formation of attitudes and behaviors across multiple contexts. Values have been shown to be strongly tied to perceptions of and attitudes toward polarizing topics such as climate change, and preliminary evidence suggests that values are also associated with attitudes to antimicrobial resistance and stewardship. In this article, we draw on lessons learned in other fields (human health care, climate change science) to explore how values could be tied to the extrinsic and intrinsic factors that drive antimicrobial use and prescribing in animal agriculture. We also provide suggestions for ways to build a bridge between the veterinary and social sciences and incorporate values into future research aimed at promoting antimicrobial stewardship in animal agriculture.

Factors associated with sufficient knowledge of antibiotics and antimicrobial resistance in the Japanese general population

We conducted two online surveys about antibiotics targeted at the Japanese general population in March 2017 and February 2018. In total, 6,982 participants completed the questionnaire. Factors associated with knowledge of antibiotics, knowledge of antimicrobial resistance (AMR) and appropriate behavioural changes were evaluated by a machine learning approach using DataRobot. Factors strongly associated with three dependent variables in the model were extracted based on permuation importance. We found that the strongest determinant of knowledge of antibiotics and AMR was education level. Knowledge of antibiotics was strongly associated with the frequency of internet use. Exposure to primary information was associated with motivation for appropriate behavioural changes. Improving the availability of primary information would be a beneficial intervention. Individuals lacking higher education and without opportunities to obtain primary information should be considered a target population for effective interventions.

The complex phenomenon of dysrational antibiotics prescribing decisions in German primary healthcare: a qualitative interview study using dual process theory

Background

Antibiotic prescription rates in primary care in Germany are moderate, but still considered too high. The ARena study (Sustainable reduction of antibiotic-induced antimicrobial resistance) was initiated to foster awareness and understanding of the growing challenge and promotes rational antibiotics use for acute, non-complicated and self-limiting infections.

Methods

The present study was performed as part of the process evaluation of the ARena study. Interviews were conducted with a purposive sample of physicians participating in the ARena study to identify factors relevant to primary care physicians' decision-making when prescribing antibiotics for acute non-complicated infections. Generated data were audio-recorded. Pseudonymized verbatim transcripts were coded using a pre-defined framework. The Dual Process Theory was applied to provide understanding of individual health professional factors that induce dysrational prescribing decisions.

Results

Based on medical as well as non-medical considerations, physicians developed habits in decision making on antibiotics prescribing. They acknowledged inadequate antibiotics prescribing for acute, non-complicated infections in situations involving uncertainty regarding diagnosis, prognosis, continuity of care, patient expectations and when not knowing the patient. Educative efforts empowered physicians to override habitual prescribing. A theory-driven model provides transparency as to how dysrational prescribing decisions occur and suggests remedy by providing new experiences and new recognizable patterns through educative efforts.

Conclusions

Educational interventions may only change prescribing behaviours if they result in active rational rather than routine-based decision-making on antibiotics prescribing.

Trial registration

ISRCTN, ISRCTN58150046.

The Knowledge, Attitudes, and Practices of Community Pharmacists in their Approach to Antibiotic Use: A Nationwide Survey in Italy

Background: This investigation has been carried out to evaluate the knowledge, attitudes, and practices toward antibiotic resistance and antibiotic use among community pharmacists in Italy and to investigate their influencing factors. Methods: A cross-sectional telephone survey using a semi-structured interview was performed between September 2018 and April 2019 among a random sample of community pharmacists. Results: Almost two thirds (61.5%) correctly answered that the overuse of antibiotics in primary care, hospital settings, and veterinary medicine is a significant cause of antibiotic resistance. Males, those who worked a lower number of hours per week, and those who acquired information through scientific journals and educational activity were more likely to know that the overuse of antibiotics causes antibiotic resistance. More than two thirds of those pharmacists (70.8%) often or always inform the public about the risks of antibiotic resistance. Those who have been practicing for a higher number of years were more likely to act in that way, whereas pharmacy directors and those who did not need additional information on antibiotic resistance were less likely to inform the public. Conclusions: Pharmacists need to be aware of the issue of antibiotic resistance and policy makers should promote the implementation of antibiotic use public educational interventions in this setting.

Interprofessional perceptions and emotional impact of multidrug-resistant organisms: A qualitative study

BACKGROUND

Hospital-acquired infections caused by multidrug-resistant organisms (MDROs) are a threat to patient safety and hospital economy. Training in hygiene precautions is known to limit MDRO spread and patient morbidity. As infection prevention is a collaborative task, we developed an interprofessional educational intervention, including a reflective unit about MDRO. This article reports on the perceptions of professionals for MDRO management.

METHODS

In 2017, we conducted 8 trainings, including facilitated group discussions focusing on the question how participants think others experience MDRO. Results were analyzed using a socio-constructivist qualitative approach.

RESULTS

A total of 51 health care workers from 13 professions and 5 hospitals participated, generating 366 items for coding. Three main themes could be identified: (1) significant barriers in educating clinicians and informing lay persons, (2) emotional reactions-especially anxiety and anger-from the perspective of lay persons and professionals evoked by MDRO, and (3) perceived economic burden.

CONCLUSIONS

MDROs generate psychosocial side effects with an impact on health care management and on professional-patient relationships and interprofessional relationships. Specifically, emotions evoked by insufficient information and transparency play a major role. Therefore, hygiene trainings must not be limited to basic skills. In addition, they should be comprised of communication and educational techniques and evoke attentiveness for emotional stress.

Antibiotic resistance, the 3As and the road ahead

Antibiotic resistance is by far one of the most important health threats of our time. Only a global concerted effort of several disciplines based on the One-Health concept will help in slowing down this process and potentially mitigate the ruin of healthcare we have come to enjoy. In this review, we attempt to summarize the most basic and important topics that serve as good information tools to create Awareness. The Availability of antibiotics or the lack thereof is another significant factor that must be given thought, and finally because antibiotic resistance is a problem that will not go away, it is important to have Alternatives. Together, we have the 3As, essential concepts, in dealing with this growing and complex problem.