Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

Factors influencing antibiotic prescribing for respiratory tract infections in primary care - a comparison of physicians with different antibiotic prescribing rates

BACKGROUND

There has been a notable decrease in antibiotic prescribing in the last thirty years in Sweden. Little is known about factors influencing antibiotic prescribing over several years.

OBJECTIVE

To compare primary care physicians who, over time, reduced their antibiotic prescribing for respiratory tract infections with those who remained either high or low prescribers regarding potentially influencing factors.

DESIGN AND SETTING

A register-based study including all RTI visits in primary care in Region Kronoberg, Sweden 2006-2014. The data were divided into three 3-year periods.

SUBJECTS

The data comprised all physicians who had diagnosed at least one RTI for each of the three-year periods. The antibiotic prescribing rate adjusted for the patients' sex and age group was calculated for each physician and period, and based on the change between the first and the third period, the physicians were divided into three prescriber groups: The High Prescribing Group, the Decreasing Prescribing Group, and the Low Prescribing Group.

MAIN OUTCOME MEASURES

For the three prescriber groups, we compared factors influencing antibiotic prescribing such as the characteristics of the physicians, their use of point-of-care tests, their choice of diagnoses, and whether the patients returned and received antibiotics.

RESULTS

The High Prescribing Group ordered more point-of-care tests, registered more potential bacterial diagnoses, prescribed antibiotics at lower C-reactive protein levels, and prescribed antibiotics more often despite negative group A Streptococci test than in the Low Prescribing Group. The Decreasing Prescribing Group was between the High Prescribing Group and the Low Prescribing Group regarding these variables. The lower prescription rate in the Low Prescribing Group did not result in more return visits or new antibiotic prescriptions within 30 days.

CONCLUSION

Point-of-care testing and its interpretation differed between the prescriber groups. Focus on interpreting point-of-care test results could be a way forward in antibiotic stewardship.

Understanding patient demand for and use of antibiotics for upper respiratory tract infection: A qualitative application of the Necessity-Concerns Framework in Saudi Arabia

Background

Reducing antimicrobial resistance (AMR) is a priority for public health. Inappropriate patient demand is an important driver of unnecessary antibiotic use. To develop an effective intervention to reduce inappropriate demand for antibiotics in upper respiratory tract infections (URTIs), it is important to identify patient perceptions that influence demand for, and appropriate use of antibiotics.

Aim

To identify and describe the beliefs about antibiotics necessity and concerns that patients with URTIs have, in Riyadh, Saudi Arabia.

Method

An exploratory qualitative approach was used. One-to-one, face-to-face or telephone semi-structured interviews were conducted with participants recruited using purposive sampling (based on age and gender) from primary healthcare centre in Riyadh, Saudi Arabia were conducted. Only adult patients who currently experience URTIs symptoms and agreed to participate were recruited. Recruitment for interviews continued until data saturation point was reached. The interview guide explored patients' necessity beliefs and concerns about antibiotics, AMR perceptions, and expectations from URTIs consultation. Interview transcripts were coded using QSR NVivo 12 using framework analysis informed by the Necessity-Concerns Framework to identify key motivations driving antibiotic requests and consultations.

Results

the study interviewed 32 participants (44% were male, average age was 36.84). Results identified that the patients often relate their personal need for antibiotics when encountering an URTIs symptoms to the type, severity and duration of symptoms. Patients also linked antibiotics with quicker recovery, generally expressing few concerns about antibiotics mainly because of its short duration of use. However, some conveyed their concern about frequent administration of antibiotics and effect on the body's immune system function, which may make them more prone to infections in the future. Participants varied widely in their awareness of AMR; this was associated with many misconceptions, such as confusing AMR with antibiotics efficacy and tolerance. Interestingly, the interplay between necessity beliefs and concerns was observed to influence the decision to start and stop antibiotic, potentially impacting inappropriate antibiotic demand and unnecessary use.

Conclusion

This study highlighted important beliefs and misconceptions about antibiotics and AMR in Saudi population which can be targeted in future interventions to reduce inappropriate demand for antibiotics and optimise appropriate usage.

Randomised multicentre effectiveness trial of rapid syndromic testing by panel assay in children presenting to European emergency departments with acute respiratory infections-trial protocol for the ADEQUATE Paediatric trial

INTRODUCTION

Syndromic panel assays, that is, using one test to simultaneously target multiple pathogens with overlapping signs and symptoms, have been integrated into routine paediatric care over the past decade, mainly for more severely ill and hospitalised patients. Their wider availability and short turnaround times open the possibility to apply them to non-hospitalised patients as well. In this context, it is important to trial how clinicians make use of pathogen detection data and if their early availability influences management decisions, particularly antibiotic use and hospitalisation.

METHODS AND ANALYSIS

Advanced Diagnostics for Enhanced QUality of Antibiotic prescription in respiratory Tract infections in Emergency rooms is an individually randomised, controlled, open-label effectiveness trial comparing the impact of a respiratory pathogen panel assay (BIOFIRE Respiratory Panel 2.1plus) used as a rapid syndromic test on nasopharyngeal swabs in addition to the standard of care versus standard of care alone. The trial will 1:1 randomise 520 participants under the age of 18 at 7 paediatric emergency departments in 5 European countries. Inclusion criteria for the trial consist of two sets, with the first describing respiratory tract infections in paediatric patients and the second describing the situation of potential management uncertainty in which test results may immediately affect management decisions. Enrolment started in July 2021 and is expected to be completed in early 2024. We will perform a two-sample t-test assuming a pooled variance estimate to compare the log-transformed mean time on antibiotic treatment (in hours) and number of days alive out of the hospital within 14 days after study enrolment between the control and intervention arms.

ETHICS AND DISSEMINATION

The trial protocol and materials were approved by research ethics committees in all participating countries. The respiratory pathogen panel assay is CE marked (assessed to meet European regulations) and FDA (United States Food and Drug Administration) cleared for diagnostic use. Participants and caregivers provide informed consent prior to study procedures commencing. The trial results will be published in peer-reviewed journals and at national and international conferences. Key messages will also be disseminated via press and social media where appropriate.

TRIAL REGISTRATION NUMBER

NCT04781530.

Differences in antibiotic use between COPD and non-COPD residents based on the health information system

OBJECTIVES

To compare the differences in antibiotic use between COPD and non-COPD residents, and to explore the effect of COPD on antibiotic use.

METHODS

Participants aged 40 years old or over from the Songjiang Adult Cohort were included. Information on prescription and baseline survey was collected based on the health information system. A logit-negative binomial Hurdle model was used to explore correlations between COPD and percentage of antibiotic use and average rate of antibiotic prescribing of different types of antibiotic. Multinomial logistic regression was used to assess the association between COPD and antimicrobial combination therapy and routes of administration.

RESULTS

A total of 34576 individuals were included and 1594 (4.6%) were COPD patients. During the 6 years' follow-up, the percentage of antibiotic use for COPD patients was 98.4%, which was 7.88 (95%CI: 5.24-11.85) times of that for non-COPD patients after adjusting for potential confounders. The prescribing rate was 3220 prescriptions (95%CI: 3063.6-3385.2) per 1000 person-years for COPD patients, which was 1.96 (95%CI: 1.87-2.06) times of that for non-COPD patients. Other beta-lactam antibacterials, Macrolides, lincosamides and streptogramins, and quinolone antibacterials were the most commonly used types of antibiotic. Except for aminoglycoside antibacterials, both percentage of antibiotic use and rate of antibiotic prescription were increased in COPD patients. COPD patients were more likely to be prescribed a maximum of two antibiotics (OR=1.34, 95%CI: 1.20-1.50); and were more likely to use antibiotics intravenously (OR=2.77, 95%CI: 2.47-3.11).

CONCLUSION

COPD patients were more likely to have increased antibiotic use in a large-scale population-based adult cohort, suggesting COPD patients are a high-priority group for the management of antibiotic use in communities.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2022

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.

Exploring factors for antibiotic over-prescription in children with acute upper respiratory tract infections in Assiut, Egypt: a qualitative study

BACKGROUND

Over-prescription of antibiotics contributes to antibiotic resistance, which is a global health threat. Egypt has alarmingly high rates of antibiotic over-prescription for acute upper respiratory tract infections (URIs) in children. To effectively address this issue, it is important to understand the various factors that influence prescription behaviors. The Teixeira antibiotic prescription behavioral model (TAPBM) offers a comprehensive framework through which these factors can be explored. This qualitative study sought to investigate the perspectives of key stakeholders involved in pediatric healthcare in Egypt, with the primary goal of identifying the underlying determinants that contributed to this problem.

METHODS

This qualitative study was conducted in Assiut City, Egypt, between January and March 2023. Purposive sampling was used to select participants, including consultant pediatricians, supervisors of pediatric training programs, and specialists in infection prevention and control. Thirteen semi-structured in-depth interviews (IDIs) were conducted, audio-recorded, and transcribed. Thematic analysis was performed using MAXQDA 2020 software.

RESULTS

Two main themes emerged from the analysis: intrinsic factors related to physicians, extrinsic factors related to patients, and nonphysician factors. Intrinsic factors encompass personal characteristics and attitudes. Prescribing decisions were influenced by factors such as fear of complications, limited follow-up visits, and competition. Knowledge and education also played a significant role. Moreover, diagnostic uncertainty in distinguishing between bacterial and viral infections posed a challenge. Extrinsic factors included patient and caregiver factors, such as parental expectations and demands for antibiotics, driven by the belief that they produced rapid results. Moreover, patients' demographic factors, including socioeconomic status and living conditions, affected their prescribing behavior. Health system-related factors, such as the type of healthcare institution and the absence of formal national guidelines, were identified as influential factors. Additionally, this study highlighted the influence of the pharmaceutical industry. The potential impact of the COVID-19 pandemic on antibiotic prescriptions was addressed.

CONCLUSIONS

The study highlights the intricate interplay between intrinsic and extrinsic factors that shape antibiotic prescription decisions, underscoring the significance of addressing these factors in mitigating overprescribing.

Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries

OBJECTIVE

To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries.

METHODS

A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania.

RESULTS

Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%.

CONCLUSION

Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.

A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications

Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.

Ten Issues for Updating in Community-Acquired Pneumonia: An Expert Review

Community-acquired pneumonia represents the third-highest cause of mortality in industrialized countries and the first due to infection. Although guidelines for the approach to this infection model are widely implemented in international health schemes, information continually emerges that generates controversy or requires updating its management. This paper reviews the most important issues in the approach to this process, such as an aetiologic update using new molecular platforms or imaging techniques, including the diagnostic stewardship in different clinical settings. It also reviews both the Intensive Care Unit admission criteria and those of clinical stability to discharge. An update in antibiotic, in oxygen, or steroidal therapy is presented. It also analyzes the management out-of-hospital in CAP requiring hospitalization, the main factors for readmission, and an approach to therapeutic failure or rescue. Finally, the main strategies for prevention and vaccination in both immunocompetent and immunocompromised hosts are reviewed.

A Narrative Review of Antibiotic Prescribing Practices in Primary Care Settings in South Africa and Potential Ways Forward to Reduce Antimicrobial Resistance

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.

Antibiotic preferences and treatment durations in community-acquired infections

OBJECTIVE

Since Infectious diseases and Clinical Microbiology specialists (IDS) are guiding both the community and other health professionals, it is important to use antibiotics in accordance with the guidelines. In this study, it was aimed to evaluate the approaches of IDS to the use of antibiotics and treatment times in community-acquired infections.

METHODS

Our study was conducted as a digital survey study applied to IDS between January 2019 and December 2020. Community-acquired pneumonia, cystitis, acute tonsillopharangitis, acute otitis media, acute sinusitis, cellulitis, as well as the antibiotics they prefer and their duration of treatment, were asked by questionnaire method. A descriptive statistical analysis was performed on all the information obtained.

RESULTS

A total of 203 IDS participated in the study. About 34.7% of the participants worked as specialists for 0-5 years, 33.6% between 6 and 15 years, and 31.7% for more than 15 years. Most of the participants had problems adhering to the guidelines recommendations in their choice of antibiotics and in determining the duration of treatment. Non-compliance rates were higher among specialists who served for more than 5 years.

CONCLUSION

By providing radical changes in both specialty training and post-specialty trainings, creating online learning environments, and encouraging trainings, problems can be solved to a significant extent and new information can be accessed more quickly.

Understanding Health Worker and Community Antibiotic Prescription-Adherence Practices for Acute Febrile Illness: A Nested Qualitative Study in the Shai-Osudoku District of Ghana and the Development of a Training-and-Communication Intervention

BACKGROUND

The aim was to explore behavioral factors relating to the prescription and communication of prescription-adherence messages for patients with acute febrile illness, from which to develop a training-and-communication (T&C) intervention to be delivered as part of a clinical trial.

METHODS

The study undertook a content analysis of primary, qualitative data collection using in-depth interviews and focus group discussions, informed by the Capability, Opportunity, Motivation (COM-B) theory of behavior, the Theoretical Domains Framework (TDF), and Behavior Change Wheel (BCW) approach, in health facilities (39 health workers) and communities (66 community members) in the Shai-Osudoku District of Ghana.

RESULTS

Health workers perceive that prescribers' and dispensers' communication with patients is influenced by the following factors: patient's educational level, existing disease conditions, health worker's workload, patient's religion, language barrier between health worker and patient, outcome of laboratory results, and medicine availability. Community members' adherence to prescription was influenced by the availability of money and affordability of medicine (outside of provision by the national health insurance scheme), the severity of the condition, work schedule, and forgetfulness.

CONCLUSIONS

Our study contributes to knowledge on nesting qualitative methods in a clinical trial and reveals factors that affect the antibiotic prescription communication process. Tailored messages for patient-specific needs can shape antibiotic prescription adherence behavior and ultimately contribute to decreasing the incidence of antibiotic resistance.

Potential Saving of Antibiotics for Respiratory Infections in Several European Countries: Insights from Market Research Data

Antibiotics represent an essential pillar in the treatment of respiratory infections (RI). Overuse of antibiotics in avoidable cases and inappropriate application in bacterial infections facilitate treatment resistance, threatening their effectiveness and causing a significant healthcare challenge. We therefore assessed the savings potential for antibiotics in ambulant care of selected RI (bronchitis and cough, pharyngitis, rhinosinusitis) in several European countries based on market research data for the year 2019. Number of antibiotic packages sold in pharmacies varied, with highest values in Serbia and France, and lowest in Sweden and Switzerland. Selected RI contributed nearly half of overall ambulant antibiotic prescriptions, with around one fifth given for bronchitis and cough; the vast majority was estimated to be of viral origin with potentially avoidable antibiotic use. Antibiotic consumption for selected RI in eight European countries (Austria, Belgium, the Czech Republic, France, Germany, Poland, Slovakia, and Switzerland) amounted to nearly 100 million, with an overall savings potential between 66.2 and 83.7 million packages. The highest estimated volume of avoidable antibiotics was in France (44.7 million, 0.80 per capita), and lowest in Switzerland (1.4 million, 0.18 per capita). Due to substantial savings potential, prudent use of antibiotics and adequate application of alternatives should be promoted in daily practice.

Positive Point-of-Care Influenza Test Significantly Decreases the Probability of Antibiotic Treatment during Respiratory Tract Infections in Primary Care

This study aimed to analyse clinical and laboratory findings in primary care patients with respiratory tract infections to distinguish the group more likely to receive antibiotic treatment. The study group consisted of 631 patients (264 males; 367 females) with a median age of 48 years (IQR 36-63 years). Analysed groups included patients treated with antibiotics (n = 269 patients; 43%) and those who recovered without antibiotic treatment (n = 362 patients; 57%). Patients receiving antibiotics were older (median 51 vs. 47 years; p = 0.008) and more commonly developed fever (77% vs. 25%, p < 0.0001) and cough (63% vs. 30%; p = 0.0014). Moreover, they more frequently presented wheezing and crackles upon physical examination (28% vs. 4% and 9% vs. 0.3%; p < 0.0001 and p < 0.0001, respectively). They also had more comorbidities and came to more follow-up visits (median of 4 vs. 3 and 2 vs. 1, p < 0.0001 and p < 0.0001, respectively). Patients receiving symptomatic therapy more often had positive point-of-care tests (POCTS)-20% vs. 7%; p = <0.0001. Multivariate analysis in our cohort found comorbidities complexity (odds ratio-OR 2.62; 95% confidence interval-1.54-4.46), fever (OR 32.59; 95%CI 19.15-55.47), crackles (OR 26.35; 95%CI 2.77-250.81) and the number of visits (OR 4.15; 95%CI 2.39-7.20) as factors increasing the probability of antibiotic treatment. Positive influenza POCTS reduced the risk of antibiotic therapy (OR 0.0015; 95%CI 0.0001-0.0168).

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.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China

Objectives

This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs).

Methods

A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute.

Results

In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001).

Conclusion

Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

Co-design to increase implementation of insomnia guidelines in primary care

BACKGROUND

Sleep disorders, including insomnia, are widespread problems, which have increased during the COVID-19 pandemic. Guidelines for the treatment of insomnia prioritize non-pharmacological interventions. Nevertheless, primary care professionals lack well-developed material for patient education, that could help implement the treatment guidelines in Flanders, Belgium.

OBJECTIVE

This project's purpose is to develop complementary, written educational material, grounded in the principles of evidence-based practice, for primary care.

PATIENT INVOLVEMENT

This co-design project involved patients and health professionals. Special attention was given to including patients with low health literacy, and empowering patients when designing in mixed groups.

METHODS

Based on the framework of Sanders and Stappers (2014), data were collected and analyzed in four phases. Pre-design, needs were explored using think-aloud studies and focus groups. Next, for generative purposes, the design studio method was used. Then, evaluation of the prototype happened with another series of think-aloud studies. Finally, post-design, implementation of the product was evaluated with a short survey.

RESULTS

Twenty-five participants (10 patients and 15 healthcare professionals) contributed to the development of an educational patient leaflet called Sssssst. How do you sleep (at night)? Out of 30 professionals who received the printed leaflet for use in practice, 17 provided feedback after six months. Generally, the leaflet was well received. Visual design aspects stimulated use in practice.

DISCUSSION

Written and visual materials aid primary care professionals to educate patients on sleep and insomnia. This supporting tool also stimulates self-management in patients. Although inspiring and educational for all stakeholders, a co-design approach is no guarantee for the product to "fit all".

Antibiotic prescription for acute upper respiratory tract infections: Understanding patient and physician contributions via patients' migration

Inappropriate antibiotic use is a main driver in microbes' development of antibiotic resistance. This study explored the extent to which patient, provider, and other factors contribute to antibiotic prescriptions for acute upper respiratory tract infection. We exploited exogenous patients' temporary and permanent migration from their residential area to robustly separate patient-related, provider-related, and other factors in terms of their contributions to antibiotic use. We analyzed claims of 914,013 URI patients from the 2002-2019 Korean National Health Insurance Sample Cohort Database. The results showed that both patient- and provider-related factors affect antibiotic use for upper respiratory tract infection treatment, although providers' impact is stronger than that of patients. Further decomposition analysis confirmed that provider-related factors explain about 55% of the total variance in antibiotic use. The demand side contributes to approximately 33-34% of the variance. Providers' local market share and market competitiveness are associated with antibiotic prescription. The findings suggest that regulations to reduce antibiotic consumption in Korea should target both patients and providers with appropriate quantifiable penalties.

Respiratory microorganisms in acute pharyngitis patients: Identification, antibiotic prescription patterns and appropriateness, and antibiotic resistance in private primary care, central Malaysia

Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However, there is limited data on the antibiotic prescription appropriateness and resistance information in the Malaysian private primary care setting, therefore, this study aimed to investigate the prevalence of isolated viruses and bacteria, antibiotic resistance patterns, antibiotic prescription patterns and appropriateness by general practitioners (GPs) and factors affecting antibiotic resistance and antibiotic prescription patterns. To investigate, a cross-sectional study was conducted among 205 patients presenting with AP symptoms at private primary care clinics in central Malaysia from 3rd January 2016 to 30th November 2016. Throat swabs were collected from 205 AP patients for two purposes: (i) the detection of four common respiratory viruses associated with AP via reverse-transcription real-time PCR (qRT-PCR); and (ii) bacterial identification using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Bacterial isolates were then subjected to antibiotic susceptibility screening and McIsaac scoring was calculated post-prescription based on GP selection of criteria. Generalized estimating equations analysis with multiple logistic regression was conducted to identify factors associated with presence of virus and antibiotic prescription. The results showed that 95.1% (195/205) of patients had at least one of the four viruses, with rhinovirus (88.5%) being the most prevalent, followed by adenovirus (74.9%), influenza A virus (4.6%) and enterovirus (2.1%). A total of 862 non-repetitive colonies were isolated from the culture of throat swabs from 205 patients who were positive for bacteria. From a total of 22 genera, Streptococcus constitutes the most prevalent bacteria genus (40.9%), followed by Neisseria (20%), Rothia (13.0%), Staphylococcus (11%) and Klebsiella (4.9%). Only 5 patients carried group A beta-hemolytic streptococci (GABHS). We also report the presence of vancomycin-resistant S. aureus or VRSA (n = 9, 10.1%) among which one isolate is a multidrug-resistant methicillin-resistant S. aureus (MDR-MRSA), while 54.1% (n = 111) were found to carry at least one antibiotic-resistant bacteria species. Application of the McIsaac scoring system indicated that 87.8% (n = 180) of patients should not be prescribed antibiotics as the majority of AP patients in this study had viral pharyngitis. The antibiotic prescription appropriateness by applying post-prescription McIsaac scoring was able to rule out GABHS pharyngitis in this sample with a GABHS culture-positive sensitivity of 40% (n = 2/5) and specificity of 90% (180/200). In conclusion, antibiotic-resistant throat isolates and over-prescription of antibiotics were observed and McIsaac scoring system is effective in guiding GPs to determine occurrences of viral pharyngitis to reduce unnecessary antibiotic prescription.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nasal Microbiome and Its Interaction with the Host in Childhood Asthma

Childhood asthma is a major chronic non-communicable disease in infants and children, often triggered by respiratory tract infections. The nasal cavity is a reservoir for a broad variety of commensal microbes and potential pathogens associated with respiratory illnesses including asthma. A healthy nasal microenvironment has protective effects against respiratory tract infections. The first microbial colonisation in the nasal region is initiated immediately after birth. Subsequently, colonisation by nasal microbiota during infancy plays important roles in rapidly establishing immune homeostasis and the development and maturation of the immune system. Dysbiosis of microbiota residing in the mucosal surfaces, such as the nasopharynx and guts, triggers immune modulation, severe infection, and exacerbation events. Nasal microbiome dysbiosis is related to the onset of symptomatic infections. Dynamic interactions between viral infections and the nasal microbiota in early life affect the later development of respiratory infections. In this review, we summarise the existing findings related to nasal microbiota colonisation, dynamic variations, and host–microbiome interactions in childhood health and respiratory illness with a particular examination of asthma. We also discuss our current understanding of biases produced by environmental factors and technical concerns, the importance of standardised research methods, and microbiome modification for the prevention or treatment of childhood asthma. This review lays the groundwork for paying attention to an essential but less emphasized topic and improves the understanding of the overall composition, dynamic changes, and influence of the nasal microbiome associated with childhood asthma.

"Antibiotics are for everyone, our past and our future generations, right? If antibiotics are dead, we will be in big trouble": Building on community values for public engagement on appropriate use of antibiotics in Singapore

Introduction

Shared decision-making (SDM) and trust building through continuity of care are known to play a pivotal role in improving appropriate antibiotic prescribing and use.

Problem

However, less is known about how to effectively leverage these factors when present-or overcome them when not-to address community needs and improve patient liaison.

Methods

We addressed this question using a convergent parallel mixed-methods design. Focus group discussions (N = 13; August 2018-September 2020), were analyzed alongside a nationally-representative cross-sectional survey (N = 2004; November 2020-January 2021), in Singapore. Descriptive quantitative analyses and multivariable logistic regression were undertaken to examine antibiotic knowledge and factors associated with preference for SDM. Qualitative applied thematic analysis was integrated with these data to further explain the findings.

Findings

Poor knowledge and misbeliefs on appropriate antibiotic use and antimicrobial resistance (AMR) were identified. For example, only 9% of the surveyed population understood that AMR occurs when the bacteria, not the human body, become resistant to antibiotics. Qualitative data corroborated the survey findings and suggested a shared value was placed on public education to avoid the fallout from resistant bacterial strains on current and future generations. This study also identified the opportunity to harness community trust in primary care doctors, who were described as highly valued educators for antibiotic use and AMR. Those who had trust in doctors were 75% more likely to prefer SDM (aOR 1.75, 95% CI 1.10-2.77, P = 0.017), especially adults aged ≥50 years who were receiving continued care with a regular doctor (aOR 1.83, 95% CI 1.18-2.86, P = 0.007). Continuity of care was observed to value-add SDM by building trusting relationships, though it was often absent in younger populations.

Conclusion

This study highlights the long-term value-add of building on cultural capital pertaining to appropriate antibiotic use and AMR, by leveraging on the role of trust in doctors, desire for SDM and anchoring these in continuity of care when possible.

Recommendations

Using focused messaging and exploring alternative channels of communications such as annual check-ins or tele-consultations with a regular doctor, and emphasizing continuity of care across all age groups would help bridge the identified gaps.

Contribution of Symptomatic, Herbal Treatment Options to Antibiotic Stewardship and Microbiotic Health

Epithelial surfaces in humans are home to symbiotic microbes (i.e., microbiota) that influence the defensive function against pathogens, depending on the health of the microbiota. Healthy microbiota contribute to the well-being of their host, in general (e.g., via the gut-brain axis), and their respective anatomical site, in particular (e.g., oral, urogenital, skin, or respiratory microbiota). Despite efforts towards a more responsible use of antibiotics, they are often prescribed for uncomplicated, self-limiting infections and can have a substantial negative impact on the gut microbiota. Treatment alternatives, such as non-steroidal anti-inflammatory drugs, may also influence the microbiota; thus, they can have lasting adverse effects. Herbal drugs offer a generally safe treatment option for uncomplicated infections of the urinary or respiratory tract. Additionally, their microbiota preserving properties allow for a more appropriate therapy of uncomplicated infections, without contributing to an increase in antibiotic resistance or disturbing the gut microbiota. Here, herbal treatments may be a more appropriate therapy, with a generally favorable safety profile.

Prevalence and Predictors of Antibiotic Prescriptions at Primary Healthcare Facilities in the Dodoma Region, Central Tanzania: A Retrospective, Cross-Sectional Study

Background: Accelerated by the misuse or overuse of antibiotics, antibiotic resistance remains a global public health threat. We report the prevalence and predictors of antibiotic prescriptions in primary healthcare facilities in Dodoma, Tanzania. Methods: This retrospective cross-sectional study by medical records review was conducted in the Dodoma region, Central Tanzania. Results: In this study, children < 5 years accounted for over 45% (474/1021) of the patients consulted. The majority, 76.3% (779/1021), of consultations had an antibiotic prescribed; amoxicillin and cotrimoxazole were the most prescribed. Over 98% (766/779) of the antibiotics prescribed were on the National Essential Medicines List, but only 45% (429/779) of the antibiotic prescriptions adhered to the Standard Treatment Guidelines. The prescribing of antibiotics by clinical officers was almost 2.55 times higher than that among medical doctors (Odds Ratio (OR) = 2.546; 95% Confidence Interval (CI): 1.359, 4.769; p = 0.0035). Patients with pneumonia and upper respiratory tract infection were 15.9 (OR = 15.928; 95% CI: 2.151, 17.973; p = 0.0067) and 2 (OR = 2.064; 95% CI: 1.184, 3.600; p = 0.0106) times more likely to be prescribed antibiotics, respectively. Conclusions: We, therefore, report high rates of antibiotic prescriptions, poor adherence to standard treatment guidelines and high levels of antibiotic prescribing practices among prescribers with a diploma in clinical medicine.

Prescribing antibiotics: Factors driving decision-making in general practice. A discrete choice experiment

BACKGROUND

Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics.

AIM

To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics.

METHODS

A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated.

RESULTS

The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers.

CONCLUSION

The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance.

Evaluation of Cough Medication Use Patterns in Ambulatory Care Settings in the United States: 2003-2018

Using 2003−2018 National Ambulatory Medical Care Survey data for office-based visits and 2003−2018 National Hospital Ambulatory Medical Care Survey data for emergency department (ED) visits, we conducted cross-sectional analyses to examine cough medication (CM) use trends in the United States (US) ambulatory care settings. We included adult (≥18 years) patient visits with respiratory-infection-related or non-infection-related cough as reason-for-visit or diagnosis without malignant cancer or benign respiratory tumor diagnoses. Using multivariable logistic regressions, we examined opioid antitussive, benzonatate, dextromethorphan-containing antitussive, and gabapentinoid use trends. From 2003−2005 to 2015−2018, opioid antitussive use decreased in office-based visits (8.8% to 6.4%, Ptrend = 0.03) but remained stable in ED visits (6.3% to 5.9%, Ptrend = 0.99). In both settings, hydrocodone-containing antitussive use declined over 50%. Benzonatate use more than tripled (office-based:1.6% to 4.8%; ED:1.5% to 8.0%; both Ptrend < 0.001). Dextromethorphan-containing antitussive use increased in ED visits (1.8% to 2.6%, Ptrend = 0.003) but stayed unchanged in office-based visits (3.8% to 2.7%; Ptrend = 0.60). Gabapentinoid use doubled in office-based visits (1.1% in 2006−2008 to 2.4% in 2015−2018, Ptrend < 0.001) but was negligible in ED visits. In US office-based and ED ambulatory care settings, hydrocodone-containing antitussive use substantially declined from 2003 to 2018, while benzonatate use more than tripled, and dextromethorphan-containing antitussive and gabapentinoid use remained low (<3%).

Antibiotic dispensing during the COVID-19 pandemic: analysis of Welsh primary care dispensing data

BACKGROUND

The COVID-19 pandemic led to rapid changes in demand and delivery of primary care services that could have led to increases in antibiotic prescribing.

OBJECTIVE

We investigated the impact of the COVID-19 pandemic on oral antibiotic dispensing rates in primary care in Wales using longitudinal analysis of monthly oral antibiotic dispensing data from 1 April 2018 to 30 April 2021.

METHODS

We used All-Wales primary care dispensing data. We examined trends in oral antibiotic dispensing per 1,000 people for Wales and for individual Health Boards. We used interrupted time series analysis to estimate changes in trends pre- and post-April 2020 to assess the impact of the first and subsequent lockdowns.

RESULTS

Between April 2020 and April 2021, antibiotic dispensing in Wales was lower compared with the same period in 2018 and 2019, with an average monthly decrease of 14.00 dispensed items per 1,000 registered patients (95% confidence interval 19.89-8.11). The overall prepandemic monthly antibiotic dispensing rate ranged from 48.5 to 67.4 antibiotic items per 1,000 registered patients. From the onset of the pandemic, it ranged from 40.3 to 49.07 antibiotic items per 1,000 registered patients. This reduction was primarily driven by narrow-spectrum antibiotics. Statistically significant reductions were also observed for antibiotics commonly dispensed for the treatment of respiratory tract infections. Dispensing of antibiotics primarily used for urinary and skin infections remained stable.

CONCLUSIONS

Despite complexities of consulting during the COVID-19 pandemic in primary care we found no evidence of an increase in antibiotic dispensing during this time.

General Practitioners', Pharmacists' and Parents' Views on Antibiotic Use and Resistance in Malta: An Exploratory Qualitative Study

BACKGROUND

Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement.

Systematic review of determinants influencing antibiotic prescribing for uncomplicated acute respiratory tract infections in adult patients at the emergency department

OBJECTIVE

Overuse of antibiotics in the emergency department (ED) for uncomplicated acute respiratory tract infections (uARTIs) is a public health issue that needs to be addressed. We aimed to identify factors associated with antibiotic use for uARTIs in adults presenting at the ED.

DESIGN

We searched Medline, Embase, PsycINFO and the Cochrane Library for articles published from 1 January 2005 to 30 June 2017 using a predetermined search strategy. Titles and abstracts of English articles on antibiotic prescription and inappropriate antibiotic use for adult ARTI at EDs were assessed, followed by full article review, by 2 authors.

SETTING

Emergency departments.

PARTICIPANTS

Adults aged 18 years and older.

RESULTS

Of the 2,591 articles retrieved, 12 articles met the inclusion criteria and 11 studies were conducted in the United States. Patients with normal C-reactive protein levels and positive influenza tests were less likely to receive antibiotic treatment. Nonclinical factors associated with antibiotic use were longer waiting time and perceived patient desire for antibiotics. Patients attended by internal medicine physicians comanaged by house staff or who visited an ED which provided education to healthcare providers on antibiotics use were less likely to receive antibiotics.

CONCLUSIONS

English-language articles that fulfilled the selection criteria outside the United States were limited. Factors associated with antibiotics use are multifaceted. Education of healthcare providers presents an opportunity to improve antibiotic use.

How can behavioural science contribute to qualitative research on antimicrobial stewardship in primary care?

Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change 'tools': behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.

Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China

Objectives

This paper aims to explore the direct associations of antibiotics prescription with clinical diagnosis and bacterial detection. It also analyses the relations of clinical diagnosis with symptoms and bacterial detection, with a hope of revealing indirect links to antibiotic prescription.

Methods

The study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. Observations were conducted to record clinical diagnosis and antibiotic prescription. A semi-structured questionnaire survey was used to collected patients' sociodemographic information and reported symptoms. Sputum and throat swabs were collected for bacterial culture.

Results

Among 1,068 patients presenting in the study settings who received a diagnosis of respiratory tract infection (RTI), 87.8% of prescriptions included an antibiotic and 35.8% included two or more antibiotics. Symptomatic RTI patients to the site clinics were diagnosed mainly as having upper respiratory tract infection (32.0%), bronchitis/tracheitis (23.4%), others (16.6%), pharyngitis (11.1%), common cold (8.0%), pneumonia/bronchopneumonia (4.6%) and tonsillitis (4.3%). These clinical diagnosis were associated with symptoms to a varied degree especially for upper respiratory tract infection and bronchitis/tracheitis. Prescription of any antibiotics was positively associated with diagnosis of bronchitis/tracheitis (OR: 5.00, 95% CI: 2.63–9.51), tonsillitis (OR: 4.63, 95% CI: 1.48–14.46), pneumonia/bronchopneumonia (OR: 4.28, 95% CI: 1.40–13.04), pharyngitis (OR: 3.22, 95% CI: 1.57–6.59) and upper respiratory tract infection (OR: 3.04, 95% CI: 1.75–5.27). Prescription of two or more antibiotics was statistically significant related to diagnosis of bronchitis/ tracheitis (OR: 2.20, 95% CI: 1.44–3.35) or tonsillitis (OR: 2.97, 95% CI: 1.47–6.00). About 30% of the patients were identified with some type of bacteria. Bacteria detection was linked with pharyngitis (OR: 0.50, 95% CI: 0.28–0.88) but not prescription of antibiotics.

Conclusions

Antibiotics prescription were found with a strong relation to diagnosis of RTIs given by the clinician but was not associated with the presence of bacteria in patient samples. Part of the diagnosis may have been given by the clinician to justify their antibiotics prescription. There is clear need to use additional measures (e.g., symptoms) in conjunction with diagnosis to supervise or audit excessive antibiotics use.

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study

BACKGROUND

The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs.

METHODS

A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing.

RESULTS

A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing.

CONCLUSIONS

Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.

Effects of patient education to reduce antibiotic prescribing rates for upper respiratory infections in primary care

BACKGROUND

Antibiotic stewardship programs in primary care are necessary to reduce the estimated 30% of inappropriately written antibiotic prescriptions and reduce the spread of microbial resistance. Most programs focus on educating prescribers, but this intervention focused on educating patients.

OBJECTIVES

To develop and implement an antibiotic stewardship program in a primary care clinic to educate patients with upper respiratory infections (URIs) about antibiotic use and to assess the effectiveness of the program through antibiotic prescribing rates.

METHODS

Using materials from the Centers for Disease Control and Prevention (CDC) Be Antibiotics Aware program, posters on antibiotic use were placed in the exam rooms, graphic interchange formats (GIFs) and memes were displayed on exam room monitors, patient-provider discussions on antibiotic use were held, and written information for symptom management of URIs was provided. Retrospective chart reviews were conducted to assess antibiotic prescribing rates by four prescribers in a primary care clinic for September and October 2020 and compared to the same time period for 2019.

RESULTS

The rate of total antibiotic prescriptions decreased by 12.6% (P = 0.044) and the rate of repeat consultation antibiotic prescriptions decreased by 12.2% (P = 0.007), whereas the rate of antibiotics prescribed at the time of the visit remained unchanged (P = 0.937). All providers had decreased rates of antibiotic prescribing after the intervention.

CONCLUSION

Results of this study indicate that providing education about antibiotics to patients in need of treatment for URIs may reduce the rate of antibiotics prescribed in primary care; however, further research is warranted.

Determinants of clinician and patient to prescription of antimicrobials: Case of Mulanje, Southern Malawi

BACKGROUND

Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors that lead to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi.

METHODS

Qualitative study design exploring determinants of antimicrobial prescription from May to October, 2019, was used. In-depth interviews (n = 18) and focus group discussions (n = 2) were conducted with medical assistant (MA), clinical technicians and clinical officers (CO) from four health facilities in Mulanje district. COs are licensed medical practitioners with an initial three-year training and one-year internship while MAs are licensed medical practitioners with initial two-year training and one year internship. Purposive sampling was done to arrive at a sample size of 30 health cadres.

RESULTS

Participants pointed out that patient preferences, beliefs and clinicians' inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance.

CONCLUSION

Inappropriate use of antimicrobials is facilitated by prescription decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

Evaluation and optimization of antibiotic usage in upper respiratory tract infections in children at a tertiary care outpatient department: A clinical audit

INTRODUCTION:

Inappropriate antibiotic (ab)use contributes to antimicrobial resistance. Upper respiratory tract infection (URTI) is the most common reason for antibiotic prescription in an outpatient department (OPD). Several factors influence the high and unjustified antibiotic use in a common ailment.

MATERIALS AND METHODS:

A clinical audit was performed to assess antibiotic prescription rate (APR) for URTI in the pediatric OPD against the available benchmark. The prescription pattern was assessed, and interventions were formulated to improve prescription behavior. Data of all children attending OPD and fulfilling the criteria for URTI group were collected from the online hospital management system and analyzed. Interventions, in the form of discussions, presentations, posters, and guidelines (Indian Ministry of Health Guidelines for URTI) regarding etiology of URTI, and indications for antibiotic prescription were implemented. Data were monitored and feedback to consultants was given.

RESULTS:

The baseline APR was 14.7%. There was wide variation in APR (4.1%–53.1%) among consultants. Three consultants had a rate of 53.1%, 29.7%, and 28.6%, which was very high. Postintervention, the average APR decreased to 8.7%, a reduction of 40.8%. There was a reduction in APR among consultants with high APR as well. There was reduction in the use of azithromycin, a drug recommended for patients with penicillin allergy, from 21.2% to 14.4% (32.1% reduction). Amoxycillin plus clavulanic acid combination and amoxicillin alone continued to be the most prescribed antibiotics.

CONCLUSION:

Interventions through clinical audit were useful in reducing APR. The APR of 8.7% achieved in this study postintervention can be used as a benchmark by other institutions to assess APR in children with URTI.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care.

Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication.

Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well.

Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.

Lack of regulation over antibiotic prescription and dispensation: A prospective cohort in a community setting

Background

The emergence of bacterial resistance caused health authorities to attempt to implement strict regulations for rational antibiotic prescription. However, supervision is often neglected in low- and middle-income countries, leading to inappropriate administration of antibiotics. The objective of our study is to highlight the lack of monitoring in the community setting of a middle-income country.

Material and methods

We asked 68 patients presenting to an infectious diseases consultation office to report the antibiotic courses they had taken in the three months preceding their visit. We assessed for treatment indication, molecule choice, dosing and duration, as well as microbial cultures, demographics and specialty of the prescriber.

Results

Among the 68 patients included in our study, we counted a total of 95 outpatient antibiotic courses, mostly composed of quinolones (36%), followed by amoxicillin-clavulanate (21%). The prescriber was most commonly a primary care physician, but we reported several cases of auto-medication and dispensation of antibiotics by pharmacists. Only 30% of cases had true indications for antibiotics.

Conclusion

In sum, our results indicate an evident lack of regulation over the administration of antibiotics. This easy accessibility needs to be promptly addressed as we run the risk of inevitable bacterial resistance.

Prescribing Patterns for Upper Respiratory Tract Infections: A Prescription-Review of Primary Care Practice in Quetta, Pakistan and the Implications

Background: To identify and address the potential overuse of antibiotics, it is important to ascertain the prescribing practices of physicians. We, therefore, conducted this prescription analysis to document URTI-specific antibiotic prescription frequency in a public primary healthcare setting of Quetta city, Pakistan.

Methods: A retrospective record review was conducted of all prescriptions for URTIs in Combined Military Hospital, Quetta from 1 March to 31st May 2021. The Mann-Whitney U and Jonckheere–Terpstra test was used to evaluate the association between the tendencies of a different group of prescribers. p-value of <0.05 was of statistical significance.

Results: Over the 3 months, 50,705 prescriptions were screened and analyzed according to the established inclusion and exclusion criteria. A total of 4,126 (8.13%) URTI prescriptions met the inclusion criteria, of which 2,880 (69.80%) prescriptions contained antibiotics. Among all antibiotics, penicillins (Amoxicillin + Clavulanate) were the most prescribed antibiotic, constituting 1,323 (45.9%) of total antibiotics prescribed for all cases, followed by the Macrolide group 527 (18.2%). The Jonckheere–Terpstra test revealed a statistically significant association between the status of the prescriber and the diagnosis (p = 0.002). Furthermore, a moderate positive trend was reported with specialists being more competent in antibiotic prescribing based on their diagnosis, followed by postgraduates and house officers (τ = 0.322).

Conclusion: The prescribing patterns for the management of URTIs in the hospital were inconsistent with current guidelines. Strict adherence to guidelines must be ensured and antibiotic prescribing for URTIs should be discouraged.

Insertion of a Clinical Pathway Pop-Up Window into a Computer-Based Prescription System: A Method to Promote Antibiotic Stewardship in Upper Respiratory Tract Infection

Outpatient antibiotics are most frequently prescribed for upper respiratory tract infection (URI); however, most such prescriptions are inappropriate. We aimed to determine the effect of an electronic clinical pathway on the rates of overall and rational prescription of antibiotics in patients with URI. A pilot quasi-experimental study was conducted in a university hospital and two of its nearby primary care units (PCU) in northeast Thailand from June to September 2020. Clinical pathway pop-up windows were inserted into the hospital’s computer-based prescription system. Care providers were required to check the appropriate boxes before they were able to prescribe amoxicillin or co-amoxiclav. We examined a total of 675 visits to the outpatient department due to URI at three points in time: pre-intervention, immediately post-intervention, and 6 weeks post-intervention. Patients in the latter group tended to be younger and visits were more likely to be general practitioner-related and to the student PCU than in the other two groups. In addition, the rate of antibiotic prescription was significantly lower at 6 weeks after intervention than at either of the other time periods (32.0% vs 53.8% pre-intervention and 46.2% immediately post-intervention; p < 0.001), and the proportion of rational antibiotic prescriptions increased significantly after implementation. Antibiotic prescription rates were lower at the community primary care unit and higher when the physician was a resident or a family doctor. The deployment of an electronic clinical pathway reduced the rate of unnecessary antibiotic prescriptions. The effect was greater at 6 weeks post-implementation. However, discrepancy of patients’ baseline characteristics may have skewed the findings.

Quality-of-Care Implications of Antimicrobial Prescription Patterns for Acute Respiratory Tract Infections

ABSTRACT

The Centers for Disease Control and Prevention estimates that half of the antibiotic prescriptions for acute respiratory tract infections (ARTIs) in ambulatory care settings are unnecessary. To better understand the quality-of-care implications of prescription patterns for ARTIs, we conducted a retrospective chart review of outpatient ARTI visits, across a large integrated health system, and examined the association of patient characteristics with receiving antimicrobials, as well as the association between receiving antimicrobials and healthcare utilization (outpatient and emergency department visits). We found that 55.4% of all ARTI outpatients were treated with antimicrobials. There was no association between patient demographics and antimicrobial prescriptions on either the first (p < .0771) or follow-up (p < .6316) visits. A lower comorbidity score was significantly associated with receiving antimicrobials (p < .0022). Patients who received antimicrobials at the first visit had significantly higher number of follow-up visits (p < .005) and more follow-up antimicrobial prescriptions (p < .0066) as compared with patients who did not receive antimicrobials at the first visit. Our results highlight the potential for clinicians to improve quality of care in ARTI management.

Antibiotic resistance genes in bacteria: Occurrence, spread, and control

The production and use of antibiotics are becoming increasingly common worldwide, and the problem of antibiotic resistance is increasing alarmingly. Drug-resistant infections threaten human life and health and impose a heavy burden on the global economy. The origin and molecular basis of bacterial resistance is the presence of antibiotic resistance genes (ARGs). Investigations on ARGs mostly focus on the environments in which antibiotics are frequently used, such as hospitals and farms. This literature review summarizes the current knowledge of the occurrence of antibiotic-resistant bacteria in nonclinical environments, such as air, aircraft wastewater, migratory bird feces, and sea areas in-depth, which have rarely been involved in previous studies. Furthermore, the mechanism of action of plasmid and phage during horizontal gene transfer was analyzed, and the transmission mechanism of ARGs was summarized. This review highlights the new mechanisms that enhance antibiotic resistance and the evolutionary background of multidrug resistance; in addition, some promising points for controlling or reducing the occurrence and spread of antimicrobial resistance are also proposed.

Diagnostic accuracy of point-of-care tests in acute community-acquired lower respiratory tract infections. A systematic review and meta-analysis

BACKGROUND

Point-of-care tests could be essential in differentiating bacterial and viral acute community-acquired lower respiratory tract infections and driving antibiotic stewardship in the community.

OBJECTIVES

To assess diagnostic test accuracy of point-of-care tests in community settings for acute community-acquired lower respiratory tract infections.

DATA SOURCES

Multiple databases (MEDLINE, EMBASE, Web of Science, Cochrane Library, Open Gray) from inception to 31 May 2021, without language restrictions.

STUDY ELIGIBILITY CRITERIA

Diagnostic test accuracy studies involving patients at primary care, outpatient clinic, emergency department and long-term care facilities with a clinical suspicion of acute community-acquired lower respiratory tract infections. The comparator was any test used as a comparison to the index test. In order not to limit the study inclusion, the comparator was not defined a priori.

ASSESSMENT OF RISK OF BIAS

Four investigators independently extracted data, rated risk of bias, and assessed the quality using QUADAS-2.

METHODS OF DATA SYNTHESIS

The measures of diagnostic test accuracy were calculated with 95% CI.

RESULTS

A total of 421 studies addressed at least one point-of-care test. The diagnostic performance of molecular tests was higher compared with that of rapid diagnostic tests for all the pathogens studied. The accuracy of stand-alone signs and symptoms or biomarkers was poor. Lung ultrasound showed high sensitivity and specificity (90% for both) for the diagnosis of bacterial pneumonia. Rapid antigen-based diagnostic tests for influenza, respiratory syncytial virus, human metapneumovirus, and Streptococcus pneumoniae had sub-optimal sensitivity (range 49%-84%) but high specificity (>80%).

DISCUSSION

Physical examination and host biomarkers are not sufficiently reliable as stand-alone tests to differentiate between bacterial and viral pneumonia. Lung ultrasound shows higher accuracy than chest X-ray for bacterial pneumonia at emergency department. Rapid antigen-based diagnostic tests cannot be considered fully reliable because of high false-negative rates. Overall, molecular tests for all the pathogens considered were found to be the most accurate.

Validity of caregivers' reports on prior use of antibacterials in children under five years presenting to health facilities in Gulu, northern Uganda

INTRODUCTION

Given the frequent initiation of antibacterial treatment at home by caregivers of children under five years in low-income countries, there is a need to find out whether caregivers' reports of prior antibacterial intake by their children before being brought to the healthcare facility are accurate. The aim of this study was to describe and validate caregivers' reported use of antibacterials by their children prior to seeking care at the healthcare facility.

METHODS

A cross sectional study was conducted among children under five years seeking care at healthcare facilities in Gulu district, northern Uganda. Using a researcher administered questionnaire, data were obtained from caregivers regarding reported prior antibacterial intake in their children. These reports were validated by comparing them to common antibacterial agents detected in blood and urine samples from the children using liquid chromatography with tandem mass spectrometry (LC-MS/MS) methods.

RESULTS

A total of 355 study participants had a complete set of data on prior antibacterial use collected using both self-report and LC-MS/MS. Of the caregivers, 14.4% (51/355, CI: 10.9-18.5%) reported giving children antibacterials prior to visiting the healthcare facility. However, LC-MS/MS detected antibacterials in blood and urine samples in 63.7% (226/355, CI: 58.4-68.7%) of the children. The most common antibacterials detected from the laboratory analysis were cotrimoxazole (29%, 103/355), ciprofloxacin (13%, 46/355), and metronidazole (9.9%, 35/355). The sensitivity, specificity, positive predictive value (PPV), negative predictive value and agreement of self-reported antibacterial intake prior to healthcare facility visit were 17.3% (12.6-22.8), 90.7% (84.3-95.1), 76.5% (62.5-87.2), 38.5% (33.0-44.2) and 43.9% (k 0.06) respectively.

CONCLUSION

There is low validity of caregivers' reports on prior intake of antibacterials by these children. There is need for further research to understand the factors associated with under reporting of prior antibacterial use.

Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis

Background

Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care.

Methods

We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis.

Results

We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8–4.2%/12.5% (Western primary care) and 10.3–13.8%/6.3–6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73–91.9%), influenza (6–15.2%), asthma (3.2–15%), laryngitis/tracheitis (3.6–9%), pneumonia (4.0–4.2%), COPD (0.5–3.3%), heart failure (0.3%), and suspected malignancy (0.2–1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1–35% of patients re-consulted; 0–1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough.

Conclusion

Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a “wait-and-see” strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01501-0.

Knowledge, Attitude and Practice of Family Physicians on Antimicrobial Therapy for Acute Respiratory Tract Infections - A Study from Istanbul, Turkey

Aim: We aimed to investigate the knowledge, attitude, practice of family physicians regarding an-timicrobial therapy in acute respiratory tract infections. Methods: After receiving the ethics committee approval, the data were collected by online questionnaire from a phone application with 304 physicians. Questions about socio-demographic features and knowledge, attitude, and practices on antibiotics use were asked. Using SPSS, we did the statistical analyses with appropriate procedures. Results: Among the participants, 127 (41.8%) were specialists, and 177 (58.2%) were gen-eral practitioners. The specialists gave correct answers about tonsillopharyngitis and bron-chiolitis significantly more often than the general practitioners did. The antibiotic choices for acute otitis media were not in compliance with the guidelines of the Centers for Disease Control, and between the groups, there was no significant difference in terms of initial antibiotic choice. The self-reported antibiotic prescription rate was 25%. In 10%, the most common perceived reason for inappropriate antibiotic prescription was pressure from patients. Conclusion: There remains considerable misuse of antibiotics by primary care physicians for acute respiratory tract infections. Education of physicians and patients regarding acute respiratory tract infections may be needed to lower the rate of inappropriate antibiotic pre-scriptions. Keywords: public health practice, practice patterns, primary healthcare

Changes in antibiotic prescription following an education strategy for acute respiratory infections

The objective of this study was to assess the impact of an education intervention for primary health care physicians, based on the knowledge of clinical practice guidelines and availability of rapid antigen detection test for group A streptococci (GAS), on the improvement of antibiotic prescription for patients with acute respiratory tract infections. Before and after the intervention, physicians collected data from ten consecutive patients who attended during a 3-week period. This process was performed twice a year for 6 consecutive years (2012–2017). A total of 18,001 patients were visited by 391 primary care physicians during the study period, 55.6% before intervention and 44.4% after intervention. After intervention, the antibiotic prescription decreased significantly, from 33.0 to 23.4% (p < 0.01). However, there was a statistically significant increase (p < 0.01) in the use of penicillins. This study, carried out in daily practice conditions, confirms that the educational strategy was associated with an overall reduction in the use of antibiotics and an improvement in the antibiotic prescription profile in acute respiratory tract infections.

A Choosing Wisely top-5 list to support general practitioners in Austria

From a pool of 147 reliable recommendations, ten experts from the Austrian Society of General Practice and Family Medicine selected 21 relevant recommendations as the basis for the Delphi process. In two Delphi rounds, eleven experts established a top‑5 list of recommendations designed for Austrian family practice to reduce medical overuse. Three of the chosen recommendations address the issue of antibiotic usage in patients with viral upper respiratory tract infections, in children with mild otitis media, and in patients with asymptomatic bacteriuria. The other two “do not do” recommendations concern imaging studies for nonspecific low back pain and routine screening to detect prostate cancer. A subsequent survey identified the reasons for selecting these top‑5 recommendations: the frequency of the issue, potential harms, costs, and patients’ expectations. Experts hope the campaign will save time in educating patients and provide legal protection for omitting measures.