Psychological and cultural factors influencing antibiotic prescription

'You never know when you will need an antibiotic': A qualitative study of structural barriers and cultural assumptions in antibiotic misuse among immigrants in the United States

OBJECTIVES

The use of nonprescribed antibiotics increases the risk of antibiotic resistance, which is a primary public health concern of the 21st century. This study explores structural and cultural determinants of antibiotic misuse among immigrants living in the United States who arrived from home countries with easier access to antibiotics.

METHODS

Adopting a qualitative approach, we interviewed 34 immigrants living in the United States and who had traveled back to their home countries within 1 year of the interview. We followed the steps of constructive grounded theory to analyze the data.

RESULTS

We found two primary influences of immigrants' use of nonprescribed antibiotics. The first was structural barriers to health care access in the host country, including insurance coverage, cost of an emergency department visit, cost of missing a paid day of work, complexity of the healthcare system, and communication issues with health care providers. The second was participants' cultural assumptions, including their experiences of antibiotics use, beliefs about antibiotics, a habit of self-medication, and uncertainty about future medical needs.

CONCLUSIONS

This study informs policymakers concerned with combating antibiotic resistance. Promoting antibiotic stewardship among immigrants from countries with lax antibiotic-prescribing practices and improving access to appropriate channels for preventative and same-day care may reduce the inappropriate use of antibiotics.

Selection versus transmission: Quantitative and organismic biology in antibiotic resistance

We aimed to determine the importance of selection (mostly dependent on the anthropogenic use of antimicrobials) and transmission (mostly dependent on hygiene and sanitation) as drivers of the spread of antibiotic-resistant bacterial populations. The first obstacle to estimating the relative weight of both independent variables is the lack of detailed quantitative data concerning the number of bacterial cells, potentially either pathogenic or harmless, and bacterial species exposed to antimicrobial action in the microbiotas of specific environments. The second obstacle is the difficulty of considering the relative importance of the transmission and selection exerting their combined effects on antibiotic resistance across eco-biological levels. As a consequence, advances are urgently required in quantitative biology and organismic biology of antimicrobial resistance. The absolute number of humans exposed to antibiotics and the absolute number of potentially pathogenic and commensal bacteria in their microbiomes should influence both the selection and transmission of resistant bacterial populations. The "whole Earth" microbiome, with astonishingly high numbers of bacterial cells and species, which are also exposed to anthropogenic antimicrobials in various biogeographical spaces, shapes the antibiotic resistance landscape. These biogeographical spaces influence various intensities of selection and transmission of potentially pathogenic bacteria. While waiting for more precise data, biostatistics analysis and mathematical or computational modeling can provide proxies to compare the influence of selection and transmission in resistant bacteria. In European countries with lower sanitation levels, antibiotic consumption plays a major role in increasing antibiotic resistance; however, this is not the case in countries with high sanitation levels. Although both independent variables are linked, their relative influence on the level of antibiotic resistance varies according to the particular location. Therefore, interventions directed to decrease antibiotic resistance should be designed "a la carte" for specific locations with particular ecological conditions, including sanitation facilities.

Non-Canonical Aspects of Antibiotics and Antibiotic Resistance

The understanding of antibiotic resistance, one of the major health threats of our time, is mostly based on dated and incomplete notions, especially in clinical contexts. The "canonical" mechanisms of action and pharmacodynamics of antibiotics, as well as the methods used to assess their activity upon bacteria, have not changed in decades; the same applies to the definition, acquisition, selective pressures, and drivers of resistance. As a consequence, the strategies to improve antibiotic usage and overcome resistance have ultimately failed. This review gathers most of the "non-canonical" notions on antibiotics and resistance: from the alternative mechanisms of action of antibiotics and the limitations of susceptibility testing to the wide variety of selective pressures, lateral gene transfer mechanisms, ubiquity, and societal factors maintaining resistance. Only by having a "big picture" view of the problem can adequate strategies to harness resistance be devised. These strategies must be global, addressing the many aspects that drive the increasing prevalence of resistant bacteria aside from the clinical use of antibiotics.

Analysis of antimicrobial drug usage in psychiatric specialized hospitals during the pandemic in China

BACKGROUND

This study aims to compare antimicrobial drug usage in our hospital to Jiangsu Province and China from 2020 to 2022.

RESEARCH DESIGN AND METHODS

A detailed analysis was performed using data from the National Antimicrobial Drug Clinical Application Monitoring Network. Several parameters were studied: the rate of antimicrobial drug use, number and types of drugs used, the rate of combined use, rate of microbiological examinations, drug use intensity, and cumulative Defined Daily Doses (DDDs).

RESULTS

From 2020 to 2022, our hospital's antimicrobial drug usage rate was consistently lower than Jiangsu Province and China. The average number of drug types and the combined drug use rate were higher in 2020 but fell below those in Jiangsu Province and China in 2021 and 2022. Our microbiological examination rate consistently surpassed that of Jiangsu Province and China. Furthermore, our Antimicrobial Usage Density and cumulative DDDs were notably lower. While AUD remained stable, DDDs showed a decreasing trend. The most dominant drug in DDDs was cefditoren, a third-generation cephalosporin.

CONCLUSIONS

During the pandemic years, our hospital not only met the requirements for antimicrobial drug usage, microbiological examination, AUD, and cumulative DDDs but also demonstrated a consistent year-by-year decrease in drug usage and DDDs.

Ionized water-soluble organic nanosheets with light/ultrasound dual excitation channels for efficient killing of multidrug-resistant bacteria

A novel ionized heavy-atom-free two-dimensional organic nanosheet was prepared and exhibited highly selective generation of singlet oxygen under both light and ultrasound excitation. These ionized nanosheets displayed excellent dispersibility in water and enhanced singlet oxygen production efficiency compared to their non-assembled monomers. Antimicrobial experiments have revealed their potent bactericidal effects on drug-resistant E. coli and S. aureus under both visible light and ultrasound irradiation.

Attachment and mother-infant interactions in dyads with infants born full-term, moderate-to-late preterm, and very-to-extreme preterm

BACKGROUND

The impact of prematurity status on attachment quality remains indeterminate. Some studies found no differences between infants born preterm (PT) and infants born full-term (FT), while other investigations present opposite results.

AIMS

We aim to contribute to this body of research by studying mother-infant interactive behaviors and quality of attachment in 3 independent samples: Full-Term (FT), Moderate-to-Late Preterm (MLPT) and Very-to-Extreme Preterm (VEPT).

STUDY DESIGN

This is a longitudinal laboratory study conducted from 3 to 12 months of age (corrected-age in the case of infants born PT).

SUBJECTS

The participants are 213 Portuguese infants (FT = 105; MLPT = 52; VEPT = 56) and their mothers.

OUTCOME MEASURES

Mother-infant interactive behavior was observed in free-play at 3 and 9 months (corrected-age). Infant attachment was observed in Strange Situation at 12 months.

RESULTS

Secure attachment is more prevalent in infants born FT, and ambivalent attachment is more prevalent in infants born VEPT. Infants with a secure attachment have higher gestational age and weight at birth. Infant and maternal interactive behavior quality is associated with attachment patterns and varies according to infant prematurity status. Last, the results indicate changes in maternal sensitivity and infant difficult behavior from 3 to 9 months of infant's age.

CONCLUSIONS

Our findings indicate that prematurity status impacts attachment quality. Changes in maternal and infant behavior from 3 to 9 months suggest a period of rapid non-linear development, supporting a transactional multilayered approach to the study of mother-infant relationship.

Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework

This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.

Predicting attachment in Portuguese infants born very or extremely preterm: Understanding the roles of infant regulatory behavior, maternal sensitivity, and risk factors

A growing body of research shows that early attachment relationships are foundational for children's later developmental and psychosocial outcomes. However, findings are mixed regarding whether preterm birth predicts later attachment, but insecurity is generally more prevalent among infants at higher medical and/or social/familial risk. This longitudinal study aimed to identify specific relational, familial/demographic, and perinatal predictors of attachment in a sample of 63 Portuguese infants born very or extremely preterm (VEPT, <32 gestational weeks) and their mothers from diverse socioeconomic backgrounds. One-third of the mothers had social/family risk factors (e.g., single parent, immigrant, unemployed, low education, and/or low income). At 3 months (corrected age), dyads were observed during social interaction in the Face-to-Face Still-Face paradigm (FFSF) and during free play. At 12 months, mother-infant dyads were observed in Ainsworth's Strange Situation. Over half (58.7%) of the infants were classified as insecurely attached. Social-Positive Oriented regulatory behavior pattern, higher maternal sensitivity, higher infant cooperation during free play, number of siblings and an absence of social/family risk factors were associated with attachment security. Perinatal variables were unrelated to attachment. Findings indicate that both relational and social contextual factors contribute to attachment in this biologically vulnerable sample.

What are the missing pieces needed to stop antibiotic resistance?

As recognized by several international agencies, antibiotic resistance is nowadays one of the most relevant problems for human health. While this problem was alleviated with the introduction of new antibiotics into the market in the golden age of antimicrobial discovery, nowadays few antibiotics are in the pipeline. Under these circumstances, a deep understanding on the mechanisms of emergence, evolution and transmission of antibiotic resistance, as well as on the consequences for the bacterial physiology of acquiring resistance is needed to implement novel strategies, beyond the development of new antibiotics or the restriction in the use of current ones, to more efficiently treat infections. There are still several aspects in the field of antibiotic resistance that are not fully understood. In the current article, we make a non-exhaustive critical review of some of them that we consider of special relevance, in the aim of presenting a snapshot of the studies that still need to be done to tackle antibiotic resistance.

Antibiotic Consumption, Illness, and Maternal Sensitivity in Infants with a Disorganized Attachment

Prior research found an association between mother-infant attachment and antibiotic use. Ambivalent-attached infants are more likely to take antibiotics than other infants, and their mothers tend to be less sensitive to their needs than most. This finding is important because it shows the association between psychological processes, early relationships, and health outcomes. We aim to learn about children with high-risk attachment relationships, such as disorganized-attached infants. This study compares antibiotic use, infant-mother interactive behavior, and health indicators according to infant attachment patterns (including disorganized attachment). For this purpose, we observed mothers-infants' interactive behavior in free play at nine months and infants' attachment in the Ainsworth Strange Situation at twelve months. Participants included 77 girls and 104 boys (full-term and preterm) and their mothers. Paradoxically, mothers of disorganized-attached infants reported that their children were ill only 1.56 times on average, but 61% of their children used antibiotics in the first nine months. The other mothers reported that their children were sick 5.73 times on average, but only 54% of their children used antibiotics in the same period. Infants with disorganized attachment had mothers who were more literate and less sensitive. These results add to a body of research that shows that early high-risk relationships affect children's lives at multiple levels.

Multi-Drug Resistance in Bacterial Genomes-A Comprehensive Bioinformatic Analysis

Antimicrobial resistance is presently one of the greatest threats to public health. The excessive and indiscriminate use of antibiotics imposes a continuous selective pressure that triggers the emergence of multi-drug resistance. We performed a large-scale analysis of closed bacterial genomes to identify multi-drug resistance considering the ResFinder antimicrobial classes. We found that more than 95% of the genomes harbor genes associated with resistance to disinfectants, glycopeptides, macrolides, and tetracyclines. On average, each genome encodes resistance to more than nine different classes of antimicrobial drugs. We found higher-than-expected co-occurrences of resistance genes in both plasmids and chromosomes for several classes of antibiotic resistance, including classes categorized as critical according to the World Health Organization (WHO). As a result of antibiotic-resistant priority pathogens, higher-than-expected co-occurrences appear in plasmids, increasing the potential for resistance dissemination. For the first time, co-occurrences of antibiotic resistance have been investigated for priority pathogens as defined by the WHO. For critically important pathogens, co-occurrences appear in plasmids, not in chromosomes, suggesting that the resistances may be epidemic and probably recent. These results hint at the need for new approaches to treating infections caused by critically important bacteria.

Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China

OBJECTIVE

This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China.

METHODS

Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi's method were used to generate qualitative codes and identify themes.

RESULTS

Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications.

CONCLUSION

Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.

Plasmids Increase the Competitive Ability of Plasmid-Bearing Cells Even When Transconjugants Are Poor Donors, as Shown by Computer Simulations

Bacterial cells often suffer a fitness cost after conjugative plasmids' entry because these cells replicate slower than plasmid-free cells. Compensatory mutations may appear after tens of or a few hundred generations, reducing or eliminating this cost. A previous work based on a mathematical model and computer simulations has shown that plasmid-bearing cells already adapted to the plasmid may gain a fitness advantage when plasmids transfer into neighboring plasmid-free cells because these cells are still unadapted to the plasmid. These slow-growing transconjugants use fewer resources, which can benefit donor cells. However, opportunities for compensatory mutations in transconjugants increase if these cells become numerous (through replication or conjugation). Moreover, transconjugants also gain an advantage when transferring the plasmid, but the original donors may be too distant from conjugation events to gain an advantage. To understand which consequence prevails, we performed further computer simulations allowing versus banning transfer from transconjugants. The advantage to donors is higher if transconjugants do not transfer plasmids, mainly when donors are rare and when the plasmid transfer rate (from donors) is high. These results show that conjugative plasmids are efficient biological weapons even if the transconjugant cells are poor plasmid donors. After some time, conjugative plasmids gain other host-benefit genes, such as virulence and drug-resistance.

Plasmid Costs Explain Plasmid Maintenance, Irrespective of the Nature of Compensatory Mutations

Conjugative plasmids often carry virulence and antibiotic-resistant genes. Therefore, understanding the behavior of these extra-chromosomal DNA elements gives insights into their spread. Bacteria frequently replicate slower after plasmids' entry, an observation inconsistent with the plasmids' ubiquity in nature. Several hypotheses explain the maintenance of plasmids among bacterial communities. However, the numerous combinations of bacterial species and strains, plasmids, and environments claim a robust elucidatory mechanism of plasmid maintenance. Previous works have shown that donor cells already adapted to the plasmid may use the plasmid as a 'weapon' to compete with non-adapted plasmid-free cells. Computer simulations corroborated this hypothesis with a wide range of parameters. Here we show that donor cells benefit from harboring conjugative plasmids even if compensatory mutations in transconjugant cells occur in the plasmid, not on chromosomes. The advantage's leading causes are as follows: mutations take time to appear, many plasmids remain costly, and re-transfer of mutated plasmids usually occurs in sites distant to the original donors, implying little competition between these cells. Research in previous decades cautioned against uncritical acceptance of the hypothesis that resistance cost helps to preserve antibiotics' effectiveness. This work gives a new twist to this conclusion by showing that costs help antibiotic-resistant bacteria to compete with plasmid-free cells even if compensatory mutations appear in plasmids.

Antimicrobial Resistance in the Global Health Network: Known Unknowns and Challenges for Efficient Responses in the 21st Century

Antimicrobial resistance (AMR) is one of the Global Health challenges of the 21st century. The inclusion of AMR on the global map parallels the scientific, technological, and organizational progress of the healthcare system and the socioeconomic changes of the last 100 years. Available knowledge about AMR has mostly come from large healthcare institutions in high-income countries and is scattered in studies across various fields, focused on patient safety (infectious diseases), transmission pathways and pathogen reservoirs (molecular epidemiology), the extent of the problem at a population level (public health), their management and cost (health economics), cultural issues (community psychology), and events associated with historical periods (history of science). However, there is little dialogue between the aspects that facilitate the development, spread, and evolution of AMR and various stakeholders (patients, clinicians, public health professionals, scientists, economic sectors, and funding agencies). This study consists of four complementary sections. The first reviews the socioeconomic factors that have contributed to building the current Global Healthcare system, the scientific framework in which AMR has traditionally been approached in such a system, and the novel scientific and organizational challenges of approaching AMR in the fourth globalization scenario. The second discusses the need to reframe AMR in the current public health and global health contexts. Given that the implementation of policies and guidelines are greatly influenced by AMR information from surveillance systems, in the third section, we review the unit of analysis ("the what" and "the who") and the indicators (the "operational units of surveillance") used in AMR and discuss the factors that affect the validity, reliability, and comparability of the information to be applied in various healthcare (primary, secondary, and tertiary), demographic, and economic contexts (local, regional, global, and inter-sectorial levels). Finally, we discuss the disparities and similarities between distinct stakeholders' objectives and the gaps and challenges of combatting AMR at various levels. In summary, this is a comprehensive but not exhaustive revision of the known unknowns about how to analyze the heterogeneities of hosts, microbes, and hospital patches, the role of surrounding ecosystems, and the challenges they represent for surveillance, antimicrobial stewardship, and infection control programs, which are the traditional cornerstones for controlling AMR in human health.

The Association between Prematurity, Antibiotic Consumption, and Mother-Infant Attachment in the First Year of Life

Antibiotics have individual and public-health drawbacks. Nevertheless, mother-infant attachment quality and maternal sensitivity are associated with antibiotic use. Ambivalent-attached infants are more likely to consume antibiotics than other infants. Conceivably, the emotional over-externalization of ambivalent-attached infants and maternal anxiety when infants are ill raise concerns in healthcare professionals, leading to antibiotic over-prescriptions. However, because infants prematurely born, particularly those with less than 32 weeks of gestation, are under more accurate health vigilance, the impact of infant and maternal behavior on antibiotic prescription may vanish in this sample. To test this hypothesis, we performed a longitudinal study to compare antibiotic use and the quality of mother-infant attachment in three groups: 86 infants born at full-term, 44 moderate-to-late preterm infants (32-36 gestation weeks), and 58 very-to-extreme preterm infants (<32 gestation weeks). Infants' attachment was observed with the Ainsworth Strange Situation's experimental paradigm at 12 months of corrected age. Findings indicate that infant attachment strategy is associated with antibiotics uptake, but results vary across samples. The proportion of infants that used antibiotics is highest among ambivalent-attached infants in the full-term sample but highest among avoidant-attached infants in the very-to-extreme premature sample. Moreover, higher infant gestational age and lower maternal sensitivity determine higher antibiotic use.