Outpatient antibiotic prescribing in the United States: 2000 to 2010

An evaluation of antibiotic prescription pattern and drug rationality analysis among outpatients at public health setting, India

BACKGROUND

Antibiotic resistance (AMR) is a significant worldwide health problem, with inappropriate antibiotic prescription being a major contributing factor. Prudent antibiotic use is essential for enhancing health outcomes and reducing AMR. This study assesses antibiotic prescribing practices and their logic in a public community health facility catering to 12,900 urban and rural populations in North India.

METHODS

Cross-sectional research was performed from August 2021 to August 2022, examining 1219 outpatient antibiotic prescriptions. The data encompassed medication kind, dose, duration, adherence to therapeutic criteria, and rationale evaluated by ID specialists and clinical pharmacologists. The evaluation was conducted in accordance with standard procedures, including those from NCDC and PGIMER. Demographics, antibiotic classifications, WHO AWaRe categories, diagnoses, and compliance with the essential drug list (EDL) were evaluated.

RESULTS

The results indicated that 45.9 % of prescriptions were for males and 54 % for females, predominantly involving individuals aged 20-40 years. Amoxicillin + clavulanic acid (27.2 %) was the most often given antibiotic, followed by metronidazole (13.4 %) and azithromycin (10.3 %). The WHO AWaRe categorization revealed that 49.7 % of antibiotics were categorized as "Access," 27.3 % as "Watch," and none as "Reserve." An examination of rationality indicated that 57 % of urinary tract infection prescriptions were justified, but just 29 % of respiratory tract infection prescriptions were deemed logical. Diarrhea and respiratory tract infections were recognized as primary targets for minimizing superfluous antibiotic consumption.

CONCLUSION

The research underscores the necessity for enhanced antibiotic prescription protocols in outpatient environments. Specialized education for healthcare professionals, improved prescription oversight, and compliance with evidence-based protocols are essential for fostering judicious antibiotic utilization and addressing AMR.

A Four-Gene Signature from Blood to Exclude Bacterial Etiology of Lower Respiratory Tract Infection in Adults

Unnecessary antibiotic use is a major driver of antimicrobial resistance, an urgent public health threat. There is an unmet need for improved diagnostics for identifying bacterial etiology in acute respiratory infection (ARI). Hospitalized adults with ARI underwent comprehensive microbiologic testing and those with definitive viral (n = 280), bacterial (n = 129), or mixed viral-bacterial infection (n = 95) had whole blood RNA sequencing. A hard-thresholded, mostly relaxed, LASSO-constrained logistic regression model was used to select a parsimonious gene set (ITGB4, ITGA7, IFI27, FAM20A) highly capable of discriminating any bacterial from nonbacterial infection (cross validated AUC = 0.90). The 4-gene signature was validated in two independent cohorts (AUC = 0.90-0.94). Thresholding the 4-gene risk score to yield 90% sensitivity to detect bacterial infection resulted in 71% specificity and 91% negative predictive value. This 4-gene signature defining the absence of bacterial ARI may supplement clinical judgement for management of antibiotics in ARI.

Antimicrobial prescribing practices for enteric bacterial infections in an integrated health care system, Wisconsin, 2004-2017

BACKGROUND

Few studies have evaluated antibiotic prescribing practices for bacterial enteric infections. Unnecessary antibiotics can result in adverse events and contribute to the emergence of antimicrobial resistance. We assessed treatment practices among patients with laboratory-confirmed enteric infections in a regional healthcare system in Wisconsin, USA.

METHODS

We used electronic health records to identify patients with laboratory-confirmed nontyphoidal Salmonella, Shigella, Shiga toxin-producing Escherichia coli (STEC), and Campylobacter infections during 2004-2017. Relevant clinical data, including diagnosis codes for chronic conditions and receipt of immunosuppressive medications and antibiotic prescriptions, were extracted. We defined appropriate treatment based on pathogen, patient characteristics, and practice guidelines for the study period.

RESULTS

We identified 2064 patients infected with Campylobacter (1251; 61 %), Salmonella (564; 27 %), STEC (199; 10 %), or Shigella (50; 2 %). Overall, 425 (20 %) patients were immunocompromised, ranging from 17 % with Salmonella to 46 % with STEC. There were 220 (11 %) hospitalizations. Antibiotics were prescribed most frequently for Campylobacter (53 %), followed by Shigella (46 %) and Salmonella (44 %) infections. Among those prescribed antibiotics, prescriptions were appropriate for 71 % of Campylobacter, 100 % of Shigella, and 81 % of Salmonella infections. Antibiotics were prescribed for 24 % of STEC infections, despite recommendations against use. Guideline adherence generally decreased with age, except for Shigella infections, where adherence was highest for adults ≥ 50 years.

CONCLUSIONS

Antibiotic prescribing for laboratory-confirmed enteric infections was usually appropriate but did not follow practice guidelines in a substantial minority of cases, presenting opportunity for improvement. Antibiotic stewardship initiatives should address acute bacterial gastrointestinal infections in addition to other common infections.

A Rapid Host Response Blood Test for Bacterial/Viral Infection Discrimination Using a Portable Molecular Diagnostic Platform

Background

Difficulty discriminating bacterial versus viral etiologies of infection drives unwarranted antibacterial prescriptions and, therefore, antibacterial resistance.

Methods

Utilizing a rapid portable test that measures peripheral blood host gene expression to discriminate bacterial and viral etiologies of infection (the HR-B/V assay on Biomeme's polymerase chain reaction-based Franklin platform), we tested 3 cohorts of subjects with suspected infection: the HR-B/V training cohort, the HR-B/V technical correlation cohort, and a coronavirus disease 2019 cohort.

Results

The Biomeme HR-B/V test showed very good performance at discriminating bacterial and viral infections, with a bacterial model accuracy of 84.5% (95% confidence interval [CI], 80.8%-87.5%), positive percent agreement (PPA) of 88.5% (95% CI, 81.3%-93.2%), negative percent agreement (NPA) of 83.1% (95% CI, 78.7%-86.7%), positive predictive value of 64.1% (95% CI, 56.3%-71.2%), and negative predictive value of 95.5% (95% CI, 92.4%-97.3%). The test showed excellent agreement with a previously developed BioFire HR-B/V test, with 100% (95% CI, 85.7%-100.0%) PPA and 94.9% (95% CI, 86.1%-98.3%) NPA for bacterial infection, and 100% (95% CI, 93.9%-100.0%) PPA and 100% (95% CI, 85.7%-100.0%) NPA for viral infection. Among subjects with acute severe acute respiratory syndrome coronavirus 2 infection of ≤7 days, accuracy was 93.3% (95% CI, 78.7%-98.2%) for 30 outpatients and 75.9% (95% CI, 57.9%-87.8%) for 29 inpatients.

Conclusions

The Biomeme HR-B/V test is a rapid, portable test with high performance at identifying patients unlikely to have bacterial infection, offering a promising antibiotic stewardship strategy that could be deployed as a portable, laboratory-based test.

Reduce, reinforce, and replenish: safeguarding the early-life microbiota to reduce intergenerational health disparities

Socioeconomic (SE) disparity and health inequity are closely intertwined and associated with cross-generational increases in the rates of multiple chronic non-communicable diseases (NCDs) in North America and beyond. Coinciding with this social trend is an observed loss of biodiversity within the community of colonizing microbes that live in and on our bodies. Researchers have rightfully pointed to the microbiota as a key modifiable factor with the potential to ease existing health inequities. Although a number of studies have connected the adult microbiome to socioeconomic determinants and health outcomes, few studies have investigated the role of the infant microbiome in perpetuating these outcomes across generations. It is an essential and important question as the infant microbiota is highly sensitive to external forces, and observed shifts during this critical window often portend long-term outcomes of health and disease. While this is often studied in the context of direct modulators, such as delivery mode, family size, antibiotic exposure, and breastfeeding, many of these factors are tied to underlying socioeconomic and/or cross-generational factors. Exploring cross-generational socioeconomic and health inequities through the lens of the infant microbiome may provide valuable avenues to break these intergenerational cycles. In this review, we will focus on the impact of social inequality in infant microbiome development and discuss the benefits of prioritizing and restoring early-life microbiota maturation for reducing intergenerational health disparities.

Mapping the evidence about the natural history of acute infections commonly seen in primary care and managed with antibiotics: a scoping review

BACKGROUND

Knowing the natural history of acute infections in primary care, defined as the course of a disease over time in the absence of specific therapy or treatment, can inform clinicians' and patients' expectations about illness recovery, but this evidence is fragmented across the literature. This scoping review aimed to map existing research and research gaps relevant to the natural history of acute infections.

METHODS

We searched MEDLINE, Embase and CENTRAL using a 2-phase hierarchical search approach. In Phase A, we focused on identifying systematic reviews synthesising natural history data for eligible infections (acute respiratory, urinary, and skin and soft tissue) and systematic reviews of treatment effectiveness (of RCTs with placebo or no treatment arm, or cohort studies). For infections without existing reviews, in Phase B, we searched for primary studies (placebo-controlled RCTs or cohort studies). Two reviewers independently screened and extracted the data (study characteristics, outcome data - e.g., symptom duration, proportion with resolution at various time points).

RESULTS

We identified 40 systematic reviews, reporting on 45 infections, most commonly (90%) respiratory tract infections. Six (15%) of these aimed to synthesise natural history information. Most reviews reported the proportion of participants with symptom resolution at various time point/s, with 58% providing data on mean symptom duration. Recovery data show the spontaneous resolution of some infections in some people. We found no eligible studies for cellulitis, ecthyma, carbuncle, and erysipelas.

CONCLUSIONS

Our review has shown that natural history evidence exists for many common acute infections. It can be utilised by clinicians in implementing patient-centred antibiotic stewardship strategies in primary care. Future research should focus on generating natural history evidence for skin and soft tissue infections and urinary tract infections.

Antibiotic prescribing practices in community and clinical settings during the COVID-19 pandemic in Nairobi, Kenya

The COVID-19 pandemic has significantly impacted healthcare systems, including antibiotic use practices. We present data on patterns of antibiotic dispensing and use in community and hospital settings respectively in Nairobi, Kenya during the pandemic. We conducted interviews with 243 pharmacies in Nairobi using a standardised questionnaire from November to December 2021. The data collected included demographic characteristics, antibiotic customers, types of antibiotics sold, and antibiotic prescribing practices. Additionally, we retrospectively reviewed health records for 992 and 738 patients admitted in COVID-19 and general wards at two large inpatient hospitals between April 2020 and May 2021, and January 2019 to October 2021, respectively. Demographic, utilisation of laboratory services, treatment, clinical, and outcome data were collected using a modified Global WHO Point Prevalence Surveys (Global-PPS) tool. Almost all pharmacies (91.4%) served customers suspected of having COVID-19 with a mean weekly number of 15.6 customers. All pharmacies dispensed antibiotics, mainly azithromycin and beta lactams to suspected COVID-19 infected customers. 83.4% of hospitalised COVID-19 patients received at least one antibiotic at some point during their hospitalisation, which was significantly higher than the 53.8% in general ward patients (p<0.001). Similarly, the average number of antibiotics administered to COVID-19 patients was higher than that of patients in the general ward (1.74 vs 0.9). Azithromycin and ceftriaxone were the most commonly used antibiotics in COVID-19 patients compared to ceftriaxone and metronidazole in the general wards. Only 2% of antibiotic prescriptions for COVID-19 patients were supported by microbiological investigations, which was consistent with the proportion of 6.8% among the general ward population. Antibiotics were commonly prescribed to customers and patients suspected of having COVID-19 either in community pharmacies or in hospital, without a prescription or laboratory diagnosis. These findings emphasize the crucial role of antibiotic stewardship, particularly in community pharmacies, in the context of COVID-19.

Inappropriate prescription of intravenous antibiotics at a tertiary children's hospital in China

BACKGROUND

Antibiotics are one of the most frequently prescribed medication classes worldwide. Inappropriate prescription of antibiotics has increased the risk of drug-resistant infections and associated mortality. The aim of this study was to examine the patterns of intravenous antibiotics prescribing in emergency and outpatient departments of a tertiary children's hospital in China.

METHODS

Data on intravenous prescriptions dispensed by the emergency and outpatient department from January 1, 2015 to May 31, 2016 were extracted from the information system of the Children's Hospital of Fudan University. Prevalence of intravenous antibiotics use and the suitability of intravenous antibiotic prescription were evaluated on the basis of a completed microbiological examination, antibiotics susceptibility testing, and dose prescribed for patients diagnosed with pneumonia, acute bronchitis, fever, and acute upper respiratory infection (AURI) patients. The prescription rate was expressed as the number of intravenous antibiotic prescriptions per total number of prescriptions.

RESULTS

Overall, 94.2% of pediatric patients and 78.5% of issued intravenous prescriptions were for antibiotics. beta-lactam antibacterial (90.5%) and macrolides (18.5%) were the most commonly used categories of antibiotics, while cefuroxime (28.8%) was the most used antibiotic. Besides, pneumonia (31.3%), acute bronchitis (14.1%), fever (6.5%), and AURI (5.5%) were the most commonly recorded infections. However, in these four diseases, the rate of conducting microbiological examination was 0.3%, 0.2%, 2.1%, and 2.8%, respectively. Approximately, 52.1%, 40.0%, 40.4%, and 30.5% of intravenous antibiotic prescriptions were inappropriately used in pneumonia, acute bronchitis, fever, and AURI, respectively. Doses higher and lower than the recommended were often for each of these four diseases.

CONCLUSIONS

The frequency of intravenous antibiotic prescription was high in pediatric emergency and outpatient departments. Inappropriate use of intravenous antibiotics commonly occurred in pneumonia, acute bronchitis, fever, and AURI. Appropriate interventions and prevention strategies need to be developed to curtail inappropriate prescribing of antibiotics.

Addressing Challenges in Standardizing Helicobacter pylori Treatment Protocols: Importance and Review

Helicobacter pylori, one of the top carcinogens, is associated with most cases of gastric cancer-related deaths worldwide. Over the past two decades, the rising rates of antibiotic resistance in the bacterium have reduced the efficacy of conventional antibiotic-based treatments. This underscores the urgency for continued research and novel treatment approaches. Establishing a worldwide accepted physician guideline for antibiotic prescription is crucial to combat antibiotic resistance and improve H. pylori infection management. Therefore, it is important to address the challenges that complicate the establishment of a universally accepted treatment protocol to prescribe an antibiotic regimen to eradicate H. pylori. The answers to the questions of why conventional standard triple therapy remains a first-line treatment choice despite its low efficacy, and how different factors affect therapy choice, are needed to identify these challenges. Hence, this review addresses concerns related to H. pylori treatment choice, role of antibiotic resistance and patient compliance in treatment outcomes, first-line vs. second-line therapy options, and methods for enhancing existing treatment methods. We also present a chart to aid antibiotic treatment prescription, which may support physician guidelines in this aspect. Eradication of H. pylori and patient adherence is paramount in overcoming antibiotic resistance in the bacterium, and our chart summarizes key considerations and suggests novel approaches to achieve this goal.

Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid

Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.

A Real-World Study on the Clinical Characteristics, Outcomes, and Relationship between Antibiotic Exposure and Clostridioides difficile Infection

Clostridioides difficile is a Gram-positive bacteria that causes nosocomial infections, significantly impacting public health. In the present study, we aimed to describe the clinical characteristics, outcomes, and relationship between antibiotic exposure and Clostridioides difficile infection (CDI) in patients based on reports from two databases. Thus, we conducted a retrospective study of patients diagnosed with CDI from Sibiu County Clinical Emergency Hospital (SCCEH), Romania, followed by a descriptive analysis based on spontaneous reports submitted to the EudraVigilance (EV) database. From 1 January to 31 December 2022, we included 111 hospitalized patients with CDI from SCCEH. Moreover, 249 individual case safety reports (ICSRs) from EVs were analyzed. According to the data collected from SCCEH, CDI was most frequently reported in patients aged 65-85 years (66.7%) and in females (55%). In total, 71.2% of all patients showed positive medical progress. Most cases were reported in the internal medicine (n = 30, 27%), general surgery (n = 26, 23.4%), and infectious disease (n = 22, 19.8%) departments. Patients were most frequently exposed to ceftriaxone (CFT) and meropenem (MER). Also, in the EV database, most CDI-related ADRs were reported for CFT, PIP/TAZ (piperacillin/tazobactam), MER, and CPX (ciprofloxacin). Understanding the association between previous antibiotic exposure and the risk of CDI may help update antibiotic stewardship protocols and reduce the incidence of CDI by lowering exposure to high-risk antibiotics.

The epidemiology of pediatric outpatient acute respiratory tract infections in the US: a multi-facility analysis of multiplex PCR testing from 2018 to 2023

IMPORTANCE

Post-pandemic, it is essential to understand the epidemiology of pediatric acute respiratory tract infections (ARTIs). Our multi-facility study elucidates the outpatient epidemiology of pediatric ARTI using highly multiplexed PCR testing, providing critical insights into the evolving landscape of the etiological agents with a particular focus on the years following the emergence of SARS-CoV-2. Utilizing data from two different multiplex PCR panels, our research provides a comprehensive analysis of respiratory pathogen positivity from 2018 to 2023. Our findings indicate that over half of the annual test results identified at least one pathogen, primarily of viral origin. Intriguingly, despite the surge in testing during the COVID-19 pandemic, pathogen detection rates remain similar to the pre-pandemic era. These data hold significant implications for directing antimicrobial stewardship strategies, curbing unnecessary antibiotic use in pediatric respiratory diseases, and the value of multiplex PCR testing in the outpatient setting among pediatrics.

Host-response transcriptional biomarkers accurately discriminate bacterial and viral infections of global relevance

Diagnostic limitations challenge management of clinically indistinguishable acute infectious illness globally. Gene expression classification models show great promise distinguishing causes of fever. We generated transcriptional data for a 294-participant (USA, Sri Lanka) discovery cohort with adjudicated viral or bacterial infections of diverse etiology or non-infectious disease mimics. We then derived and cross-validated gene expression classifiers including: 1) a single model to distinguish bacterial vs. viral (Global Fever-Bacterial/Viral [GF-B/V]) and 2) a two-model system to discriminate bacterial and viral in the context of noninfection (Global Fever-Bacterial/Viral/Non-infectious [GF-B/V/N]). We then translated to a multiplex RT-PCR assay and independent validation involved 101 participants (USA, Sri Lanka, Australia, Cambodia, Tanzania). The GF-B/V model discriminated bacterial from viral infection in the discovery cohort an area under the receiver operator curve (AUROC) of 0.93. Validation in an independent cohort demonstrated the GF-B/V model had an AUROC of 0.84 (95% CI 0.76-0.90) with overall accuracy of 81.6% (95% CI 72.7-88.5). Performance did not vary with age, demographics, or site. Host transcriptional response diagnostics distinguish bacterial and viral illness across global sites with diverse endemic pathogens.

Knowledge, attitudes and behaviors on antimicrobial resistance among general public across 14 member states in the WHO European region: results from a cross-sectional survey

Background

Antimicrobial resistance (AMR) is a major global public health threat requiring urgent action. Pan-European data on knowledge, attitudes and behaviors among the general public regarding antibiotic use and AMR is limited.

Methods

A multicentric, cross-sectional survey of the general public was conducted in the capital cities of 14 Member States of the WHO European Region. A validated questionnaire from the AMR Eurobarometer survey was used to collect data on antibiotic use and knowledge, access to antibiotics, and understanding of policy responses through face-to-face exit interviews.

Results

Out of 8,221 respondents from 14 Member States, 50% took antibiotics in the past 12 months and the majority (53%) obtained their most recent course from a medical practitioner. The most reported reasons for taking antibiotics orally in the past 12 months were cold (24%), sore throat (21%), cough (18%), and flu (16%). Overall, 84% of participants showed a lack of knowledge about appropriate antibiotic use. However, only 37% of respondents reported receiving any information in the past year about the importance of avoiding unnecessary antibiotic use. Doctors were the most cited (50%) and most trusted (80%) source of information. Among respondents who experienced COVID-19, 28% took antibiotics with a prescription, while 8% took antibiotics without a prescription.

Conclusion

This study highlights the urgent need for targeted awareness campaigns and educational initiatives to address knowledge gaps and promote responsible antibiotic use. The findings emphasize the role of the general population in combating AMR. The data serve as baseline information for future evaluations and interventions in the Region.

Priorities and Progress in Diagnostic Research by the Antibacterial Resistance Leadership Group

The advancement of infectious disease diagnostics, along with studies devoted to infections caused by gram-negative and gram-positive bacteria, is a top scientific priority of the Antibacterial Resistance Leadership Group (ARLG). Diagnostic tests for infectious diseases are rapidly evolving and improving. However, the availability of rapid tests designed to determine antibacterial resistance or susceptibility directly in clinical specimens remains limited, especially for gram-negative organisms. Additionally, the clinical impact of many new tests, including an understanding of how best to use them to inform optimal antibiotic prescribing, remains to be defined. This review summarizes the recent work of the ARLG toward addressing these unmet needs in the diagnostics field and describes future directions for clinical research aimed at curbing the threat of antibiotic-resistant bacterial infections.

Choosing Wisely interventions to reduce antibiotic overuse in the safety net

OBJECTIVES

Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs).

STUDY DESIGN

Interrupted time series.

METHODS

A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics.

RESULTS

Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences.

CONCLUSIONS

These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

Rapid, Point-of-Care Host-Based Gene Expression Diagnostics Using Giant Magnetoresistive Biosensors

Host-based gene expression analysis is a promising tool for a broad range of clinical applications, including rapid infectious disease diagnostics and real-time disease monitoring. However, the complex instrumentation requirements and slow turnaround-times associated with traditional gene expression analysis methods have hampered their widespread adoption at the point-of-care (POC). To overcome these challenges, we have developed an automated and portable platform that utilizes polymerase chain reaction (PCR) and giant magnetoresistive (GMR) biosensors to perform rapid multiplexed, targeted gene expression analysis at the POC. As proof-of-concept, we utilized our platform to amplify and measure the expression of four genes (HERC5, HERC6, IFI27, and IFIH1) that were previously shown to be upregulated in hosts infected with influenza viruses. The compact instrument conducted highly automated PCR amplification and GMR detection to measure the expression of the four genes in multiplex, then utilized Bluetooth communication to relay results to users on a smartphone application. To validate the platform, we tested 20 cDNA samples from symptomatic patients that had been previously diagnosed as either influenza-positive or influenza-negative using a RT-PCR virology panel. A non-parametric Mann-Whitney test revealed that day 0 (day of symptom onset) gene expression was significantly different between the two groups (p < 0.0001, n = 20). Hence, we preliminarily demonstrated that our platform could accurately discriminate between symptomatic influenza and non-influenza populations based on host gene expression in ∼30 min. This study not only establishes the potential clinical utility of our proposed assay and device for influenza diagnostics but it also paves the way for broadscale and decentralized implementation of host-based gene expression diagnostics at the POC.

Global trend of antimicrobial resistance in common bacterial pathogens in response to antibiotic consumption

The emergence of antimicrobial resistance (AMR) is a growing public health threat worldwide and antibiotic consumption is being increasingly recognized as the main selective pressure driving this resistance. However, global trend in antibiotic resistance in response to antibiotic consumption is not fully understood. In this study, we collected national resistance data on specific resistant pathogens considered by the World Health Organization (WHO) as priority and antibiotic consumption data for 61 countries to assess the global trends in antibiotic resistance of those common bacterial pathogens and their association with antibiotic consumption. The low- and middle-income countries (LMICs) represented the largest hotspots of resistance, which presented relatively higher resistance rates in common bacterial pathogens but lower antibiotic consumption rates compared to high-income countries (HICs). Specifically, we developed the Normalized Antibiotic Resistance/Consumption Index (NARCI) and produced global maps of NARCI to roughly assess the appropriateness of antibiotic consumption across countries and to indicate the potentially inappropriate antibiotic consumption in LMICs compared with HICs. Additionally, we linked antibiotic consumption rates and resistance rates of target pathogens, in conjunction with NARCI and the correlation analysis between antibiotic use and resistance, to inform strategies to alleviate the threat of antibiotic resistance worldwide.

Impact of antibiotics on off-target infant gut microbiota and resistance genes in cohort studies

BACKGROUND

Young children are frequently exposed to antibiotics, with the potential for collateral consequences to the gut microbiome. The impact of antibiotic exposures to off-target microbes (i.e., bacteria not targeted by treatment) and antibiotic resistance genes (ARGs) is poorly understood.

METHODS

We used metagenomic sequencing data from paired stool samples collected prior to antibiotic exposure and at 1 year from over 200 infants and a difference-in-differences approach to assess the relationship between subsequent exposures and the abundance or compositional diversity of microbes and ARGs while adjusting for covariates.

RESULTS

By 1 year, the abundance of multiple species and ARGs differed by antibiotic exposure. Compared to infants never exposed to antibiotics, Bacteroides vulgatus relative abundance increased by 1.72% (95% CI: 0.19, 3.24) while Bacteroides fragilis decreased by 1.56% (95% CI: -4.32, 1.21). Bifidobacterium species also exhibited opposing trends. ARGs associated with exposure included class A beta-lactamase gene CfxA6. Among infants attending day care, Escherichia coli and ARG abundance were both positively associated with antibiotic use.

CONCLUSION

Novel findings, including the importance of day care attendance, were identified through considering microbiome data at baseline and post-intervention. Thus, our study design and approach have important implications for future studies evaluating the unintended impacts of antibiotics.

IMPACT

The impact of antibiotic exposure to off-target microbes and antibiotic resistance genes in the gut is poorly defined. We quantified these impacts in two cohort studies using a difference-in-differences approach. Novel to microbiome studies, we used pre/post-antibiotic data to emulate a randomized controlled trial. Compared to infants unexposed to antibiotics between baseline and 1 year, the relative abundance of multiple off-target species and antibiotic resistance genes was altered. Infants who attended day care and were exposed to antibiotics within the first year had a higher abundance of Escherichia coli and antibiotic resistance genes; a novel finding warranting further investigation.

Antibiotic resistant bacteria: A bibliometric review of literature

Antibiotic-resistant bacteria (ARB) are a serious threat to the health of people and the ecological environment. With this problem becoming more and more serious, more countries made research on the ARB, and the research number has been sharply increased particularly over the past decade. Therefore, it is quite necessary to globally retrace relevant researches on the ARB published from 2010 to 2020. This will help researchers to understand the current research situation, research trends and research hotspots in this field. This paper uses bibliometrics to examine publications in the field of ARB from 2010 to 2020 that were retrieved from the Web of Science (WOS). Our study performed a statistical analysis of the countries, institutions, journals, authors, research areas, author keywords, Essential Science Indicators (ESI) highly cited papers, and ESI hotspots papers to provide an overview of the ARB field as well as research trends, research hotspots, and future research directions in the field. The results showed that the number of related studies is increasing year by year; the USA is most published in the field of ARB; China is the most active in this field in the recent years; the Chinese Acad Sci published the most articles; Sci. Total Environ. published the greatest number of articles; CM Manaia has the most contributions; Environmental Sciences and Ecology is the most popular research area; and "antibiotic resistance," "antibiotics," and "antibiotic resistance genes" were the most frequently occurring author keywords. A citation analysis showed that aquatic environment-related antibiotic resistance is a key research area in this field, while antimicrobial nanomaterial-related research is a recent popular topic.

Impact of Respiratory Infection and Chronic Comorbidities on Early Pediatric Antibiotic Dispensing in the United States

BACKGROUND

In the United States, children aged <5 years receive high volumes of antibiotics, which may contribute to antibiotic resistance. It has been unclear what role preventable illnesses and chronic comorbidities play in prompting antibiotic prescriptions.

METHODS

We conducted an observational study with a cohort of 124 759 children aged <5 years born in the United States between 2008 and 2013 with private medical insurance. Study outcomes included the cumulative number of antibiotic courses dispensed per child by age 5 and the proportion of children for whom at least 1 antibiotic course was dispensed by age 5. We identified which chronic medical conditions predicted whether a child would be among the top 20% of antibiotic recipients.

RESULTS

Children received a mean of 6.8 (95% confidence interval [CI]: 6.7-6.9) antibiotic courses by age 5, and 91% (95% CI: 90%-92%) of children had received at least 1 antibiotic course by age 5. Most antibiotic courses (71%; 95% CI: 70%-72%) were associated with respiratory infections. Presence of a pulmonary/respiratory, otologic, and/or immunological comorbidity substantially increase a child's odds of being in the top 20% of antibiotic recipients. Children with at least 1 of these conditions received a mean of 10.5 (95% CI: 10.4-10.6) antibiotic courses by age 5.

CONCLUSIONS

Privately insured children in the United States receive many antibiotics early in life, largely due to respiratory infections. Antibiotic dispensing varies widely among children, with more antibiotics dispensed to children with pulmonary/respiratory, otologic, and/or immunological comorbidities.

Outpatient Antibiotic Resistance Patterns of Escherichia coli Urinary Isolates Differ by Specialty Type

Antibiotic-resistant E. coli infections represent a major cause of morbidity and mortality and pose a challenge to antibiotic stewardship. We analyzed a large outpatient data set of E. coli urinary isolates to determine whether resistance patterns vary between types of outpatient practices. Using deidentified data from a clinical reference laboratory over 5 years and logistic regression, we examined the association of antibiotic resistance with outpatient practice type, controlling for testing year, patient sex, and patient age. The odds of antibiotic resistance were significantly higher in urology/nephrology practices for ampicillin (odds ratio [OR] 1.36; 95% CI, 1.10 to 1.69), ciprofloxacin (OR 2.29; 95% CI, 1.77 to 2.94), trimethoprim-sulfamethoxazole (OR 1.52; 95% CI, 1.18 to 1.94), and gentamicin (OR 1.72; 95% CI, 1.16 to 2.46). Odds of resistance were also higher for ciprofloxacin in oncology practices (OR 1.54; 95% CI, 1.08 to 2.15) and "all other specialties" (OR 1.33; 95% CI, 1.13 to 1.56). In contrast, specimens from obstetrics and gynecology practices had lower odds of having resistance to ampicillin (OR 0.90; 95% CI, 0.82 to 0.99) and trimethoprim-sulfa (OR 0.83; 95% CI, 0.73 to 0.93) but higher odds of having resistance to nitrofurantoin (OR 1.33; 95% CI, 1.03 to 1.70). Other findings included lower odds of having resistance to trimethoprim-sulfa in pediatric practices (OR 0.78; 95% CI, 0.64 to 0.94) and lower odds of having resistance to gentamicin in isolates from internal medicine practices (OR 0.66; 95% CI, 0.51 to 0.84) (all P < 0.05). IMPORTANCE Patterns of antibiotic resistance in E. coli urinary isolates can vary between outpatient specialties. The use of clinical data to create practice and specialty-specific antibiograms in outpatient settings may improve antibiotic stewardship.

Antimicrobial Stewardship at Transitions of Care to Outpatient Settings: Synopsis and Strategies

Inappropriate antibiotic use and associated consequences, including pathogen resistance and Clostridioides difficile infection, continue to serve as significant threats in the United States, with increasing incidence in the community setting. While much attention has been granted towards antimicrobial stewardship in acute care settings, the transition to the outpatient setting represents a significant yet overlooked area to target optimized antimicrobial utilization. In this article, we highlight notable areas for improved practices and present an interventional approach to stewardship tactics with a framework of disease, drug, dose, and duration. In doing so, we review current evidence regarding stewardship strategies at transitional settings, including diagnostic guidance, technological clinical support, and behavioral and educational approaches for both providers and patients.

GEOGRAPHIC VARIATION OF INFECTIOUS COMPLICATIONS FOLLOWING PROSTATE BIOPSY IN THE UNITED STATES: RESULTS FROM A POPULATION-BASED COHORT OF PRIVATELY INSURED PATIENTS

OBJECTIVE

To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database.

MATEREIAL AND METHODS

Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications.

RESULTS

During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 to 0.2 in 2015 (p=0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (p=0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (p<0.05).

CONCLUSIONS

While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

A qualitative approach to examining antimicrobial prescribing in the outpatient dental setting

OBJECTIVE

To understand barriers and facilitators to evidence-based prescribing of antibiotics in the outpatient dental setting.

DESIGN

Semistructured interviews.

SETTING

Outpatient dental setting.

PARTICIPANTS

Dentists from 40 Veterans' Health Administration (VA) facilities across the United States.

METHODS

Dentists were identified based on their prescribing patterns and were recruited to participate in a semistructured interview on perceptions toward prescribing. All interviews were recorded, transcribed, and double-coded for analysis, with high reliability between coders. We identified general trends using the theoretical domains framework and mapped overarching themes onto the behavior change wheel to identify prospective interventions that improve evidence-based prescribing.

RESULTS

In total, 90 dentists participated in our study. The following barriers and facilitators to evidence-based prescribing emerged as impacts on a dentist's decision making on prescribing an antibiotic: access to resources, social influence of peers and other care providers, clinical judgment, beliefs about consequences, local features of the clinic setting, and beliefs about capabilities.

CONCLUSIONS

Findings from this work reveal the need to increase awareness of up-to-date antibiotic prescribing behaviors in dentistry and may inform the best antimicrobial stewardship interventions to support dentists' ongoing professional development and improve evidence-based prescribing.

The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners

Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92-98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65-87%). Faced with intermediate CRP results, GPs preferred 3-5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.

Prospective Validation of a Rapid Host Gene Expression Test to Discriminate Bacterial From Viral Respiratory Infection

Importance

Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship.

Objective

To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI.

Design, Setting, and Participants

This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc.

Interventions

The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection.

Main Outcomes and Measures

Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score <0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score >0.73]) and compared with procalcitonin measurement.

Results

Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P < .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P < .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection.

Conclusions and Relevance

In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.

Epidemiology of Antibiotic Use and Drivers of Cross-Border Procurement in a Mexican American Border Community

Background

The U.S.-Mexico Border is an area of opportunity for improved health care access; however, gaps remain as to how and where U.S. border residents, particularly those who are underinsured, obtain care. Antibiotics are one of the most common reported drivers of cross-border healthcare access and a medication of particular concern since indiscriminate or inappropriate use is associated with antimicrobial resistance. In addition, many studies assessing preferences for Mexican pharmaceuticals and healthcare in U.S. border residents were done prior to 2010 when many prescription medications, including antibiotics, were available over the counter in Mexico.

Methods

Data used in this study were collected during the baseline examination of an ongoing longitudinal cohort study in Starr Country, Texas, one of 14 counties on the Texas-Mexico border. Participants self-reported the name, date of use, and the source country of each antibiotic used in the past 12 months. Logistic regression was used to determine social, cultural, and clinical features associated with cross-border procurement of antibiotics.

Results

Over 10% of the study cohort reported using antibiotics in the past 30 days with over 60% of all rounds used in the past 12 months sourced from Mexico. A lack of health insurance and generation score, a measure of acculturation, were the strongest predictors of cross-border procurement of antibiotics.

Conclusions

Factors previously associated with cross-border acquisition of antibiotics are still present despite changes in 2010 to prescription drug regulations in Mexico. These results may be used to inform future public health initiatives to provide culturally sensitive education about responsible antibiotic stewardship and to address barriers to U.S. healthcare and pharmaceutical access in medically underserved, impoverished U.S.-Mexico border communities.

The Use of Antibiotics in Hospice and Palliative Care Settings

Antibiotics are commonly prescribed medications in the hospice and palliative care setting, as well as in many other healthcare settings. The overuse or negligent use of antibiotics is associated with the harmful consequence of fostering the development of antibiotic-resistant pathogens. Thus, there is an urgent need to critically examine and audit antibiotic use in all aspects of healthcare. In the status quo, there is a lack of consistent standards and guidelines surrounding the use of antibiotics in hospice and palliative care settings, leading to significant variations in how antibiotics are prescribed and administered in end-of-life care. It is apparent that greater thought needs to go into antibiotic decisions for patients receiving hospice or palliative care, especially considering the harmful consequences of the overprescription of antibiotics. The literature suggests that many clinicians prescribe antibiotics inappropriately for patients who would not benefit from their use or prescribe them without adequate documentation. Clinicians should be deliberate about when they prescribe antibiotics and adhere to the appropriate documentation standards and procedures within their institution or community. Future research should seek to generate generalizable knowledge about which patients will benefit most from antibiotic therapy during end-of-life care.

Systematic comparison of published host gene expression signatures for bacterial/viral discrimination

Background

Measuring host gene expression is a promising diagnostic strategy to discriminate bacterial and viral infections. Multiple signatures of varying size, complexity, and target populations have been described. However, there is little information to indicate how the performance of various published signatures compare to one another.

Methods

This systematic comparison of host gene expression signatures evaluated the performance of 28 signatures, validating them in 4589 subjects from 51 publicly available datasets. Thirteen COVID-specific datasets with 1416 subjects were included in a separate analysis. Individual signature performance was evaluated using the area under the receiving operating characteristic curve (AUC) value. Overall signature performance was evaluated using median AUCs and accuracies.

Results

Signature performance varied widely, with median AUCs ranging from 0.55 to 0.96 for bacterial classification and 0.69–0.97 for viral classification. Signature size varied (1–398 genes), with smaller signatures generally performing more poorly (P < 0.04). Viral infection was easier to diagnose than bacterial infection (84% vs. 79% overall accuracy, respectively; P < .001). Host gene expression classifiers performed more poorly in some pediatric populations (3 months–1 year and 2–11 years) compared to the adult population for both bacterial infection (73% and 70% vs. 82%, respectively; P < .001) and viral infection (80% and 79% vs. 88%, respectively; P < .001). We did not observe classification differences based on illness severity as defined by ICU admission for bacterial or viral infections. The median AUC across all signatures for COVID-19 classification was 0.80 compared to 0.83 for viral classification in the same datasets.

Conclusions

In this systematic comparison of 28 host gene expression signatures, we observed differences based on a signature’s size and characteristics of the validation population, including age and infection type. However, populations used for signature discovery did not impact performance, underscoring the redundancy among many of these signatures. Furthermore, differential performance in specific populations may only be observable through this type of large-scale validation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13073-022-01025-x.

Change in use of pediatric oral antibiotics in Japan, pre- and post-implementation of an antimicrobial resistance action plan

BACKGROUND

Most antimicrobials are prescribed to outpatients, making outpatient antibiotic prescription an important target for antibiotic stewardship. A national antimicrobial resistance (AMR) action plan was developed in 2016 by the Japanese government with various antimicrobials steawardship activities for pediatric outpatients. We aimed to evaluate changes in antibiotic use pre- and post-implementation of the AMR action plan.

METHODS

All antimicrobials prescribed to pediatric outpatients in Japan from 2011 to 2018 were retrospectively analyzed using data from a national database. Antimicrobials dispensed for patients aged ≤19 years were reviewed. Antimicrobial use was surveyed by age, year of use, type of antimicrobial prescribed, and prescribing facility. Five cities were selected as pilot areas to investigate the variations, based on the clinical specialties of the prescribing physicians.

RESULTS

Antimicrobial usage varied with age. Specifically, usage decreased post-AMR in patients aged ≤8 years and increased in those aged >15 years. Further, antimicrobial prescriptions tended to decrease after 2016 in primary care clinics and hospitals. In the pilot areas of the study, 35% of all oral antimicrobials were prescribed in otolaryngology departments, and 8% were prescribed in dermatology clinics. Notably, antimicrobial prescriptions from both departments showed an upward trend from 2011 to 2018.

CONCLUSION

The use of antimicrobial agents decreased in children younger than 8 years in pediatric clinics, hospitals, and internal medicine clinics. However, use increased in children older than 15 years and in other specialty clinics. Settings with an increasing use of antimicrobials are potential targets for the next antibiotic stewardship program and should be investigated in detail.

Antimicrobial prescription practices for outpatients with acute respiratory tract infections: A retrospective, multicenter, medical record-based study

Antimicrobial stewardship for outpatients with acute respiratory tract infections (ARTIs) should be urgently promoted in this era of antimicrobial resistance. Previous large-sample studies were based on administrative data and had limited reliability. We aimed to identify current antimicrobial prescription practices for ARTIs by directly basing on medical records. This multicenter retrospective study was performed from January to December in 2018, at five medical institutes in Japan. We targeted outpatients aged ≥18 years whose medical records revealed International Classification of Diseases (ICD-10) codes suggesting ARTIs. We divided the eligible cases into three age groups (18-64 years, 65-74 years, and ≥75 years). We defined broad-spectrum antimicrobials as third-generation cephalosporins, macrolides, fluoroquinolones, and faropenem. Primary and secondary outcomes were defined as the proportion of antimicrobial prescriptions for the common cold and other respiratory tract infections, respectively. Totally, data of 3,940 patients were collected. Of 2,914 patients with the common cold, 369 (12.7%) were prescribed antimicrobials. Overall, compared to patients aged ≥75 years (8.5%), those aged 18-64 years (16.6%) and those aged 65-74 years (12.1%) were frequently prescribed antimicrobials for the common cold (odds ratio [95% confidential interval]; 2.15 [1.64-2.82] and 1.49 [1.06-2.09], respectively). However, when limited to cases with a valid diagnosis of the common cold by incorporating clinical data, no statistical difference was observed among the age groups. Broad-spectrum antimicrobials accounted for 90.2% of the antimicrobials used for the common cold. Of 1,026 patients with other respiratory infections, 1,018 (99.2%) were bronchitis, of which antimicrobials were prescribed in 49.9% of the cases. Broad-spectrum antimicrobials were the main agents prescribed, accounting for nearly 90% of prescriptions in all age groups. Our data suggested a favorable practice of antimicrobial prescription for outpatients with ARTIs in terms of prescribing proportions, or quantitative aspect. However, the prescriptions were biased towards broad-spectrum antimicrobials, highlighting the need for further antimicrobial stewardship in the outpatient setting from a qualitative perspective.

Association between asthma status and prenatal antibiotic prescription fills among women in a Medicaid population

OBJECTIVE

Pregnant women with asthma have increased frequency of respiratory viral infections and exacerbations. Because of these risks, women with asthma may be subject to increased surveillance during pregnancy and may, therefore, be at increased risk of antibiotic receipt. The objective of this study was to assess the relationship between maternal asthma and outpatient prenatal antibiotic prescription fills to inform antibiotic stewardship.

METHODS

We included women who delivered a singleton, term, non-low birthweight, and otherwise healthy infant enrolled in the Tennessee Medicaid Program. Maternal asthma and prenatal antibiotic fills were ascertained from healthcare encounters and outpatient pharmacy claims. We examined the association between maternal asthma and prenatal antibiotic fills using modified Poisson regression.

RESULTS

Our study population included 168354 pregnant women, 4% of whom had asthma. Women with asthma had an increased risk of filling at least one prenatal antibiotic prescription (adjusted risk ratio [aRR] 1.27, 95% confidence interval [CI] 1.25-1.28) and had an increased number of fills during pregnancy (aRR 1.54, 95% CI 1.51-1.57) compared to women without asthma. Among those who filled at least one antibiotic prescription, women with asthma had earlier first prenatal antibiotic prescription fill and increased likelihood of filling at least one course of broad-spectrum antibiotics during pregnancy (versus narrow-spectrum).

CONCLUSIONS

Pregnant women with asthma had more outpatient antibiotic prescription fills than pregnant women without asthma. These findings highlight that pregnant women with asthma disproportionately fill more antibiotic prescriptions during pregnancy, providing data that may inform antibiotic stewardship.

Multi-targeted metallo-ciprofloxacin derivatives rationally designed and developed to overcome antimicrobial resistance

Antimicrobial resistance is a major global threat to human health due to the rise, spread and persistence of multi-drug-resistant bacteria or 'superbugs'. There is an urgent need to develop novel chemotherapeutics to overcome this overarching challenge. The authors derivatized a clinically used fluoroquinolone antibiotic ciprofloxacin (Cip), and complexed it to a copper phenanthrene framework. This resulted in the development of two novel metallo-antibiotics of general formula [Cu(N,N)(CipHA)]NO₃ where N,N represents a phenanthrene ligand and CipHA represents a hydroxamic acid of Cip derivative. Comprehensive studies, including a detailed proteomic study in which Staphylococcus aureus cells were exposed to the complexes, were undertaken to gain an insight into their mode of action. These new complexes possess potent antibacterial activity against S. aureus and methicillin-resistant S. aureus. In addition, they were found to be well tolerated in vivo in Galleria mellonella larvae, which has both functional and structural similarities to the innate immune system of mammals. These findings suggest that proteins involved in virulence, pathogenesis, and the synthesis of nucleotides and DNA repair mechanisms are most affected. In addition, both complexes affected similar cell pathways when compared with clinically used Cip, including cationic antimicrobial peptide resistance. The Cu-DPPZ-CipHA (DPPZ = dipyrido[3,2-a:2',3'-c]phenazine) analogue also induces cell leakage, which leads to an altered proteome indicative of reduced virulence and increased stress.

Association of a Clinician's Antibiotic-Prescribing Rate With Patients' Future Likelihood of Seeking Care and Receipt of Antibiotics

Background

One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients’ prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics for subsequent ARIs.

Methods

Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician’s antibiotic prescribing rate to the patients’ and their spouses’ rates of ARI antibiotic receipt in the subsequent year.

Results

Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2–3.8, P < 0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients’ spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6–7.7, P < 0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits.

Conclusions

Receipt of antibiotics for an ARI increases the likelihood that patients and their spouses will receive antibiotics for future ARIs.

Discriminating Bacterial and Viral Infection Using a Rapid Host Gene Expression Test

OBJECTIVES

Host gene expression signatures discriminate bacterial and viral infection but have not been translated to a clinical test platform. This study enrolled an independent cohort of patients to describe and validate a first-in-class host response bacterial/viral test.

DESIGN

Subjects were recruited from 2006 to 2016. Enrollment blood samples were collected in an RNA preservative and banked for later testing. The reference standard was an expert panel clinical adjudication, which was blinded to gene expression and procalcitonin results.

SETTING

Four U.S. emergency departments.

PATIENTS

Six-hundred twenty-three subjects with acute respiratory illness or suspected sepsis.

INTERVENTIONS

Forty-five-transcript signature measured on the BioFire FilmArray System (BioFire Diagnostics, Salt Lake City, UT) in ~45 minutes.

MEASUREMENTS AND MAIN RESULTS

Host response bacterial/viral test performance characteristics were evaluated in 623 participants (mean age 46 yr; 45% male) with bacterial infection, viral infection, coinfection, or noninfectious illness. Performance of the host response bacterial/viral test was compared with procalcitonin. The test provided independent probabilities of bacterial and viral infection in ~45 minutes. In the 213-subject training cohort, the host response bacterial/viral test had an area under the curve for bacterial infection of 0.90 (95% CI, 0.84-0.94) and 0.92 (95% CI, 0.87-0.95) for viral infection. Independent validation in 209 subjects revealed similar performance with an area under the curve of 0.85 (95% CI, 0.78-0.90) for bacterial infection and 0.91 (95% CI, 0.85-0.94) for viral infection. The test had 80.1% (95% CI, 73.7-85.4%) average weighted accuracy for bacterial infection and 86.8% (95% CI, 81.8-90.8%) for viral infection in this validation cohort. This was significantly better than 68.7% (95% CI, 62.4-75.4%) observed for procalcitonin (p < 0.001). An additional cohort of 201 subjects with indeterminate phenotypes (coinfection or microbiology-negative infections) revealed similar performance.

CONCLUSIONS

The host response bacterial/viral measured using the BioFire System rapidly and accurately discriminated bacterial and viral infection better than procalcitonin, which can help support more appropriate antibiotic use.

Association of antibiotics use in preschool age with atopic and allergic skin diseases in young adulthood: a population-based retrospective cohort study

BACKGROUND

Overuse and misuse of antibiotics is a public health problem in low-income and middle-income countries. Although the association of antibiotics with atopic and allergic diseases has been established, most studies focused on prenatal exposure and the occurrence of disease in infants or young children.

OBJECTIVE

To investigate the association of preschool use of antibiotics with atopic and allergic skin diseases in young adulthood.

DESIGN

Population-based retrospective cohort.

SETTING AND PARTICIPANTS

The first-year college students (n=20 123) from five universities were investigated. The sampled universities are located in Changsha, Wuhan, Xiamen, Urumqi and Hohhot, respectively.

METHODS

We conducted a dermatological field examination and a questionnaire survey inquiring the participants about the frequency of upper respiratory tract infection (URTI) and the preschool antibiotics use (prior to 7 years old). The two-level probit model was used to estimate the associations, and adjusted risk ratio (aRR) and 95% CI were presented as the effect size.

RESULTS

A total of 20 123 participants with complete information was included in the final analysis. The frequent antibiotics use intravenously (aRR 1.36, 95% CI 1.14 to 1.62) and orally (aRR 1.18, 95% CI 1.01 to 1.38) prior to 7 years old was significantly associated with atopic dermatitis in young adulthood. Similar trends could be observed in allergic skin diseases among those who use antibiotics orally and intravenously, with RRs of 1.16 (95% CI 1.01 to 1.34) and 1.33 (95% CI 1.13 to 1.57), respectively.

CONCLUSIONS

Preschool URTI and antibiotics use significantly increases the risk of atopic and allergic skin diseases in young adulthood.

Rigorous antibiotic stewardship in the hospitalized elderly population: saving lives and decreasing cost of inpatient care

Background

There is limited literature evaluating the effect of antibiotic stewardship programmes (ASPs) in hospitalized geriatric patients, who are at higher risk for readmissions, developing Clostridioides difficile infection (CDI) or other adverse outcomes secondary to antibiotic treatments.

Methods

In this cohort study we compare the rates of 30 day hospital readmissions because of reinfection or development of CDI in patients 65 years and older who received ASP interventions between January and June 2017. We also assessed their mortality rates and length of stay. Patients were included if they received antibiotics for pneumonia, urinary tract infection, acute bacterial skin and skin structure infection or complicated intra-abdominal infection. The ASP team reviewed patients on antibiotics daily. ASP interventions included de-escalation of empirical or definitive therapy, change in duration of therapy or discontinuation of therapy. Treatment failure was defined as readmission because of reinfection or a new infection. A control group of patients 65 years and older who received antibiotics between January and June 2015 (pre-ASP) was analysed for comparison.

Results

We demonstrated that the 30 day hospital readmission rate for all infection types decreased during the ASP intervention period from 24.9% to 9.3%, P < 0.001. The rate of 30 day readmissions because of CDI decreased during the intervention period from 2.4% to 0.30%, P = 0.02. Mortality in the cohort that underwent ASP interventions decreased from 9.6% to 5.4%, P = 0.03. Lastly, antibiotic expenditure decreased after implementation of the ASP from $23.3 to $4.3 per adjusted patient day, in just 6 months.

Conclusions

Rigorous de-escalation and curtailing of antibiotic therapies were beneficial and without risk for the hospitalized patients 65 years and over.

Caregivers' Perspectives of Pharmacist Intervention in Children's Antibiotic Prescriptions for Upper Respiratory Tract Infections

Background: Community pharmacists can help fight antimicrobial resistance by intervening in children's antibiotic prescriptions for upper respiratory tract infections (URTIs). However, caregivers' attitudes and perspectives on this are unknown. Objective: To evaluate children's caregivers' acceptability of pharmacists intervening in their antibiotic prescriptions for URTIs with respect to their knowledge of and attitude toward pharmacists and knowledge, beliefs, and behaviors related to antibiotics. Methods: A 69-item survey was created and sent to a panel of caregivers. ANCOVA and path analysis were used to evaluate the relationship between caregiver characteristics and their acceptability of pharmacists intervening in children's antibiotic prescriptions for URTIs. Results: Responses from 246 caregivers who met the inclusion and exclusion criteria were analyzed. Mean caregivers' acceptability of pharmacists intervening in children's antibiotic prescriptions for URTIs was 3.25 out of 5 (±1.01). The ANCOVA model (adjusted R² = .636) showed positive attitude toward pharmacists and being more accepting of health advice from pharmacists since the start of the COVID-19 pandemic were associated with higher caregiver acceptability of pharmacists intervening in children's antibiotic prescriptions. Caregivers with better relationships with their pharmacist also tend to have better attitudes toward pharmacists. Not wanting antibiotics for symptom relief was associated with decreased acceptability scores. Conclusion: Overall caregiver acceptability of pharmacists intervening in antibiotic prescriptions was slightly above neutral. Building a relationship with caregivers could help change their attitude and increase the acceptability of pharmacists intervening in children's antibiotic prescriptions. Caregivers seeking symptomatic relief may be more open to non-antibiotic alternatives.

The infant gut resistome is associated with E. coli and early-life exposures

BACKGROUND

The human gut microbiome harbors a collection of bacterial antimicrobial resistance genes (ARGs) known as the resistome. The factors associated with establishment of the resistome in early life are not well understood. We investigated the early-life exposures and taxonomic signatures associated with resistome development over the first year of life in a large, prospective cohort in the United States. Shotgun metagenomic sequencing was used to profile both microbial composition and ARGs in stool samples collected at 6 weeks and 1 year of age from infants enrolled in the New Hampshire Birth Cohort Study. Negative binomial regression and statistical modeling were used to examine infant factors such as sex, delivery mode, feeding method, gestational age, antibiotic exposure, and infant gut microbiome composition in relation to the diversity and relative abundance of ARGs.

RESULTS

Metagenomic sequencing was performed on paired samples from 195 full term (at least 37 weeks' gestation) and 15 late preterm (33-36 weeks' gestation) infants. 6-week samples compared to 1-year samples had 4.37 times (95% CI: 3.54-5.39) the rate of harboring ARGs. The majority of ARGs that were at a greater relative abundance at 6 weeks (chi-squared p < 0.01) worked through the mechanism of antibiotic efflux. The overall relative abundance of the resistome was strongly correlated with Proteobacteria (Spearman correlation = 78.9%) and specifically Escherichia coli (62.2%) relative abundance in the gut microbiome. Among infant characteristics, delivery mode was most strongly associated with the diversity and relative abundance of ARGs. Infants born via cesarean delivery had a trend towards a higher risk of harboring unique ARGs [relative risk = 1.12 (95% CI: 0.97-1.29)] as well as having an increased risk for overall ARG relative abundance [relative risk = 1.43 (95% CI: 1.12-1.84)] at 1 year compared to infants born vaginally.

CONCLUSIONS

Our findings suggest that the developing infant gut resistome may be alterable by early-life exposures. Establishing the extent to which infant characteristics and early-life exposures impact the resistome can ultimately lead to interventions that decrease the transmission of ARGs and thus the risk of antibiotic resistant infections.

New Approach to the Surveillance of Pediatric Infectious Diseases From Ambulatory Pediatricians in the Digital Era

BACKGROUND

Many ambulatory networks in several countries have established syndromic surveillance systems to detect outbreaks of different illnesses. Here, we describe a new Pediatric and Ambulatory Research in Infectious diseases network that combined automated data extraction from the computers of primary care pediatricians.

METHODS

Pediatricians who used the same software, AxiSanté 5-Infansoft for electronic medical records were specially trained in infectious diseases, encouraged to comply with French treatments' recommendations, use of point-of-care tests and vaccination guidelines. Infectious disease diagnoses in children <16 years old in the records triggered automatic data extraction of complete records. A quality control process and external validation were developed.

RESULTS

From September 2017 to February 2020, 107 pediatricians enrolled 57,806 children (mean age 2.9 ± 2.6 years at diagnosis) with at least one infectious disease diagnosis among those followed by the network. Among the 118,193 diagnoses, the most frequent were acute otitis media (n = 44,924, 38.0%), tonsillopharyngitis (n = 13,334, 11.3%), gastroenteritis (n = 12,367, 10.5%), influenza (n = 11,062, 9.4%), bronchiolitis (n = 10,531, 8.9%), enteroviral infections (n = 8474, 7.2%) and chickenpox (n = 6857, 5.8%). A rapid diagnostic test was performed in 84.7% of cases of tonsillopharyngitis and was positive in 44%. The antibiotic recommendations from French guidelines were strictly followed: amoxicillin was the most prescribed antibiotic and less than 10% of presumed viral infections were treated.

CONCLUSIONS

This "tailor-made" network set up with quality controls and external validation represents a new approach to the surveillance of pediatric infectious diseases in the digital era and could highly optimize pediatric practices.

Antibiotic use and colorectal neoplasia: a systematic review and meta-analysis

Background and aims

Colorectal cancer (CRC) is the third most common cancer for women and men and the second leading cause of cancer death in the USA. There is emerging evidence that the gut microbiome plays a role in CRC development, and antibiotics are one of the most common exposures that can alter the gut microbiome. We performed a systematic review and meta-analysis to characterise the association between antibiotic use and colorectal neoplasia.

Methods

We searched PubMed, EMBASE, and Web of Science for articles that examined the association between antibiotic exposure and colorectal neoplasia (cancer or adenoma) through 15 December 2019. A total of 6031 citations were identified and 6 papers were included in the final analysis. We assessed the association between the level of antibiotic use (defined as number of courses or duration of therapy) and colorectal neoplasia using a random effects model.

Results

Six studies provided 16 estimates of the association between level of antibiotic use and colorectal neoplasia. Individuals with the highest levels of antibiotic exposure had a 10% higher risk of colorectal neoplasia than those with the lowest exposure (effect size: 1.10, 95% CI 1.01 to 1.18). We found evidence of high heterogeneity (I²=79%, p=0.0001) but not of publication bias.

Conclusions

Higher levels of antibiotic exposure is associated with an increased risk of colorectal neoplasia. Given the widespread use of antibiotics in childhood and early adulthood, additional research to further characterise this relationship is needed.

Sustained Reductions in Overall and Unnecessary Antibiotic Prescribing at Primary Care Clinics in a Veterans Affairs Healthcare System Following a Multifaceted Stewardship Intervention

BACKGROUND

Most antibiotic prescribing is in outpatient settings. However, antibiotic stewardship has focused overwhelmingly on hospitalized patients. In a few studies, behavioral interventions decreased unnecessary outpatient prescribing against acute respiratory infections, but data are conflicting on sustained benefits after intervention discontinuation.

METHODS

We conducted a prospective, observational study in 7 primary care clinics, in which an intervention comprised of clinician education, peer comparisons, and computer decision support order sets was directed against all antibiotic prescribing. After 6 months, peer comparisons were discontinued. Antibiotic prescribing was compared in the baseline (January-June 2016), intervention (January-June 2017), and postintervention (January-June 2018) periods.

RESULTS

Mean antibiotic prescriptions significantly decreased from 76.9 (baseline) to 49.5 (intervention) and 56.3 (postintervention) per 1000 visits (35.6% and 26.8% reductions, respectively; P values < .001). The rate of unnecessary antibiotic prescribing (ie, antibiotic not indicated) decreased from 58.8% (baseline) to 37.8% (intervention) and 44.3% (postintervention) (35.7% and 24.7% decreases, respectively; P = .001 and P = .01). Overall, 19.9% (27/136), 36.6% (66/180), and 34.9% (67/192) of antibiotics were prescribed optimally (ie, antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) during the baseline, intervention, and postintervention periods, respectively (baseline vs intervention and postintervention, P = .001 and P = .003, respectively). Differences between intervention and postintervention periods in overall, unnecessary, or optimal antibiotic prescribing were not significant.

CONCLUSIONS

A multifaceted outpatient stewardship intervention achieved reductions in overall, unnecessary, and suboptimal antibiotic prescription rates, which were sustained for a year after components of the intervention were discontinued. There is opportunity for further improvement, as inappropriate and suboptimal prescribing remained common.

Antibiotic Prescription Rates After eVisits Versus Office Visits in Primary Care: Observational Study

Background

Direct-to-consumer telemedicine is an increasingly used modality to access primary care. Previous research on assessment using synchronous virtual visits showed mixed results regarding antibiotic prescription rates, and research on assessment using asynchronous chat-based eVisits is lacking.

Objective

The goal of the research was to investigate if eVisit management of sore throat, other respiratory symptoms, or dysuria leads to higher rates of antibiotic prescription compared with usual management using physical office visits.

Methods

Data from 3847 eVisits and 759 office visits for sore throat, dysuria, or respiratory symptoms were acquired from a large private health care provider in Sweden. Data were analyzed to compare antibiotic prescription rates within 3 days, antibiotic type, and diagnoses made. For a subset of sore throat visits (n=160 eVisits, n=125 office visits), Centor criteria data were manually extracted and validated.

Results

Antibiotic prescription rates were lower following eVisits compared with office visits for sore throat (169/798, 21.2%, vs 124/312, 39.7%; P<.001) and respiratory symptoms (27/1724, 1.6%, vs 50/251, 19.9%; P<.001), while no significant differences were noted comparing eVisits to office visits for dysuria (1016/1325, 76.7%, vs 143/196, 73.0%; P=.25). Guideline-recommended antibiotics were prescribed similarly following sore throat eVisits and office visits (163/169, 96.4%, vs 117/124, 94.4%; P=.39). eVisits for respiratory symptoms and dysuria were more often prescribed guideline-recommended antibiotics (26/27, 96.3%, vs 37/50, 74.0%; P=.02 and 1009/1016, 99.3%, vs 135/143, 94.4%; P<.001, respectively). Odds ratios of antibiotic prescription following office visits compared with eVisits after adjusting for age and differences in set diagnoses were 2.94 (95% CI 1.99-4.33), 11.57 (95% CI 5.50-24.32), 1.01 (95% CI 0.66-1.53), for sore throat, respiratory symptoms, and dysuria, respectively.

Conclusions

The use of asynchronous eVisits for the management of sore throat, dysuria, and respiratory symptoms is not associated with an inherent overprescription of antibiotics compared with office visits.

Trial Registration

ClinicalTrials.gov NCT03474887; https://clinicaltrials.gov/ct2/show/NCT03474887

Respiratory Tract Infection Management and Antibiotic Prescription in Children: A Unique Study Comparing Three Levels of Healthcare in The Netherlands

BACKGROUND

Respiratory tract infections (RTIs) are common in children with febrile illness visiting the general practitioner (GP) or emergency department. We studied the management of children with fever and RTI at 3 different levels of healthcare in The Netherlands, focusing on antibiotic prescription.

METHODS

This prospective observational study is part of the Management and Outcome of Febrile children in Europe study. Data were used from face-to-face patient contacts of children with febrile illness in three healthcare settings in Nijmegen, The Netherlands during 2017. These settings were primary (GP), secondary (general hospital) and tertiary care (university hospital).

RESULTS

Of 892 cases with RTI without complex comorbidities, overall antibiotic prescription rates were 29% with no differences between the 3 levels of healthcare, leading to an absolute number of 5031 prescriptions per 100,000 children per year in primary care compared with 146 in secondary and tertiary care combined. The prescription rate in otitis media was similar in all levels: 60%. In cases with lower RTI who received nebulizations prescription rates varied between 19% and 55%.

CONCLUSIONS

Antibiotic prescription rates for RTIs in children were comparable between the 3 levels of healthcare, thus leading to a majority of antibiotics being prescribed in primary care. Relatively high prescription rates for all foci of RTIs were found, which was not in agreement with the national guidelines. Antibiotic stewardship needs improvement at all 3 levels of healthcare. Guidelines to prescribe small spectrum antibiotics for RTIs need to be better implemented in hospital care settings.

Behavioural interventions to address rational use of antibiotics in outpatient settings of low-income and lower-middle-income countries

Objectives

To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature.

Methods

The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis.

Results

Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists.

Conclusions

Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.

A Novel Approach to Evaluate Antibiotic Utilization Across the Spectrum of Inpatient and Ambulatory Care and Implications for Prioritization of Antibiotic Stewardship Efforts

BACKGROUND

Antibiotic overuse remains a significant problem. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system to prioritize antibiotic stewardship efforts.

METHODS

We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly selected days from 2017 to 2018. For inpatients and perioperative patients, administrations of antibiotics were recorded, whereas prescriptions were recorded for outpatients.

RESULTS

On the study days, 10.9% (95% confidence interval [CI], 10.6%-11.3%) of patients received antibiotics. Of all antibiotics, 54.1% were from ambulatory care (95% CI, 52.6%-55.7%), 38.0% were from the hospital (95% CI, 36.6%-39.5%), and 7.8% (95% CI, 7.1%-8.7%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult non-critical care inpatient wards accounted for 26.4% (95% CI, 25.0%-27.7%), 23.8% (95% CI, 22.6%-25.2%), and 23.9% (95% CI, 22.7%-25.3%) of antibiotic use, respectively. Only 9.2% (95% CI, 8.3%-10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of gram-negative activity accounted for 30.4% (95% CI, 29.0%-31.9%) of antibiotics. Infections of the respiratory tract were the leading indication for antibiotics.

CONCLUSIONS

In an integrated healthcare system, more than half of antibiotic use occurred in the emergency department/urgent care centers and outpatient clinics. Antibiotics with a broad spectrum of gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.

Changes in US Outpatient Antibiotic Prescriptions From 2011-2016

BACKGROUND

While antibiotics are life-saving drugs, their use is not without risk, including adverse events and antibiotic resistance. The majority of US antibiotic prescriptions are prescribed in outpatient settings, making outpatient antibiotic prescribing an important antibiotic stewardship target. The primary objective of this study was to describe trends in US outpatient oral antibiotic prescriptions from 2011-2016.

METHODS

We estimated annual oral antibiotic prescription rates using national prescription dispensing count data from IQVIA Xponent, divided by census estimates for 2011-2016. We calculated the ratio of broad- to narrow-spectrum prescriptions by dividing broad-spectrum prescription rates by narrow-spectrum prescription rates. We used Poisson models to estimate prevalence rate ratios, comparing 2011 and 2016 antibiotic prescription rates, and linear models to evaluate temporal trends throughout the study period.

RESULTS

Oral antibiotic prescription rates decreased 5%, from 877 prescriptions per 1000 persons in 2011 to 836 per 1000 persons in 2016. During this period, rates of prescriptions dispensed to children decreased 13%, while adult rates increased 2%. The ratio of broad- to narrow-spectrum antibiotics decreased from 1.62 in 2011 to 1.49 in 2016, driven by decreases in macrolides and fluoroquinolones. The proportion of prescriptions written by nurse practitioners and physician assistants increased during the study period; in 2016, these providers prescribed over one-quarter of all antibiotic prescriptions.

CONCLUSIONS

Outpatient antibiotic prescription rates, especially of broad-spectrum agents, have decreased in recent years. Clinicians who prescribe to adults, including nurse practitioners and physician assistants, are important targets for antibiotic stewardship.