Recent trends in antibiotic prescriptions for acute respiratory tract infections in pediatric ambulatory care in Taiwan, 2000–2009: A nationwide population-based study

Prescribing antibiotics for children with dengue infection in Taiwan: who are at risk and who are high prescribers?

Inappropriate antibiotic use contributes to antimicrobial resistance, a global public health threat. The non-specific manifestations of dengue, itself a growing public health threat, lead to avoidable empiric antibiotic prescription, particularly in children. In this national pooled population-based cross-sectional study, we evaluated child and physician characteristics associated with antibiotics prescription in confirmed dengue cases in Taiwan. Linking national health care insurance claims and reports of confirmed dengue cases from 2008 to 2015, there were 7086 children with confirmed dengue with 21 744 outpatient visits and 2520 inpatient admissions. We assessed the presence of antibiotic prescription in outpatient and inpatient settings separately a week before or after the confirmation date. Logistic regression models with generalized estimating equations were applied to identify patient, practitioner, and other factors associated with antibiotic prescription. A total of 29.4% of children <18 years old with dengue who did not have a concomitant bacterial infection were prescribed antibiotics during the 14-day assessment period. Antibiotics prescription was reduced from 13.5% to 6.3% and from 43.2% to 19.3% in outpatient and inpatient settings, respectively, after dengue was confirmed. Young children were more likely to receive antibiotics. Significant variations in antibiotic prescribing across physicians were observed only in outpatient settings: physicians ≥60 years old and physicians practicing at clinics and in non-urban facilities were more likely to prescribe antibiotics. Antibiotics were less likely to be prescribed during an exceptional 2-year epidemic than in other years. Antibiotic prescribing for dengue, an arboviral infection affecting half of the global population, was shown to occur in 29% of paediatric cases in Taiwan. That potentially avoidable antibiotic consumption could be reduced by improving antibiotic stewardship, informed by understanding the conditions under which antibiotics are prescribed and the availability of prevention strategies for viral diseases, including dengue. We identified a number of such factors in this national population-based study.

Changes in the Prescription of Antibiotics and Phytopharmaceuticals in Children Treated for Acute Upper and Lower Respiratory Tract Infections in Pediatric Practices in Germany in 2013, 2018, and 2022

Background: Little is known about the recent trends in antibiotic and phytopharmaceutical prescribing for acute upper (URIs) and lower respiratory tract infections (LRIs) in children and adolescents. Therefore, this study investigated changes in the prescription of antibiotics and phytopharmaceuticals in children diagnosed with acute URIs and LRIs in pediatric practices in Germany in 2013, 2018, and 2022. Methods: The present retrospective study included children aged 2-12 years diagnosed with acute URIs or LRIs in one of 180 pediatric practices in 2013, 2018, and 2022. The URIs included nasopharyngitis, sinusitis, pharyngitis, tonsillitis, laryngitis and tracheitis, and upper respiratory infections of multiple and unspecified sites, while the LRIs corresponded to bronchitis. The primary outcomes were the proportion of children being prescribed antibiotics and the proportion of those being prescribed phytopharmaceuticals. Results: A total of 120,894 children were diagnosed with acute URIs or LRIs in 2013 compared to 116,844 in 2018 and 127,821 in 2022. The prevalence of antibiotic prescription decreased for all diagnoses between 2013 and 2022. This decrease was statistically significant for both 2013-2018 and 2018-2022 for nasopharyngitis, pharyngitis, and bronchitis. Meanwhile, there was a significant increase in the use of phytopharmaceuticals for all diagnoses between 2013 and 2018. The prevalence of phytopharmaceutical prescription decreased slightly between 2018 and 2022, but this decrease was generally not statistically significant. Conclusions: The prescription of antibiotics has decreased and that of phytopharmaceuticals has increased in children diagnosed with acute URIs and LRIs in Germany over the last decade. More data are needed to corroborate these findings in other settings.

Financial incentives for infection prevention and antimicrobial stewardship to reduce antibiotic use: Japan's nationwide observational study

BACKGROUND

The Japanese government introduced financial incentives to reduce nationwide antibiotic use in hospital settings.

AIM

This study aimed to determine whether the nationwide financial incentives for creating infection prevention and control (IPC) teams introduced in 2012 and antimicrobial stewardship (ASP) teams introduced in 2018 were associated with changes in antibiotic use and health resource utilization at a national level.

METHODS

We conducted time-series analyses and a difference-in-differences study consisting of 3,057,517 inpatients with infectious diseases from 472 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. The primary outcome was the days of therapy (DOT) of antibiotic use per 100 patient-days (PDs). The secondary outcomes consisted of types of antibiotic used, health resource utilization, and mortality.

RESULTS

A total of 5,201,304 financial incentives were observed during 2012-2018, which resulted in a total of 12.1 billion JPY (≈110 million USD). Time-series analyses found decreasing trends in total antibiotic use (79.3-72.5 DOTs/100 PDs (8.6% reduction)) and carbapenem use (9.0-7.0 DOTs/100 PDs (7.8% reduction)) from 2011 to 2018 without adversely affecting other healthcare outcomes (e.g., mortality). In the difference-in-differences analyses, we did not observe meaningful changes in total antibiotic use between the incentivized and unincentivized hospitals for ASP teams, except for the northern part of Japan. No dose-response relationships were observed between the amount of financial incentives and reductions in antibiotic use during 2011-2019.

CONCLUSIONS

Further research and efforts are needed to accelerate antimicrobial stewardship in hospital settings in Japan.

Antibiotic prescribing patterns at children's outpatient departments of primary care institutions in Southwest China

BACKGROUND

Inappropriate use of antibiotics in children is common in many countries. The purpose of the study was to explore patterns of antibiotic prescribing in children's outpatient clinics in primary care institutions in a province of southwest China.

METHODS

We obtained electronic prescription data from 75 primary care institutions in Guizhou province in 2020. The classification of incorrect spectrum of antibiotics, unnecessary use and combined use of antibiotics was based on the Guiding Principle of Clinical Use of Antibiotics (2015, China) and guidelines from the USA Centers for Disease Control and Prevention. Potential risk factors for inappropriate use of antibiotics were identified using bivariate analyses. The generalized estimation equation was used to identify independent predictors of inappropriate use of antibiotics.

RESULTS

A total of 158,267 antibiotic prescriptions were retrieved. Acute upper respiratory tract infections were the most common diseases, accounting for 74.9% of all prescriptions. The main antibiotic group used was penicillins (63.7%), followed by cephalosporins (18.8%). Of 137,284 visits, 18.3% of antibiotic prescriptions were appropriate and the percentage of unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics was 76.9, 2.4 and 2.4%, respectively. Physicians with lower professional titles and more than 40 years of work duration were relatively more likely to prescribe inappropriate antibiotics.

CONCLUSION

The inappropriate use of antibiotics in children is still prominent in primary care institutions of southwest China. The education and training of physicians and caregivers in these institutions should be strengthened.

The consequence of financial incentives for not prescribing antibiotics: a Japan's nationwide quasi-experiment

BACKGROUND

For addressing antibiotic overuse, Japan designed a health care policy in which eligible medical facilities could claim a financial reward when antibiotics were not prescribed for early-stage respiratory and gastrointestinal infections. The policy was introduced in a pilot manner in paediatric clinics in April 2018.

METHODS

We conducted a quasi-experimental, propensity score-matched, difference-in-differences (DID) design to determine whether the nationwide financial incentives for appropriate non-prescribing of antibiotics as antimicrobial stewardship [800 JPY (≈7.3 US D) per case] were associated with changes in prescription patterns, including antibiotics, and health care use in routine paediatric health care settings at a national level. Data consisted of 9 253 261 cases of infectious diseases in 553 138 patients treated at 10 180 eligible or ineligible facilities.

RESULTS

A total of 2959 eligible facilities claimed 316 770 cases for financial incentives and earned 253 million JPY (≈2.29 million USD). Compared with ineligible facilities, the introduction of financial incentives in the eligible facilities was associated with an excess reduction in antibiotic prescriptions [DID estimate, -228.6 days of therapy (DOTs) per 1000 cases (95% CI, -272.4 to -184.9), which corresponded to a relative reduction of 17.8% (95% CI, 14.8 to 20.7)]. The introduction was also associated with excess reductions in drugs for respiratory symptoms [DID estimates, -256.9 DOTs per 1000 cases (95% CI, -379.3 to -134.5)] and antihistamines [DID estimate, -198.5 DOTs per 1000 cases (95% CI, -282.1 to -114.9)]. There was no excess in out-of-hour visits [DID estimate, -4.43 events per 1000 cases (95% CI, -12.8 to 3.97)] or hospitalizations [DID estimate, -0.08 events per 1000 cases (95% CI, -0.48 to 0.31)].

CONCLUSIONS

Our findings suggest that financial incentives to medical facilities for not prescribing antibiotics were associated with reductions in prescriptions for antibiotics without adverse health care consequences. Japan's new health policy provided us with policy options for immediately reducing inappropriate antibiotic prescriptions by relatively small financial incentives.

Population-based assessment of factors influencing antibiotic prescribing for adults with dengue infection in Taiwan

Background

Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors.

Methods

57,301 adult dengue cases reported in Taiwan between 2008–2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan’s National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients.

Results

Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings.

Conclusions

In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing.

Antimicrobial resistance is a growing global public health threat. The non-specific clinical manifestations of dengue overlap with signs and symptoms of other febrile illnesses common to tropical and subtropical zones making differential diagnosis between dengue and bacterial infections difficult, hence, leading to potentially unnecessary antibiotic prescribing. However, our understanding of factors underlying antibiotic prescribing for dengue is rather limited. Taiwan has experienced periodic dengue outbreaks and has a comprehensive national health insurance database including reliable infectious diseases surveillance and prescribing records. The findings in Taiwan show that other than commonly known patient characteristics, provider and contextual factors play a significant role. Physician’s age and practice setting were significant factors influencing the decision to prescribe antibiotics, particularly in outpatient visits. The likelihood of prescribing an antibiotic to dengue patients was reduced by more than 50% in medical visits occurring after the dengue infection was confirmed. Understanding patient, provider and contextual factors in antibiotics prescription for dengue infections can provide insights for improved antibiotic stewardship and unnecessary antibiotic treatment for dengue.

Change in clinical practice variations for antibiotic prescriptions across different pediatric clinics: A Japan's nationwide observational study

BACKGROUND

In 2016, the Japanese government set the National Action Plan on antimicrobial resistance to reduce antibiotic prescriptions. However, the trends and variations of antibiotic prescription patterns in a routine healthcare setting during the fiscal year 2013-2018 across different clinics at a national level are unclear.

METHODS

This retrospective cohort study included all clinics with >100 pediatric outpatients with infectious diseases per month during the fiscal year 2013-2018 using a national database in Japan. We investigated the trends in antibiotic prescription rates and their patterns and variations across different clinics over the six years following the 2019 World Health Organization Access, Watch, Reserve antibiotic groups, and Amoxicillin Index.

RESULTS

A total of 2278 clinics with 94,414,170 infectious disease-related visits were eligible for the study. Most clinics showed higher Watch percentages (median 85.4%; IQR, 68.5-95.1) than Access percentages (median, 13.8%; IQR, 4.2-30.7) and Amoxicillin Index (median, 13.3%; IQR, 3.9-30.4). The introduction of the Action Plan changed annual absolute reductions in the antibiotic prescription rates from -16.0 DOTs/1000 visitors (95%CI, -16.4-15.6) to -239.3 per 1000 visitors (95%CI, -240.0-238.6). However, these impacts were heterogeneous across clinics. From 2013 to 2018, 41.4% reduced the antibiotic prescription rates by >33.3% (median, -1035.5 DOTs/1000 visitors; IQR, -1519.4-680.2), 18.7% did not change the rates (median, -40.3 DOTs/1000 visitors; IQR, -168.4-68.6), and 7.3% increased the rates by >10% (499.5 DOTs per 1000 visitors; IQR, 232.6-837.5).

CONCLUSIONS

We observed the National Action Plan's impacts and extensive prescription variations across different pediatric clinics. However, one-fourth of clinics did not improve antibiotic prescription patterns even after introducing the Action Plan.

Evidence-based public policy making for medicines across countries: findings and implications for the future

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

Trends and patterns in antibiotic prescribing for adult outpatients with acute upper respiratory tract infection in Japan, 2008-2018

INTRODUCTION

This study aimed to characterize the patterns and trends in the use of major oral antibiotics prescribed for adult outpatients diagnosed with acute upper respiratory tract infections (AURTIs) in Japan between 2008 and 2018.

METHODS

We analyzed administrative claims data for adults in Japan, between April 2008 and September 2018. The trends in oral antibiotic prescription were illustrated using the prescribing rate, and tested using interrupted time series analysis. We also assessed the factors associated with antibiotic prescription for AURTIs.

RESULTS

Data on 7.54 million antibiotic prescriptions in 1,937,379 adults with AURTIs were analyzed; people ≥65-years old were scarcely included. The antibiotic prescribing rate declined from 49.9% in 2008 to 39.0% in 2018, and the rate of decrease accelerated after the national action plan on antimicrobial resistance was launched in April 2016. Acute nasopharyngitis was the most common indication. Cephalosporins (35.2%), macrolides (32.2%), fluoroquinolones (24.6%), and penicillins (5.88%) were the most commonly prescribed antibiotic classes. Sex, age, type and specialty of the facility, and season affected the likelihood of being prescribed antibiotics. The majority of antibiotics prescribed were broad-spectrum, but use of penicillins showed a higher rate of increase after 2016.

CONCLUSIONS

The percentage of antibiotic prescriptions for AURTIs decreased significantly after implementing the action plan, indicating that it was effective to some extent. However, since the use of broad-spectrum antibiotics was high, there is scope for improving the prescribing pattern, including the types of antimicrobial agents; this is considered to be a future issue.

Exploring Quality of Life, Stress, and Risk Factors Associated with Irritable Bowel Syndrome for Female University Students in Taiwan

Irritable bowel syndrome (IBS) is a common recurrent functional gastrointestinal disorder that impacts on patients physically and mentally. Studies on IBS have focused on adults, yet few studies have examined IBS among female university students. The aim of this study was to investigate the prevalence of IBS for female university students and its related factors. Using a cross-sectional study design, a total of 2520 female university students were recruited in southern Taiwan. The structured questionnaires, including the Rome III IBS diagnostic questionnaire, IBS symptom severity scale, Perceived Stress Scale, and World Health Organization Quality of Life BREF questionnaire (WHOQOL-BREF) were used for data collection. A total of 1894 female students complete the questionnaires. The response rate was 75.15%. The results indicated 193 female students with IBS and the prevalence of IBS was 10.1%. IBS female students had higher levels of stress and lower QOL than non-IBS female students. The risk factors for female university students developing IBS were dysmenorrhea, food avoidance, class absenteeism, and the lower physical domain of QOL. It is advised to consider these factors when providing students with counselling and relevant services in the expectation of alleviating their IBS symptoms, reducing the incidence rate of IBS, and further improving their QOL.

National trends in appropriate antibiotics use among pediatric inpatients with uncomplicated lower respiratory tract infections in Japan

BACKGROUND

Japan was ranked as the worst country of 36 high-income countries in terms of oral antibiotic consumptions for children. Knowing the patterns and variations of antibiotic use for pediatric inpatients with uncomplicated respiratory infections is an important step to promote judicious antibiotic use.

METHODS

Discharge records were extracted for children aged between 3 months and 15 years with acute lower respiratory tract infections for the fiscal years 2010-2014 using a national inpatient database in Japan. We investigated the trends in antibiotic use using mixed effect regression models and ascertained variations and clustering of the practice patterns across different hospitals using unsupervised machine learning methodology.

RESULTS

A total of 280,298 children were included in the study. Total and broad-spectrum antibiotic use, except for fluoroquinolone, showed decreasing trends from 2010 to 2014. Additionally, the proportions of patients who received no antibiotics or only penicillin increased from 17.1% to 9.9% in 2010 to 24.5% and 13.7% in 2014, respectively. Cluster analysis showed that only one-quarter of hospitals used no antibiotics for 28.8% of children and only penicillin for 53.7% of children. In the remaining clusters of hospitals, the piperacillin, 3rd generation cephalosporins, and penicillin beta-lactamase inhibitors were used for 68.5%, 68.5%, and 69.6% of the patients who received antibiotics.

CONCLUSIONS

Slightly increasing trends in narrow-spectrum antibiotics were observed. However, the treatment strategy in only one-quarter of hospitals was consistent with the current recommendations. Hospital level interventions to promote and monitor antibiotic use could be helpful to improve antibiotic use for pediatric inpatients.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

A live attenuated H5N2 prime- inactivated H5N1 boost vaccination induces influenza virus hemagglutinin stalk specific antibody responses

BACKGROUND

The emergence and spread of highly pathogenic avian influenza (H5N1) viruses have raised global concerns of a possible human pandemic, spurring efforts towards H5N1 influenza vaccine development and improvements in vaccine administration methods. We previously showed that a prime-boost vaccination strategy induces robust and broadly cross-reactive antibody responses against the hemagglutinin globular head domain. Here, we specifically measure antibodies against the conserved hemagglutinin stem region in serum samples obtained from the prior study to determine whether stalk-reactive antibodies can also be induced by the prime-boost regimen.

METHOD

Serum samples collected from 60 participants before vaccination and on days 7, 28 and 90 following boosting vaccination were used in this study. 40 participants received two doses of live attenuated H5N2 vaccine (LAIV H5N2) followed by one dose of inactivated H5N1 vaccine a year later, while 20 participants received only the inactivated H5N1 vaccine. We tested these serum samples for stalk-reactive antibodies via enzyme-linked immunosorbent (ELISA) and microneutralization assays.

RESULTS

Stalk-specific antibody levels measured by both assays were found to be significantly higher in primed individuals than the unprimed group. ELISA results showed that 22.5, 70.5 and 57.5% of primed participants had a four-fold or more increase in stalk antibody titers on days 7, 28 and 90 following boosting vaccination, respectively; whereas the unprimed group had no increase. Peak geometric mean titers (GMT) for stalk antibodies in the LAIV H5N2 experienced group (24,675 [95% CI; 19,531-31,174]) were significantly higher than those who received only the inactivated H5N1 vaccine (8877 [7140-11,035]; p < 0·0001). Moreover, stalk antibodies displaying neutralizing activity also increased in primed participants, but not in the unprimed group.

CONCLUSION

Our finding emphasizes the importance of prime-boost vaccination for effectively inducing stalk antibodies, which is an attractive target for developing vaccines that induce stalk reactive antibodies.

Antibiotic prescription among outpatients in a prefecture of Japan, 2012-2013: a retrospective claims database study

OBJECTIVES

To investigate oral antibiotic prescribing patterns and identify factors associated with antibiotic prescriptions, with the aim of guiding future interventions to reduce inappropriate prescribing.

DESIGN

Retrospective cohort study.

SETTING

Database of public health insurance claims in Kumamoto prefecture (Japan).

PARTICIPANTS

Beneficiaries of the national or late elders' health insurance system between April 2012 and March 2013.

MAIN OUTCOME MEASURES

Of the 7 770 481 outpatient visits, 682 822 had a code for antibiotics (860 antibiotic prescriptions per 1000 population). Third-generation cephalosporins (35%), macrolides (32%) and quinolones (21%) were the most frequently prescribed. Acute respiratory tract infections (ARTIs), including viral upper respiratory infections (URI) (22%), pharyngitis (18%), bronchitis (11%) and sinusitis (10%) were the most frequently diagnosed for antibiotic prescribing, followed by gastrointestinal (9%), urinary tract (8%) and skin, cutaneous and mucosal infections (5%). Antibiotic prescribing rates for viral URI, pharyngitis, bronchitis, sinusitis and gastrointestinal infections were 35%, 54%, 53%, 57% and 30%, respectively. In multivariable analysis for ARTIs and gastrointestinal infections, patient age (10-19 years especially), patient sex (male) and facility scale (free-standing clinics or small-scale hospital-based clinics) were associated with increased antibiotic prescribing.

CONCLUSIONS

Broad-spectrum antibiotics constituted 88% of oral outpatient antibiotic prescriptions. Approximately 70% of antibiotics were prescribed for ARTIs and gastroenteritis with modest benefit from antibiotic treatment. The quality of antibiotic prescribing needs to be improved. Antimicrobial stewardship interventions should target ARTIs and gastroenteritis, as well as young patients and small-scale institutions.

Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations

OBJECTIVES

The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral.

DESIGN

Cross-sectional design.

SETTING

One urban primary care OOH facility located in the midwest of Ireland.

PARTICIPANTS

457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants.

RESULTS

435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic.

CONCLUSIONS

Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.

Antimicrobial prescribing for children in primary care

AIM

To describe the patterns of antimicrobial prescribing in general practice for children aged ≤18 years.

METHODS

This is a review of routinely collected patient data extracted from computerised medical records from 39 general practices in eastern metropolitan Melbourne over a 5-year period, 2010-2014.

MAIN OUTCOME MEASURES

Proportion of paediatric consultations resulting in antibiotic prescription, type and frequency of antibiotics prescribed, antibiotic prescribing stratified by age, reason for indication and inter-practice variation.

RESULTS

There were 744 883 consultations for 89 983 individual paediatric patients and 85 913 prescriptions for antibiotics during the study period. Of these antibiotic prescriptions, 75 410 were associated with a consultation, and 10 503 (12.2% of all prescriptions) had no associated consultation in the data. On average, one in five individual children was prescribed an antibiotic each year. The most commonly prescribed antibiotics were cephalexin, amoxycillin/clavulanate, cefaclor, phenoxymethylpenicillin and roxithromycin. Less than 3% of all prescriptions were for amoxycillin. Prescribing of cefaclor and roxithromycin decreased, although cefaclor remained the third most common antibiotic choice for general practitioners. Peaks in prescribing were noted over winter months. Reason for prescription was not recorded for 82% of prescriptions. The frequency of antibiotic prescription per consultation varied substantially (2.1-19.7%) between general practitioner clinics. Overall, antibiotic prescribing decreased by 2.3% over the 5-year period.

CONCLUSIONS

This study provides a focused examination of antibiotic prescribing practices for children in Australian general practice. More information is required to better understand specific prescribing practices in children, including the low frequency of amoxycillin prescription and ongoing prescription of cefaclor.

Nationwide study of outpatient oral antimicrobial utilization patterns for children in Japan (2013-2016)

BACKGROUND

Antimicrobial resistance (AMR) is a major multinational public health concern. The Japanese government set goals in its AMR action plan to reduce use of oral cephalosporins, macrolides, and quinolones by half between 2013 and 2020. We aimed to evaluate antimicrobial use in children in Japan by observing prescription patterns as an interim assessment of the national AMR action plan.

METHODS

Using the national health claims database, we retrospectively analyzed all oral antimicrobials dispensed from outpatient pharmacies in Japan to children under 15 years old from 2013 to 2016 by age, prefecture, type of antimicrobial, and year. Data were presented as days of therapy (DOTs) per 1000 pediatric inhabitants per day (DOTs/PID). The χ² test for trends was performed to evaluate annual changes in DOTs/PID overall as well as within each stratum.

RESULTS

A total of 721,627,553 oral antimicrobial DOTs were identified during 2013-2016. No statistically significant changes were observed in total antimicrobial use in children (2013: 28.54 DOTs/PID; 2016: 28.70 DOTs/PID; P_trend = 0.25) and amount of cephalosporins, macrolides, and quinolones prescribed. Prescription rates of all antimicrobials were highest among children 1-5 years old, peaking at 1 year old. Targeted antimicrobials for the AMR action plan showed similar distribution by age.

CONCLUSION

The amount of antimicrobials prescribed to children in Japan is not decreasing. Overall antimicrobial prescriptions, as well as prescriptions of cephalosporins, macrolides, and quinolones, were most prevalent in children ≤5 years old. Rigorous antimicrobial stewardship interventions targeting infants and younger children are necessary.

Increased use of third-generation cephalosporin antibiotics in the outpatient setting in Korean children and adolescents

BACKGROUND

Antimicrobial resistance is a concern to public health, and controlling antibiotic use is therefore important. This study analyzed the trend in outpatient antibiotic prescriptions in children and adolescents in Korea.

METHODS

Using National Prescribing Sample data from the Korea Health Insurance Review and Assessment Service between 1 January 2010 and 31 December 2014, we analyzed outpatient systemic antibiotic (anatomical therapeutic chemical [ATC] J01) prescriptions in patients aged 2-17 years. The antibiotic rate was defined as the proportion of all outpatient prescriptions for antibiotics. We calculated absolute and relative differences with 95%CI between 2010 and 2014 in the antibiotic rate by age group (2-6, 7-11, and 12-17 years) and the percentage of antibiotic prescriptions by antibiotic class. Seven of the most commonly used antibiotic drugs were identified based on defined daily dose.

RESULTS

A total of 7 261 176 prescriptions were written for 1 039 756 pediatric patients between 2010 and 2014. The antibiotic rate in all patients increased from 34.8% in 2010 to 70.4% in 2014, resulting in the relative difference of 102.1% (95%CI: 101.7-102.5). Extended spectrum penicillins were the most commonly prescribed antibiotic class, accounting for 40.0-41.0% of all antibiotic prescriptions. The use of third-generation cephalosporins increased steeply with the relative difference of 55.7% (95%CI: 55.2-56.2). Amoxicillin/clavulanate, an extended spectrum antibiotic drug, was the predominately used antibiotic drug but the use of cefpodoxime, a third-generation cephalosporin, increased by 96%.

CONCLUSIONS

The use of outpatient antibiotics, especially third-generation cephalosporins, has increased in children and adolescents in Korea.

Individual feedback to reduce inappropriate antimicrobial prescriptions for treating acute upper respiratory infections in an outpatient setting of a Thai university hospital

OBJECTIVES

Excessive use of antimicrobial agents for acute upper respiratory infections (URIs) is one of the most common problems in clinical practice. Interventions are required to reduce antimicrobial overuse in these common infections.

METHODS

During a 9-month study period (June 2014-February 2015), a quasi-experimental (pre-/post-) study was conducted among internal medicine residents and fellows in an outpatient setting of Siriraj Hospital, Thailand. The aim of the study was to determine the effectiveness of individual feedback to reduce inappropriate antimicrobial prescriptions for treating URIs. The administrative ICD-10 database was used to identify index physicians with at least one outpatient experience of URI. Data on antimicrobial prescriptions were extracted from the hospital pharmacy database. A confidential letter and SMS were sent to all index physicians about the extent of antimicrobial therapy they prescribed for treating URIs during the pre-intervention period.

RESULTS

The proportion of antimicrobial use among the index encounters showed a significant reduction from 34.7% in the pre-intervention period to 26.1% in the post-intervention period (P=0.02). Segmented logistic regression analysis confirmed the significant impact of the intervention on reducing antimicrobial prescriptions (P=0.02).

CONCLUSION

This integrated intervention is simple and non-labour intensive and may therefore be used sustainably in resource-limited settings.

Seasonal variations in sleep disorders of nurses

AIMS AND OBJECTIVES

To investigate the difference between nurses and the general population regarding seasonal variations in sleep disorders during 2004-2008. The effects of season and group interaction on sleep disorders with regard to different comorbidities were also examined.

BACKGROUND

Studies on seasonal variations in sleep disorders were mainly conducted in Norway for the general population. Furthermore, whether different comorbidities cause seasonal variations in sleep disorders in nurses remains unknown.

DESIGN

A retrospective study.

METHODS

Data from the Taiwan National Health Insurance Research Database were used in generalised estimating equation Poisson distribution models to investigate the differences in sleep disorders between nurses and the general population diagnosed with sleep disorders (each n = 7643) as well as the interaction effects of sleep disorders between the groups with respect to different seasons. Furthermore, the interaction effects between groups and seasons on sleep disorders in the subgroups of comorbid anxiety disorders and depressive disorders were studied.

RESULTS

Both the nurses and the general population had fewer outpatient visits for sleep disorders in winter than in other seasons. The nurses had fewer outpatient visits for sleep disorders than the general population did in each season. The nurses had more outpatient visits for sleep disorders in winter than in summer compared with the general population in the comorbid depressive disorder subgroup but not in the comorbid anxiety disorder subgroup.

CONCLUSIONS

Nurses and the general population exhibited similar seasonal patterns of sleep disorders, but nurses had fewer outpatient visits for sleep disorders than the general population did in each season. For nurses with comorbid depressive disorders, outpatient visits for sleep disorders were more numerous in winter than in summer, potentially because nurses with comorbid depressive disorders are affected by shorter daylight exposure during winter.

RELEVANCE TO CLINICAL PRACTICE

Depression and daylight exposure may be considered in mitigating sleep disorders in nurses.

Risk of Allergic Rhinitis, Allergic Conjunctivitis, and Eczema in Children Born to Mothers with Gum Inflammation during Pregnancy

Purpose

Despite links between maternal and child health status, evidence on the association between gum infection in pregnant mothers and childhood allergies is scarce. We aim to evaluate the risk of developing allergy in children born to periodontal mothers in a nationwide study.

Methods

We conducted a 9-year population-based, retrospective cohort study using Taiwan’s National Health Insurance database. A study cohort of 42,217 newborns born to mothers with periodontal disease during pregnancy was identified in 2001 and matched with 42,334 babies born to mothers without any infection (control) by mother’s age at delivery and baby sex. With a follow-up period from 2001 to 2010, we observed the incidence of allergic rhinitis (AR), allergic conjunctivitis (AC), and eczema in these children. Cox proportional hazards regression models were performed with premature deaths as competing risk for the estimation of allergic disease risks.

Results

Nine-year cumulative incidences were the highest among children born to periodontal mothers; they reached 46.8%, 24.2%, and 40.4% (vs. 39.5%, 18.3% and 34.8% in control) for AR, AC, and eczema, respectively. Our results showed moderately increased risks for the allergies in children born to periodontal mothers relative to their matched non-inflammatory control (adjusted HRs: 1.17, 95% CI: 1.15–1.20; 1.27, 1.24–1.31; 1.14, 1.12–1.17, respectively). Because the impact of food consumption and living environment cannot be considered using insurance data, we attempted to control it by adjusting for parental income and mother’s residential area.

Conclusions

Overall cumulative incidence and risks of children born to periodontal mothers for AR, AC, and eczema are significantly higher than those born to non-inflammatory mothers. Gum infection in women during pregnancy is an independent risk factor for allergic diseases in children, thus its intergenerational consequences should be considered in gestational care.