Antibiotic appropriateness at outpatient settings in Ethiopia: the need for an antibiotic stewardship programme

Background

Antibiotics are drugs of natural or synthetic origin used to treat various infections. The practice of excessive and inappropriate antibiotics use is the main global cause of bacterial resistance, which is one of the most serious global public health threats. It is estimated that about 50% of global antibiotic prescriptions are inappropriate. This study assesses the prevalence and pattern of inappropriate prescriptions of antibiotics amongst ambulatory care visits in Ethiopia.

Methods

A facility-based, cross-sectional study with a quantitative approach was conducted amongst randomly selected prescriptions issued for outpatients from May to June 2022 at Debre Markos Specialized Comprehensive Hospital, Northwest Ethiopia. Descriptive statistics, such as frequencies and percentages, were computed. For group comparisons, χ2 and independent sample t-tests were computed. The statistical significance of the association was considered at p<0.05.

Results

A total of 2640 antibiotics were prescribed for patients in the outpatient setting with various bacterial infections via 911 prescriptions, of which 49.5% were non-compliant with the national treatment guideline. Guideline non-compliant prescriptions increased remarkably amongst patients in the outpatient setting diagnosed with community-acquired pneumonia (38.8% versus 30.1%; p=0.006) and peptic ulcer disease (14.9% versus 9%; p=0.006). Moreover, inappropriate prescription was significantly higher amongst patients taking amoxicillin/clavulanic acid (33.2% versus 48.2%; p<0.001) and cephalexin (17.8% versus 24.3%; p=0.016).

Conclusion

Large proportions of antibiotic prescriptions for outpatients were non-compliant with the national treatment guideline, suggesting that prescribers need to give special attention to outpatients whilst ordering antibiotics such as amoxicillin/clavulanic acid and cephalexin. Antibiotic stewardship efforts to optimize outpatient antibiotic prescriptions and reduce the use of potentially inappropriate antibiotics are needed in Ethiopia.

Antimicrobial Agent Use for Urinary Tract Infection in Long-Term Care Facilities in Spain: Results from a Retrospective Analytical Cohort Analysis

Urinary tract infections (UTIs) are highly prevalent in long-term care facilities, constituting the most common infection in this setting. Our research focuses on analyzing clinical characteristics and antimicrobial prescriptions for UTIs in residents across nursing homes (NH) in Spain. This is a retrospective analytical cohort analysis using a multifaceted approach based on the normalization process theory to improve healthcare quality provided by nursing staff in 34 NHs in Spain. In this study, we present the results of the first audit including 719 UTI cases collected between February and April 2023, with an average age of 85.5 years and 74.5% being women. Cystitis and pyelonephritis presented distinct symptom patterns. Notably, 6% of asymptomatic bacteriuria cases were treated. The prevalence of dipstick usage was 83%, and that of urine culture was only 16%, raising concerns about overreliance, including in the 46 asymptomatic cases, leading to potential overdiagnosis and antibiotic overtreatment. Improved diagnostic criteria and personalized strategies are crucial for UTI management in NHs, emphasizing the need for personalized guidelines on the management of UTIs to mitigate indiscriminate antibiotic use in asymptomatic cases.

Cost-effectiveness and impact on infections and associated antimicrobial resistance of 20-valent pneumococcal conjugate vaccine in US children previously immunized with PCV13

AIM

The US Food and Drug Administration approved the 20-valent pneumococcal conjugate vaccine (PCV20) to prevent pneumococcal disease. In the context of routine PCV20 vaccination, we evaluated the cost-effectiveness and public health and economic impact of a PCV20 catch-up program and estimated the number of antibiotic prescriptions and antibiotic-resistant infections averted.

MATERIALS AND METHODS

A population-based, multi-cohort, decision-analytic Markov model was developed using parameters consistent with previous PCV20 cost-effectiveness analyses. In the intervention arm, children aged 14-59 months who previously completed PCV13 vaccination received a supplemental dose of PCV20. In the comparator arm, no catch-up PCV20 dose was given. The direct and indirect benefits of vaccination were captured over a 10-year time horizon.

RESULTS

A PCV20 catch-up program would prevent 5,469 invasive pneumococcal disease cases, 50,286 hospitalized pneumonia cases, 218,240 outpatient pneumonia cases, 582,302 otitis media cases, and 1,800 deaths, representing a net gain of 30,014 life years and 55,583 quality-adjusted life years. Furthermore, 720,938 antibiotic prescriptions and 256,889 antibiotic-resistant infections would be averted. A catch-up program would result in cost savings of $800 million. These results were robust to sensitivity and scenario analyses.

CONCLUSIONS

A PCV20 catch-up program could prevent pneumococcal infections, antibiotic prescriptions, and antimicrobial-resistant infections and would be cost-saving in the US.

Drug Utilization Research and Predictors of Outcomes in the Intensive Care Unit of a Tertiary Care Hospital: A Prospective Observational Study

BACKGROUND

Multiple drugs are commonly prescribed to intensive care unit (ICU) patients owing to the disease profile, multiple organ dysfunction, prophylaxis, management of stress ulcers, nosocomial infections, etc. This study aimed to evaluate the drug utilization patterns and factors influencing mortality and duration of stay in ICU patients.  Methodology: A prospective observational study was conducted in the ICU of our tertiary care hospital, Postgraduate Institute of Medical Sciences, Rohtak. Data was collected from treatment charts of patients using a structured pretested proforma. World Health Organization Anatomical Therapeutic Chemical/Defined Daily Dose (WHO ATC/DDD) methodology and core prescribing indicators were used to assess drug utilization data. The effect of different variables on mortality and duration of stay in the ICU was evaluated using regression analysis.

RESULTS

An average of 8.78 drugs were prescribed per patient. Among the 922 prescriptions, anti-infectives, anti-inflammatory drugs, and drugs acting on the gastrointestinal tract were the most frequent medication classes prescribed. Polypharmacy and trade name prescribing were common. For most of the drugs, the prescribed daily dose corresponded to the WHO-DDD except ceftriaxone and levofloxacin. Age, presence of cardiac disorders, and Glasgow Coma Scale (GCS) score at admission directly correlated with mortality while the use of diuretics had a negative correlation with the duration of ICU stay.  Conclusions: There is a need to rationalize drug therapy in the ICU with regard to limiting polypharmacy and emphasizing generic drug name prescribing and adherence to the essential drug list. Antibiotic prescription patterns, in particular, deserve a special focus keeping in mind the multitude of factors demanding aggressive antibiotic use in critically ill intensive care patients.

Synthesis and Meta-analysis of 3 Randomized Trials Conducted in Burkina Faso, Ghana, and Uganda Comparing the Effects of Point-of-Care Tests and Diagnostic Algorithms Versus Routine Care on Antibiotic Prescriptions and Clinical Outcomes in Ambulatory Patients <18 Years of Age With Acute Febrile Illness

This meta-analysis included 3 randomized trials conducted in sub-Saharan Africa comparing the effects of point-of-care tests and diagnostic algorithms versus routine care on antibiotic prescriptions and clinical outcomes in ambulatory patients presenting at outpatient facilities with acute uncomplicated febrile illness.

A simple clinical decision rule may help to rule out severe bacterial infection and spare antibiotics in febrile young children

AIM

To assess the performance of a new clinical decision rule (CDR) to identify patients at a low risk of invasive bacterial infection (IBI) among febrile children and its theoretical impact on antibiotic use.

METHODS

Prospective study including consecutive children <5 years of age who presented in one French paediatric emergency department with fever without source between January and December 2016. With the collected data, we constructed a CDR based on a sequential approach based on age, clinical toxic signs, urinalysis and procalcitonin level. We evaluated its diagnostic performances to identify IBI and its potential impact on antibiotic use.

RESULTS

Among the 1061 children (IBI 11/1061, 1.0%), 693 (65.3%) were classified at low or intermediate risk of IBI, with an IBI prevalence of 0%. The sensitivity and specificity of the CDR to predict IBI were 100% and 73.9%. Negative and positive predictive value were 100% and 3.9%, respectively. Using this new CDR, the current antibiotics exposure would theoretically be reduced from 33.6% to 24.1%.

CONCLUSION

The promising interest of this clinical decision rule, using simple and accessible biological and clinical tools, needs to be confirm with an external validation study, which will allow its use in clinical practice.

Impact of selective reporting of antibiotic susceptibility testing results for urinary tract infections in the outpatient setting: A prospective controlled before-after intervention study

OBJECTIVES

The use of selective reporting of antibiotic susceptibility testing (AST) results is a recommended antimicrobial stewardship strategy to improve the appropriateness of antibiotic prescriptions. We conducted a large, pragmatic, prospective, multicentre, controlled (selective reporting versus complete reporting) before-after intervention study to assess the impact of selective reporting of AST results for Escherichia coli-positive urine cultures on the prescription of broad-spectrum antibiotics carrying a higher risk of selection of resistance (i.e., amoxicillin-clavulanate, third-generation cephalosporins, and quinolones) in the outpatient setting. We also looked for possible unintended clinical consequences of the intervention leading to consultations and/or hospitalisations.

METHODS

We compared two groups of laboratories located in a French region. We collected data from the health insurance databases before (2017) and after the implementation of the intervention (2019). The primary outcome was the prescription proportions of broad-spectrum antibiotics.

RESULTS

We included 42,956 Escherichia coli-positive urine cultures with AST. The decrease of the proportion of broad-spectrum antibiotic prescriptions between 2017 and 2019 was significantly higher for selective reporting of AST, attributable to a decrease in the prescription proportion of third-generation cephalosporins (- 8.5% for selective reporting versus - 0.1% for complete reporting, p < 0.001). This impact was more marked for targeted therapy and female patients. Requests from clinicians for the complete reporting of AST results were infrequent (1.2% of all the selective AST results reported in 2019). No unintended consequences were observed.

CONCLUSION

The results showed a positive impact of the selective reporting of AST results, but room for improvement is still important.

REGISTRATION AT CLINICAL TRIALS

NCT03612297.

Antibiotic Prescription Patterns for Acute Respiratory Infections in Rural Primary Healthcare Settings in Guangdong, China: Analysis of 162,742 Outpatient Prescriptions

Overuse and inappropriate use of antibiotics are important contributors to bacterial antimicrobial resistance (AMR), especially in ambulatory primary healthcare (PHC) settings in low- and middle-income countries. This study aimed to investigate antibiotic prescription patterns among patients with acute respiratory infections (ARIs) in rural PHC facilities in the Guangdong Province, China. A total of 444,979 outpatient prescriptions were extracted from the electronic medical record system of 35 township health centers (THCs) and 2 community health centers (CHCs) between November 2017 and October 2018. We used the chi-square test to analyze the antibiotic prescription patterns and binary logistic regression to explore patient-related factors associated with antibiotic prescriptions. Of the 162,742 ARI prescriptions, 85.57% (n = 139,259) included at least one antibiotic. Among the 139,259 prescriptions with antibiotics, 37.82% (n = 52,666) included two or more antibiotics, 55.29% (n = 76,993) included parenteral antibiotics, and 56.62% (n = 78,852) included Watch group antibiotics. The binary logistic regression indicated that (1) female patients were slightly less likely to be prescribed antibiotics than males (adjusted odds ratio (OR) = 0.954, 95% confidence interval [CI] [0.928-0.981]; p = 0.001); and (2) compared to patients aged ≤5 years, those who were 6-15 years old (adjusted OR = 1.907, 95% CI [1.840-1.978]; p < 0.001), 16-60 years old (adjusted OR = 1.849, 95% CI [1.785-1.916]; p < 0.001), and >60 years old (adjusted OR = 1.915, 95% CI [1.810-2.026]; p < 0.001) were more likely to be prescribed antibiotics. The overuse and irrational use of antibiotics in PHC settings remain major healthcare challenges in rural Guangdong. Thus, it is imperative to implement targeted antimicrobial stewardship (AMS) policies to address this problem.

Effect of unifaceted and multifaceted interventions on antibiotic prescription control for respiratory diseases: A systematic review of randomized controlled trials

BACKGROUND

The global health system is improperly using antibiotics, particularly in the treatment of respiratory diseases. We aimed to examine the effectiveness of implementing a unifaceted and multifaceted intervention for unreasonable antibiotic prescriptions.

METHODS

Relevant literature published in the databases of Pubmed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and Wanfang was searched. Data were independently filtered and extracted by 2 reviewers based on a pre-designed inclusion and exclusion criteria. The Cochrane collaborative bias risk tool was used to evaluate the quality of the included randomized controlled trials studies.

RESULTS

A total of 1390 studies were obtained of which 23 studies the outcome variables were antibiotic prescription rates with the number of prescriptions and intervention details were included in the systematic review. Twenty-two of the studies involved educational interventions for doctors, including: online training using email, web pages and webinar, antibiotic guidelines for information dissemination measures by email, postal or telephone reminder, training doctors in communication skills, short-term interactive educational seminars, and short-term field training sessions. Seventeen studies of interventions for health care workers also included: regular or irregular assessment/audit of antibiotic prescriptions, prescription recommendations from experts and peers delivered at a meeting or online, publicly reporting on doctors' antibiotic usage to patients, hospital administrators, and health authorities, monitoring/feedback prescribing behavior to general practices by email or poster, and studies involving patients and their families (n = 8). Twenty-one randomized controlled trials were rated as having a low risk of bias while 2 randomized controlled trials were rated as having a high risk of bias. Six studies contained negative results.

CONCLUSION

The combination of education, prescription audit, prescription recommendations from experts, public reporting, prescription feedback and patient or family member multifaceted interventions can effectively reduce antibiotic prescription rates in health care institutions. Moreover, adding multifaceted interventions to educational interventions can control antibiotic prescription rates and may be a more reasonable method.

REGISTRATIONS

This systematic review was registered in PROSPERO, registration number: CRD42020192560.

An Evaluation of Antibiotic Prescription Rationality at Lower Primary Healthcare Facilities in Three Districts of South-Western Uganda

Purpose

Antimicrobial resistance is now one of the leading five causes of death globally. This study evaluated the rationality of antibiotic prescriptions at lower primary care levels in three districts of Southwestern Uganda.

Methods

This prospective cross-sectional study reviewed 9899 antibiotic prescriptions at 39 health centers following a drug delivery cycle by National Medical Stores in three phases (19 days each on average). Phase 1 started 3 days after delivery, mid-way (Phase 2) and towards the end (Phase 3). The proportion of rationally prescribed antibiotics was determined using a modified criterion by Badar and in reference to Uganda Clinical Guidelines (UCG). Using multivariate logistic regression, the factors associated with rational prescription were determined with 95% confidence intervals.

Results

Seven of every 10 antibiotic prescriptions were irrational. Half the prescriptions were made by unauthorized personnel (nurses) and many of the pediatric prescriptions (916, 46.5%) did not bear body weight measurements to guide appropriate dosing. Also, the proportion of rational prescriptions in reference to UCG, 2016 was very low (3387, 34.2%). However, a high proportion of antibiotic prescriptions were legibly written (9462, 95.7%), prescribed by generic names (9083, 91.8%) and had a diagnosis (9677, 97.8%) indicated. Multivariate logistic analysis showed that; availability of medicines (phase 1) (phase 2 AOR=1.14, 95% CI:1.02-1.28, phase 3, AOR=1.23, 95% CI:1.1-1.38), legibly written prescription (AOR=0.61, 95% CI: 0.47-0.78), indication of a date on the prescription (AOR=0.56, 95% CI0.38-0.81) and being a medical officer were factors associated with rational antibiotic prescription.

Conclusion

We observed a high rate of irrational prescription in the study sites and the majority of these were by unauthorized personnel. A review of antibiotic use policies and focused interventions is crucial in these settings.

Effect of point-of-care influenza tests on antibiotic prescriptions by emergency physicians in a French hospital

BACKGROUND

Influenza is a public health issue worldwide. Although antibiotics should not be used to treat viral infections, they are often prescribed to patients with influenza-like illness (ILI). Such misuse promotes antibiotic resistance. The role of rapid point-of-care tests (POCT) in preventing antibiotic misuse in adults with ILI symptoms remains relatively unexplored.

AIM

To evaluate whether POCT implemented in 2018-2019 to detect influenza viruses lead to a decrease in antibiotic prescriptions compared to laboratory based influenza tests.

METHODS

Adult patients with ILI in one emergency department (ED) were retrospectively enrolled over three epidemic seasons (from 2016-2017 to 2018-2019). The primary outcome was the rate of antibiotic prescriptions, which was compared between the three seasons in bivariate and multivariate analyses. Prescriptions for ancillary laboratory tests, chest X-rays and oseltamivir were also compared, along with hospitalisations and length of stay (LOS) at the ED.

FINDINGS

Overall, 1849 patients were included. Median age was over 70 throughout all three seasons. The number of antibiotic prescriptions was significantly different between the three periods in bivariate analysis (48.3% in 2016/2017, 44% in 2017/2018 and 31.1% in 2018/2019; p<0,0001) and in multivariate analysis (adjusted Odds Ratio [aOR]=0.48, 95%CI=0.30-0.76 for 2018/2019 and aOR=0.99, 95%CI=0.67-1.46 for 2017/2018, compared to 2016/2017). There were significantly fewer prescriptions of ancillary laboratory tests, X-rays, hospitalisations and more oseltamivir prescriptions in 2018/2019, compared to the previous seasons. LOS was significantly lower in 2018/2019 only for influenza-positive patients.

CONCLUSION

ED influenza POCT decreased antibiotic use and lead to less ancillary testing, X-rays and hospitalisations among patients with ILI. However, medico-economic studies are necessary before formulating definite recommendations.

Corrigendum: Can We Optimize Antibiotic Use in Norwegian Neonates? A Prospective Comparison Between a University Hospital and a District Hospital

[This corrects the article DOI: 10.3389/fped.2019.00440.].

Antibiotic Prescribing Patterns in Paediatric Primary Care in Italy: Findings from 2012-2018

Comprehensive data are needed to monitor antibiotic prescribing and inform stewardship. We aimed to evaluate the current antibiotic prescribing patterns, including treatment switching and prolongation, in the paediatric primary care setting in Italy. This database study assessed antibiotic prescriptions retrieved from Pedianet, a paediatric primary care database, from 1 January 2012 to 31 December 2018. Descriptive analyses were stratified by diagnosis class, calendar year, and children's age. Generalized linear Poisson regression was used to assess variation in the prescriptions. In total, 505,927 antibiotic prescriptions were included. From 2012 to 2018, the number of antibiotics per child decreased significantly by 4% yearly from 0.79 in 2012 to 0.62 in 2018. Amoxicillin prescriptions decreased with increasing children's age, while macrolides and third-generation cephalosporins had the opposite trend. Prescriptions were associated with a diagnosis of upper respiratory infection in 23% of cases, followed by pharyngitis (21%), bronchitis and bronchiolitis (12%), and acute otitis media (12%). Eight percent of treatment episodes were prolonged or switched class, mostly represented by co-amoxiclav, macrolides, and third-generation cephalosporins. Our findings report an overall decrease in antibiotic prescriptions, but pre-schoolers are still receiving more than one antibiotic yearly, and broad-spectrum antibiotics prescription rates remain the highest.

Antibiotic prescribing in Danish general practice in the elderly population from 2010 to 2017

OBJECTIVE

This study aimed to describe prescription of antibiotics to the elderly population in general practice in Denmark from 2010-2017.

DESIGN

This is a national register-based observational study.

SETTING

General practice, Denmark.

MAIN OUTCOME MEASURE

The main outcome measure was prescriptions/1,000 inhabitants/day (PrID) in relation to year, age and sex, indication, and antibiotic agent.

SUBJECTS

In this study, we included inhabitants of Denmark, ≥65 years of age between 01st July 2010-30th June 2017.

RESULTS

A total of 5,168,878 prescriptions were included in the study. Antibiotic prescriptions decreased from 2.2 PrID to 1.7 (-26.9%, CI95% [-31.1;-22.4]) PrID during the study. The decrease in PrID was most noticeable among 65-74-year-olds (-25%). The ≥85-year-olds were exposed to twice as many PrID than the 65-74-year-olds, but only accounted for 20% of the total use. Urinary tract infection (UTI) was the most common indication for antibiotic prescription and increased with advancing age. The most commonly prescribed antibiotics were pivmecillinam and phenoxymethylpenicillin. Prescribing with no informative indication was present in one third of all cases.

CONCLUSION

The prescription of antibiotics in the elderly population in general practice decreased from 2010 to 2017. The oldest age group was exposed twice as frequently to antibiotic prescriptions as the 65-74-year-olds. The smallest reduction was observed for the ≥85-year-olds, suggesting targeting interventions at this group.Key PointsHigh antibiotic use among elderly is well known and studies indicate mis- and overuse within this population. Our study shows.The prescription rate is decreasing within all age groups of the elderly population.The ≥85-year-olds receive twice as many prescriptions/1000/day as the 65-74-years-olds.

Physician Perceptions on the Use of Antibiotics and Probiotics in Adults: An International Survey in the Asia-Pacific Area

Background and Aims

The over-prescription of antibiotics is thought to represent a major threat to public health worldwide and is more frequently observed in some low- and middle-income countries. In the Asia-Pacific region, economic development, health care organization and population demographics are very heterogenous. The objective of this survey was to investigate antibiotic use and probiotic co-prescription among adult patients in this area.

Methods

An online survey of physicians from seven countries of the Asia-Pacific region (Australia, Japan, Indonesia, India, China, Singapore and South Korea) was performed in 2018. The questionnaire explored current practices of physicians concerning antibiotics and probiotics and factors related to prescribing decisions.

Results

A total of 387 general practitioners and 350 gastroenterologists completed the questionnaire. Physicians in Australia, Japan and South-Korea were low prescribers of antibiotics (11% to 19% of visits resulted in an antibiotic prescription), while physicians in Indonesia, India, China and Singapore were high prescribers (41% to 61%). A large majority (85%) of physicians agreed that antibiotics disrupted intestinal microbiota. The rates of co-prescription of probiotics varied from 16% in Japan to 39% in Singapore (overall, 27%). Conditions considered by physicians to be prevented by probiotics were mostly antibiotic-associated diarrhea (62%) and Clostridium difficile colitis (43%).

Conclusions

Rates of probiotic co-prescription remain low in many countries although the negative effects of antibiotics on the gut microbiota and the benefits of co-prescribing probiotics are generally known.

Prescribing of long-term antibiotics to adolescents in primary care: a retrospective cohort study

Background

Antibiotic overuse is linked to increased risk of antimicrobial resistance. Long-term antibiotics are commonly used for treating acne and prophylaxis of urinary tract infection. Their contribution to the overall burden of antibiotic use is relatively unknown.

Aim

To describe the volume of commonly prescribed long-term (≥28 days) antibiotic prescriptions in adolescents and young adults, trends over time, and comparisons with acute prescriptions.

Design and setting

A retrospective cohort study using UK electronic primary care records.

Method

Patients born between 1979 and 1996 and with data in the Care and Health Information Analytics database were included. The main outcome measures were antibiotic prescription rates per 1000 person-years and antibiotic prescription days per person-year between the ages of 11 and 21.

Results

In total, 320 722 participants received 710 803 antibiotic prescriptions between the ages of 11 and 21 years from 1998 to 2017. Of these 710 803 prescriptions, 191 443 (26.93%) were for long-term antibiotics (≥28 days and ≤6 months in duration). Long-term antibiotics accounted for more than two-thirds (72.48%) of total antibiotic exposure (days per person-year). Total long-term antibiotic prescribing peaked in 2013 at just under 6 days per person-year and declined to around 4 days in 2017.

Conclusion

Among adolescents and young adults, exposure to long-term antibiotics (primarily lymecycline used for acne) was much greater than for acute antibiotics and is likely to make an important contribution to antimicrobial resistance. Urgent action is needed to reduce unnecessary exposure to long-term antibiotics in this group. Increasing the use of, and adherence to, effective non-antibiotic treatments for acne is key to achieving this.

Reducing Expectations for Antibiotics in Patients With Upper Respiratory Tract Infections: A Primary Care Randomized Controlled Trial

PURPOSE

Many family practitioners prescribe antibiotics for patients with upper respiratory tract infections (URTIs) to meet patients' expectations. We evaluated the impact of providing brief tablet-based information about antibiotic treatment of URTIs on patients' expectations for antibiotics and on family practitioners' antibiotic-prescribing behavior.

METHODS

We performed a 3-arm randomized controlled trial among patients presenting with URTIs at 2 urban family practices in Auckland, New Zealand, during winter 2018. Participants were randomly allocated to view a presentation about the futility of antibiotic treatment of URTIs, the adverse effects associated with antibiotics, or the benefits of healthy diet and exercise (active control), immediately before their consultation. Before and after viewing the presentations, participants used a Likert scale to rate the strength of their belief that antibiotics are effective for treating URTIs and of their desire to be prescribed an antibiotic. Patients reported whether an antibiotic had been prescribed, and pharmacy dispensing records were reviewed to determine whether an antibiotic was dispensed.

RESULTS

Participants who viewed either the futility or the adverse effects presentation had greater reductions in their expectations to receive antibiotics than the control group. The mean reduction (95% CI) was 1.1 (0.8-1.3) for the futility group, 0.7 (0.4-0.9) for the adverse effects group, and 0.1 (0-0.3) for the control group (Cohen d = 0.7; P <.001). There was no significant difference among the 3 groups with regard to antibiotic prescribing (P = .84) or dispensing (P = .43).

CONCLUSIONS

A brief tablet-based waiting room intervention significantly reduced participants' expectations about receiving antibiotics for URTI immediately before their family practitioner consultation. The intervention did not influence family practitioner prescribing behavior, however.

National Trends in Incidence of Purulent Skin and Soft Tissue Infections in Patients Presenting to Ambulatory and Emergency Department Settings, 2000-2015

Nationally representative data from 2000-2015 demonstrated a rise in the incidence of outpatient visits for skin infections, peaking in 2010-2013, followed by a plateau. While cephalexin was the most frequently prescribed antibiotic at the beginning, trimethoprim-sulfamethoxazole was most frequently prescribed by the end of the study period.

Time Trends and Factors Associated with Antibiotic Prescribing in Swiss Primary Care (2008 to 2020)

Antibiotic resistance (ABR) is a major threat to public health, and the majority of antibiotics are prescribed in the outpatient setting, especially in primary care. Monitoring antibiotic consumption is one key measure in containing ABR, but Swiss national surveillance data are limited. We conducted a retrospective cross-sectional study to characterise the patterns of antibiotic prescriptions, assess the time trends, and identify the factors associated with antibiotic prescribing in Swiss primary care. Using electronic medical records data, we analysed 206,599 antibiotic prescriptions from 112,378 patients. Based on 27,829 patient records, respiratory (52.1%), urinary (27.9%), and skin (4.8%) infections were the commonest clinical indications for antibiotic prescribing. The most frequently prescribed antibiotics were broad-spectrum penicillins (BSP) (36.5%), fluoroquinolones (16.4%), and macrolides/lincosamides (13.8%). Based on the WHO AWaRe classification, antibiotics were 57.9% Core-Access and 41.7% Watch, 69% of which were quinolones and macrolides. Between 2008 and 2020, fluoroquinolones and macrolides/lincosamides prescriptions significantly declined by 53% and 51%; BSP prescriptions significantly increased by 54%. Increasing patients' age, volume, and employment level were significantly associated with antibiotic prescribing. Our results may inform future antibiotic stewardship interventions to improve antibiotic prescribing.

Antimicrobial Stewardship in General Practice: A Scoping Review of the Component Parts

There is no published health-system-wide framework to guide antimicrobial stewardship (AMS) in general practice. The aim of this scoping review was to identify the component parts necessary to inform a framework to guide AMS in general practice. Six databases and nine websites were searched. The sixteen papers included were those that reported on AMS in general practice in a country where antibiotics were available by prescription from a registered provider. Six multidimensional components were identified: 1. Governance, including a national action plan with accountability, prescriber accreditation, and practice level policies. 2. Education of general practitioners (GPs) and the public about AMS and antimicrobial resistance (AMR). 3. Consultation support, including decision support with patient information resources and prescribing guidelines. 4. Pharmacist and nurse involvement. 5. Monitoring of antibiotic prescribing and AMR with feedback to GPs. 6. Research into gaps in AMS and AMR evidence with translation into practice. This framework for AMS in general practice identifies health-system-wide components to support GPs to improve the quality of antibiotic prescribing. It may assist in the development and evaluation of AMS interventions in general practice. It also provides a guide to components for inclusion in reports on AMS interventions.

Antibiotic prescriptions in pediatric dentistry: A review

Most commonly prescribed drugs in pediatric dentistry are “Antibiotics.” Among Dentists, there is a trend toward overuse of antibiotics for nonindicated clinical conditions. This insufficient knowledge of the appropriate clinical indications for antibiotic prescriptions promotes the overuse of antibiotics and contributes to the emergence of antibiotic resistance among children. According to the various surveys done on the dental students, dentists and pediatric dentists on the antibiotic prescribing practices, overall, adherence to the professional clinical guidelines was low. There was a wide variation in dosages for all the antibiotics prescribed and for prolonged periods which were inconsistent with the recommendations. This paper reviews the current literature from the year 2000 to 2019. An electronic literature search was conducted in MEDLINE/PubMed, EBSCO host, and Google Scholar databases. The data was also collected manually from comprehensive textbooks. Some recommendations were also based on the opinion of experienced researchers and clinicians. Thus, this review aims at highlighting clinical indications, dosages, and duration of therapeutic antibiotic prescriptions for orofacial infections in the pediatric outpatients and at the same time creating an awareness, regarding the necessity of strictly adhering to the clinical guidelines for antibiotic prescriptions.

Inappropriate antibiotic prescriptions among pediatric inpatients in different type hospitals

To investigate the situation of antibiotic consumption and to assess the inappropriate use on pediatric inpatients of different types hospitals in Sichuan, China.A cross-sectional survey of antibiotic prescriptions among hospitalized children aged 1month -14years were conducted from April 2018 to June 2018 in southwestern China. Antibiotic prescriptions were extracted from electronic records during hospitalization of each inpatient in five different types hospitals.In this study, the antibiotic prescription rate of hospitalized children was 66.9% (1176/1758). Compared with tertiary children hospital (TC) (46.1%), general hospitals and non-tertiary children hospitals has higher rate of antibiotic prescription (almost 85%) (P < .001). 93.4% of inpatients received parenteral antibiotic. Overall, the most common antibiotics were Cefoperazone and enzyme inhibitor, Cefixime and Azithromycin. Lower respiratory tract infection (LRTI) was the leading reason for antibiotic consumption in pediatric wards (56.8%), followed by upper respiratory tract infection (URTI) (22.2%). For children with LRTI, Cephalosporins were heavy prescribed, especially broad-spectrum third-generation Cephalosporins (60.3%). The antibiotic prescription proportion of URTI in general hospitals and non-tertiary children hospitals (more than 18%) was higher than TC (8.1%) (P < .001).There was inappropriate use of antibiotic in hospitalized children including overuse of parenteral administration, overprescribing of antibiotic on URTI and misuse of third-generation Cephalosporins in pediatric inpatients with LRTI. Compared with tertiary freestanding children hospital, the irrational antibiotic prescription of general hospitals and non-tertiary children hospitals were more serious. Management strategy should be implementer on quality improvement of antibiotic use.

Can We Optimize Antibiotic Use in Norwegian Neonates? A Prospective Comparison Between a University Hospital and a District Hospital

Background: Worldwide, a large proportion of neonates are prescribed antibiotics without having infections leading to increased antimicrobial resistance, disturbance of the evolving microbiota, and increasing the risk of various chronical diseases. Comparing practice between different hospitals/settings is important in order to optimize antibiotic stewardship. Aim: To investigate and compare the potential for improved antibiotic stewardship in neonates in two Norwegian hospitals with different academic culture, with emphasis on antibiotic exposure in unconfirmed infections, treatment length/doses, CRP values and the use of broad-spectrum antibiotics (BSA). All types of infections were investigated, but the main focus was on early-onset sepsis (EOS). Methods: We conducted a prospective observational cohort study of antibiotic use in a Norwegian university hospital (UH) and a district hospital (DH), 2017. Unconfirmed infections were defined as culture negative infections that neither fulfilled the criteria for clinical infection (clinical symptoms, maximum CRP >30 mg/L, and treatment for at least 5 days). Results: Ninety-five neonates at the DH and 89 neonates at the UH treated with systemic antibiotics were included in the study. In total, 685 prescriptions (daily doses) of antibiotics were given at the DH and 903 at the UH. Among term and premature infants (≥ 28 weeks), 82% (75% at the UH and 86% at the DH, p = 0.172) of the treatments for suspected EOS were for unconfirmed infections, and average treatment length in unconfirmed infections was 3.1 days (both hospitals). Median dose for aminoglycoside was higher for term infants at the UH (5.96, 95% CI 5.02-6.89) compared to the DH (4.98, 95% CI 4.82-5.14; p < 0.001). At the UH, all prescriptions with aminoglycosides were gentamicin, while tobramycin accounted for 93% of all prescriptions with aminoglycosides at the DH. Conclusion: There is a potential for reduction in both antibiotic exposure and treatment length in these two neonatal units, and a systematic risk/observational algorithm of sepsis should be considered in both hospitals. We revealed no major differences between the UH and DH, but doses and choice of aminoglycosides varied significantly.

Prevalence of inappropriate antibiotic prescriptions after the great east Japan earthquake, 2011

Few studies have investigated the appropriateness of antibiotic use in postdisaster settings. We retrospectively evaluated clinical databases on health care delivered at clinics near shelters set up after the Great East Japan Earthquake, 2011. We defined appropriate, acceptable, and inappropriate antibiotic use for each diagnostic category, by applying and adopting precedent studies and clinical guidelines. From March to July, 2011, a total of 23,704 clinic visits occurred at 98 shelters with 7934 residents. Oral antibiotics were prescribed a total of 2253 times. The median age of the patients was 48.5 years old (range 0-97), and 43.7% were male. Of 2253 antibiotic prescriptions, 1944 were judged to be inappropriate (86.3% 95% CI 84.8%-87.7%). The most prescribed antibiotic was clarithromycin (646 times, 28.7%), followed by cefcapene pivoxil (644 times, 28.6%), levofloxacin (380, 16.9%), cefdinir (194, 8.6%), and cefditren pivoxil (98, 4.4%). The most frequent diagnosis for which antibiotics were prescribed was upper respiratory infection (URI, 1040 visits, 46.2%), followed by acute bronchitis (369, 16.4%), pharyngitis (298, 13.2%), traumatic injuries (194, 8.6%), acute gastroenteritis (136, 6.0%), urinary tract infections (UTIs, 123, 5.5%), and allergic rhinitis (5.1%). The majority of antibiotics prescribed at clinics after the Great East Japan Earthquake was inappropriate. Significant improvement of the use of antibiotics in postdisaster settings should be sought immediately in Japan.

Seasonality of antibiotic prescriptions for outpatients and resistance genes in sewers and wastewater treatment plant outflow

To test the hypothesis of a seasonal relationship of antibiotic prescriptions for outpatients and the abundance of antibiotic resistance genes (ARGs) in the wastewater, we investigated the distribution of prescriptions and different ARGs in the Dresden sewer system and wastewater treatment plant during a two-year sampling campaign. Based on quantitative PCR (qPCR), our results show a clear seasonal pattern for relative ARGs abundances. The higher ARGs levels in autumn and winter coincide with the higher rates of overall antibiotic prescriptions. While no significant differences of relative abundances were observed before and after the wastewater treatment for most of the relative ARGs, the treatment clearly influenced the microbial community composition and abundance. This indicates that the ARGs are probably not part of the dominant bacterial taxa, which are mainly influenced by the wastewater treatment processes, or that plasmid carrying bacteria remain constant, while plasmid free bacteria decrease. An exception was vancomycin (vanA), showing higher relative abundance in treated wastewater. It is likely that a positive selection or community changes during wastewater treatment lead to an enrichment of vanA. Our results demonstrate that in a medium-term study the combination of qPCR and next generation sequencing corroborated by drug-related health data is a suitable approach to characterize seasonal changes of ARGs in wastewater and treated wastewater.

Assessment of the Appropriateness of Antibiotic Prescriptions in Lesotho Public Hospitals: A Novel Methodology Based on Principles of Antibiotic Prescribing

The study primarily aimed at assessing the appropriateness of antibiotic prescriptions in a section of public health institutions in Lesotho using an assessment tool formulated from principles of antibiotic prescribing. Relevant data on procedures of infection diagnosis and prescribed antibiotics were collected from both inpatient and outpatient case reports for a one-month period in five public hospitals in Lesotho. These were analyzed for the appropriateness of the prescribed antibiotics. Prescription appropriateness assessment was based on conformities of prescribed antibiotics to criteria developed from pertinent principles of antibiotic prescribing. Assessed prescriptions, 307 inpatient and 865 outpatient prescriptions in total, were classified into categories of appropriateness based on extents to which they satisfied conditions defined by combinations of criteria in the assessment tool. Antibiotic prescriptions from inpatient and outpatient departments of study site hospitals were categorized into groups of different degrees of appropriateness. A total of 32.2% inpatient prescriptions and 78.4% outpatient prescriptions assessed were appropriately written for the empiric treatment of infections for which bacterial pathogens were considered absolute or possible etiologies. The use of prescription assessment tools based on principles of antibiotic prescribing is a feasible option of assessing the appropriateness of antibiotic prescriptions, particularly in low-income countries where expert panels cannot be formed.