Salivary polyreactive antibodies and Haemophilus influenzae are associated with respiratory infection severity in young children with recurrent respiratory infections

BACKGROUND

Recurrent respiratory tract infections (rRTIs) are a common reason for immunodiagnostic testing in children, which relies on serum antibody level measurements. However, because RTIs predominantly affect the respiratory mucosa, serum antibodies may inaccurately reflect local immune defences. We investigated antibody responses in saliva and their interplay with the respiratory microbiota in relation to RTI severity and burden in young children with rRTIs.

METHODS

We conducted a prospective cohort study including 100 children aged <10 years with rRTIs, their family members and healthy healthcare professionals. Total and polyreactive antibody concentrations were determined in serum and saliva (ELISA); respiratory microbiota composition (16S rRNA sequencing) and respiratory viruses (quantitative PCR) were characterised in nasopharyngeal swabs. Proteomic analysis (Olink) was performed on saliva and serum samples. RTI symptoms were monitored with a daily mobile phone application and assessed using latent class analysis and negative binomial mixed models.

RESULTS

Serum antibody levels were not associated with RTI severity. Strikingly, 28% of salivary antibodies and only 2% of serum antibodies displayed polyreactivity (p<0.001). Salivary polyreactive IgA was negatively associated with recurrent lower RTIs (adjusted OR 0.80, 95% CI 0.67-0.94) and detection of multiple respiratory viruses (adjusted OR 0.76, 95% CI 0.61-0.96). Haemophilus influenzae abundance was positively associated with RTI symptom burden (regression coefficient 0.05, 95% CI 0.02-0.08).

CONCLUSION

These results highlight the importance of mucosal immunity in RTI severity and burden, and suggest that the level of salivary polyreactive IgA and H. influenzae abundance may serve as indicators of infection severity and burden in young children with rRTIs.

Prescribing Antibiotics for Children with Acute Conditions in Public Primary Care Clinics in Singapore: A Retrospective Cohort Database Study

Data on primary care antibiotic prescription practices for children in Singapore, which are essential for health care policy, are lacking. We aimed to address this gap and to benchmark prescription practices against international standards. A retrospective cohort database study on antibiotic prescriptions for children (aged < 18 years) who visited six public primary care clinics in Singapore between 2018 and 2021 was conducted. Data were categorised according to the World Health Organization's Access, Watch, Reserve (WHO AWaRe) classification. Quality indicators from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) and the National Institute for Health and Care Excellence (NICE) guidelines were used as a measure of appropriateness of antibiotic prescribing at the individual and overall patient level. In 831,669 polyclinic visits by children between 2018 and 2021, there was a significant reduction in mean antibiotics prescribed per month during pandemic years (2020-2021) compared to pre-pandemic (2018-2019) (MD 458.3, 95% CI 365.9-550.7). Most prescriptions (95.8%) for acute conditions fell within the WHO AWaRe "Access" group. Antibiotic prescription significantly exceeded (55.2%) the relevant quality indicator for otitis media (0-20%). The proportion of children receiving appropriate antibiotics for acute respiratory infections (n = 4506, 51.3%) and otitis media (n = 174, 49.4%) was low compared to the quality indicator (80-100%). There is a need to develop local evidence-based primary care antibiotic guidelines, as well as to support the development of stewardship programmes.

Antibiotic consumption in the first months of life: A cross-sectional study

INTRODUCTION

The factors and patterns associated with antibiotic consumption in infants are unclear. Our aim was to assess the cumulative incidence of antibiotic consumption from birth to 16 months and identify factors associated with antibiotic consumption among infants aged 4-16 months.

MATERIAL AND METHODS

We conducted a cross-sectional study in 2016 in a sample of 18 882 women from Galicia, Spain, who had given birth to a live child between September 1, 2015 and August 31, 2016. We calculated the cumulative incidence of antibiotic consumption based on maternal reports regarding the infant's consumption from birth to 14 months obtained through interviews; we did not estimate consumption at ages 15 and 16 months due to the small sample size. To assess which factors were associated with antibiotic consumption, we carried out a nested case-control study matching cases and controls for birth month on a 1:1 ratio.

RESULTS

The cumulative incidence of antibiotic consumption among infants aged 0-14 months increased from 7.5% to 66.0%. The case-control study included data for 1852 cases and 1852 controls. Daycare attendance (OR: 3.8 [95% CI: 3.2-4.6]), having older siblings (OR: 1.8 [95% CI: 1.6-2.1]), health care visits to private clinics (OR: 1.6 [95% CI: 1.4-2.0]), and passive smoking (OR: 1.3 [95% CI: 1.1-1.6]) were associated with an increased probability of antibiotic consumption. Maternal age between 30-39 years or 40 years and over at the time of birth was associated with a decreased probability of antibiotic consumption (OR: 0.8 [95% CI, 0.7-1.0] and OR: 0.6 [95% CI: 0.5-0.8], respectively).

CONCLUSIONS

Some of the factors associated with antibiotic consumption in infants are modifiable and should be considered in the development of public health measures aimed at reducing antibiotic consumption.

Use of antibiotics contrary to guidelines for children's lower respiratory tract infections in different health care settings

This study aimed to evaluate antibiotic prescriptions for children with lower respiratory tract infection (LRTI) in public and private primary care clinics and in a hospital's pediatric emergency department (PED) in 2012-2013 (pre-guideline) and in 2014-2015 (post-guideline). Special attention was paid to guideline compliance, especially regarding macrolide prescriptions, which the guidelines discourage. Retrospective data of 1431 children with LRTI in November-December 2012-2015 were collected from electronic registers and checked manually. Three diagnostic groups were analyzed: community-acquired pneumonia (CAP), wheezing bronchitis, and non-wheezing bronchitis. A comparison of the pre- and post-guideline periods revealed antibiotic prescription rates of 48.7% and 48.9% (p = 0.955) for all LRTIs, respectively, and 77.6% and 71.0% (p = 0.053) for non-wheezing bronchitis. The prescription rates for all LRTIs were 24.9% in PED and 45.9% in public (p < 0.001 vs. PED) and 75.4% in private clinics (p < 0.001 vs. PED and p < 0.001 vs. public clinics). During post-guideline periods, antibiotics were prescribed for CAP less often in private (56.3%) than in public clinics (84.6%; p = 0.037) or in PED (94.3%; p < 0.001 vs. private and p = 0.091 vs. public primary clinics). Macrolide prescriptions were highest in private clinics (42.8%), followed by public primary care clinics (28.5%; p < 0.05) and PED (0.8%; p < 0.05 vs. both public and private primary care). Amoxicillin was the predominant antibiotic in public primary care and PED and macrolides in private primary care.

CONCLUSION

 Antibiotic prescribing for children with LRTI differed significantly between healthcare providers. CAP was undertreated and bronchitis overtreated with antibiotics in primary care, especially in the private clinics.

WHAT IS KNOWN

• Clinical Treatment Guidelines tend to have modest effect on physicians' antibiotic prescribing habits. • Pediatric viral LRTIs are widely treated with unnecessary antibiotics.

WHAT IS NEW

• Remarkable differences in antibiotic prescriptions in pediatric LRTIs between Finnish private and public providers were observed. • Overuse of macrolides was common especially in private clinics.

Antibiotic Prescribing for Lower Respiratory Tract Infections and Community-Acquired Pneumonia: An Italian Pediatric Emergency Department's Real-Life Experience

BACKGROUND

Lower respiratory tract infections (LRTIs) and community-acquired pneumonia (CAP) are among the most frequent reasons for referrals to the pediatric emergency department (PED). The aim of this study is to describe the management of antibiotic prescription in febrile children with LRTI or CAP admitted to a third-level PED and to investigate the different variables that can guide physicians in this decision-making.

METHODS

This is an observational, retrospective, monocentric study including patients < 14 years old who were presented to the PED for a febrile LRTI or CAP during the first six months of the year 2017. Demographic and clinical data, PED examinations, recommended therapy, and discharge modality were considered. Two multivariate logistic regression analyses were performed on patients with complete profiles to investigate the impact of demographic, laboratory, and clinical variables on antibiotic prescription and hospital admission.

RESULTS

This study included 584 patients with LRTI (n = 368) or CAP (n = 216). One hundred and sixty-eight individuals (28.7%) were admitted to the hospital. Lower age, higher heart rate, and lower SpO2 were associated with an increased risk of hospitalization. Antibiotics were prescribed to 495 (84.8%) patients. According to the multivariate logistic regression, the diagnosis and duration of fever were substantially linked with antibiotic prescription.

CONCLUSIONS

The present study reports real-life data about our PED experience. A high rate of antibiotic prescription was noted. In the future, it is necessary to improve antibiotic stewardship programs to increase clinical adherence to guidelines.

Inappropriate antibiotic prescribing in primary healthcare facilities in China: a nationwide survey, 2017-2019

OBJECTIVES

We aimed to generate comprehensive estimates of the appropriateness of outpatient antibiotic prescriptions at primary healthcare facilities (PHFs) in China.

METHODS

Between 2017 and 2019, we collected outpatient-visit prescriptions from 269 Chinese PHFs in 31 cities located in 6 provinces. Conditions that resulted in antibiotic use were classified into appropriate, potentially appropriate, and inappropriate using a well-established classification approach. We then assessed the magnitude, appropriateness, and costs of antibiotic prescribing, overall and by antibiotic classification group, diagnostic categories, and patient characteristics.

RESULTS

Of all eligible 209 662 antibiotic prescriptions, 147 758 (70.5%) were inappropriate, which accounted for 66.8% (558.0/835.3 thousand US dollars) of costs for antibiotics. Upper respiratory tract infections, acute bronchitis, and non-infectious gastroenteritis were responsible for 68.9% (101 744/147 758) of inappropriately antibiotic prescriptions. High inappropriate antibiotic prescribing rates were observed among children aged 0-5 years (78.5% (21 049/26 799)) and patients living in economically undeveloped areas (77.5% (38 430/49 587)). A total of 256 474 individual antibiotics were prescribed, of which 82.2% (210 885/256 474) were broad-spectrum antibiotics, with second-generation cephalosporins (15.1% (38 705/256 474)) and third-generation cephalosporins (14.6% (37 491/256 474)) being the most commonly prescribed subgroups.

DISCUSSION

Our findings highlight the excessive and inappropriate use of antibiotics in Chinese PHFs pending multidimensional efforts.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Polish Medical Doctors' Opinions on Available Resources and Information Campaigns concerning Antibiotics and Antibiotic Resistance, a Cross-Sectional Study

Background: Antibiotic resistance (ABR) is at the top of global health threats. This paper aims to assess Polish physicians' readiness to impact ABR through prescribing routines. Methods: Surveying Polish physicians participating in specialization courses at the Center for Postgraduate Medical Education in Warsaw, Poland from October 2019 to March 2020. Results: Information was obtained from 504 physicians aged 25-59, mean 32.8 ± 5.9 years, mainly women (65%). Most doctors (78%) prescribed antibiotics at least once a week. Physicians indicated clinical practice guidelines as resources most often consulted in the management of infections (90%). However, clinical experience was also declared a powerful resource. In total, 54% of respondents recalled receiving information about the prudent use of antibiotics within 12 months, which partially translated into changing views (56%) and practice (42%). Physicians disagreed that national campaigns provide good promotion of prudent antibiotics use (75%) or that they are effective (61%). Only 40% of doctors were aware of the national campaign promoting responsible antibiotics use, 24% had heard about the European Antibiotic Awareness Day and 20% knew about the World Antimicrobial Awareness Week. Conclusions: Prescribers most often rely on clinical practice guidelines and their own experience as resources for antibiotics use. Doctors' awareness of available resources and information campaigns concerning antibiotics and antibiotic resistance should be improved.

Quality appraisal of antibiotic consumption in the community, European Union/European Economic Area, 2009 and 2017

Objectives

The quality of antibiotic consumption in the community can be assessed using 12 drug-specific quality indicators (DSQIs) developed by the European Surveillance of Antimicrobial Consumption (ESAC) project. We compared quality in 2009 and 2017 in the EU/European Economic Area (EEA) and evaluated the impact of using different DDD values (ATC/DDD indices 2011 and 2019) for the 2009 quality assessment using these DSQIs and a joint scientific opinion (JSO) indicator.

Methods

We calculated the 12 DSQIs and the JSO indicator for 2017 and for 2009 for EU/EEA countries able to deliver values. For each of the indicators we grouped the 2017 and 2009 indicator values into four quartiles. To evaluate changes in quality between 2009 and 2017, we used the quartile distribution of the 2009 indicator values in 30 EU/EEA countries as benchmarks. In addition, we compared the quality assessment for 2009 using the ATC/DDD indices 2011 and 2019.

Results

In 2017, a difference in the quality of antibiotic consumption in the community between northern and southern EU/EEA countries remained, but also several eastern EU/EEA countries shifted towards lower quality. Quality of antibiotic consumption decreased between 2009 and 2017 in particular indicator values for penicillin, quinolone, relative β-lactam and broad- versus narrow-spectrum antibiotic consumption, and seasonal variation. Using different ATC/DDD indices did not substantially change countries’ ranking based on their DSQI values.

Conclusions

The quality of antibiotic consumption in the community as measured by the DSQIs further decreased between 2009 and 2017, especially in Southern and Eastern European countries. A continuous effort to improve antibiotic consumption is essential to reduce antibiotic consumption in general and the use of broad-spectrum antibiotics in particular.

Antibiotic use among hospitalized children with lower respiratory tract infections: a multicenter, retrospective study from Punjab, Pakistan

BACKGROUND

Lower respiratory tract infection (LRTI) is one of the triggering factors toward death in children below the age of five years necessitating appropriate antibiotic selection. This study aimed to evaluate antibiotic use among hospitalized children (≤5 years age) with LRTIs.

METHODS

A retrospective study was conducted in seven health facilities of the central region of Punjab province of Pakistan. The medical records of hospitalized children ≤5 years diagnosed with LRTI were thoroughly evaluated to get information on demographics, clinical characteristics, and details of prescribed antibiotics. The appropriateness of antibiotics was assessed according to guidelines of the British National Formulary due to a lack of indigenous standard treatment guidelines.

RESULTS

The medical records of 5926 children were searched with the majority (70.9%) diagnosed with community-acquired pneumonia (CAP) followed by acute bronchitis (14.1%). Ceftriaxone plus ampicillin and ceftriaxone plus ampicillin plus amikacin were prescribed to 39% and 11.7% study population, respectively. One-fourth of children were prescribed the wrong dose, and more than half were encountered with the incorrect route of antibiotic administration. Alarmingly, 90.2% of antibiotic prescriptions were inappropriate in our findings.

CONCLUSIONS

Current surveillance study revealed a worrying degree of antibiotic misuse among hospitalized LRTI children aged ≤5 years.

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

Community antibiotic prescribing for children in France from 2015 to 2017: a cross-sectional national study

OBJECTIVES

To assess recent community antibiotic prescribing for French children and identify areas of potential improvement.

METHODS

We analysed 221 768 paediatric (<15 years) visits in a national sample of 680 French GPs and 70 community paediatricians (IQVIA's EPPM database), from March 2015 to February 2017, excluding well-child visits. We calculated antibiotic prescription rates per 100 visits, separately for GPs and paediatricians. For respiratory tract infections (RTIs), we described broad-spectrum antibiotic use and duration of treatment. We used Poisson regression to identify factors associated with antibiotic prescribing.

RESULTS

GPs prescribed more antibiotics than paediatricians [prescription rate 26.1 (95% CI 25.9-26.3) versus 21.6 (95% CI 21.0-22.2) per 100 visits, respectively; P < 0.0001]. RTIs accounted for more than 80% of antibiotic prescriptions, with presumed viral RTIs being responsible for 40.8% and 23.6% of all antibiotic prescriptions by GPs and paediatricians, respectively. For RTIs, antibiotic prescription rates per 100 visits were: otitis, 68.1 and 79.8; pharyngitis, 67.3 and 53.3; sinusitis, 67.9 and 77.3; pneumonia, 80.0 and 99.2; bronchitis, 65.2 and 47.3; common cold, 21.7 and 11.6; bronchiolitis 31.6 and 20.1; and other presumed viral RTIs, 24.1 and 11.0, for GPs and paediatricians, respectively. For RTIs, GPs prescribed more broad-spectrum antibiotics [49.8% (95% CI 49.3-50.3) versus 35.6% (95% CI 34.1-37.1), P < 0.0001] and antibiotic courses of similar duration (P = 0.21). After adjustment for diagnosis, antibiotic prescription rates were not associated with season and patient age, but were significantly higher among GPs aged ≥50 years.

CONCLUSIONS

Future antibiotic stewardship campaigns should target presumed viral RTIs, broad-spectrum antibiotic use and GPs aged ≥50 years.

Adherence to standard treatment guidelines among prescribers in primary healthcare facilities in the Dodoma region of Tanzania

Background

Tanzania’s primary healthcare system suffers from a scarcity of financial and human resources that impedes its effectiveness to deliver dependable and uniform quality healthcare. Adherence to standard treatment guidelines (STG) can help provide more consistent and correct diagnoses and treatments and limit the irrational use of medicines and the negative health consequences that can occur as a result. The purpose of this study was to investigate prescribers’ adherence of their diagnoses and respective treatments to national STG and to identify potential areas for planning interventions.

Methods

A cross-sectional study on prescribers’ adherence to diagnosis and treatment, according to national STG, was conducted in 2012 in public primary healthcare facilities (HCF) in the Dodoma region of Tanzania. Information on 2886 patients was collected, prospectively and retrospectively, from 120 HCF across the Dodoma region using a structured questionnaire. Twenty-five broadly defined main illness groups were recorded and the nine most prevalent and relevant conditions were statistically analysed in detail.

Results

Diagnoses and related treatments were recorded and analysed in 2872 cases. The nine most prevalent conditions were upper respiratory tract infections (25%), malaria (18%), diarrhoea (9.9%), pneumonia (6.1%), skin problems (5.8%), gastrointestinal diagnoses (5%), urinary tract infections (4%), worm infestations (3.6%) and eye problems (2.1%). Only 1.8% of all diagnoses were non-communicable diseases. The proportion of prescribers’ primary diagnoses that completely adhered to national STG was 599 (29.9%), those that partially adhered totalled 775 (38.7%), wrong medication was given in 621 cases (30.9%) and no diagnosis or medication was given in nine cases (0.5%). Sixty-one percent of all patients received an antibiotic regardless of the diagnoses. Complete adherence was highest when worms were diagnosed and lowest for diarrhoea. The proportion of cases that did not adhere to STG was highest with patients with skin problems and lowest for malaria.

Conclusion

Prescribers’ general adherence to national STG in primary HCF in the public sector in Dodoma region is sub-optimal. The reasons are multifaceted and focused attention, directed at improving prescribing and pharmacotherapy, is required with a view of improving patient care and health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06257-y.

Increased antimicrobial resistance during the COVID-19 pandemic

In addition to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection itself, an increase in the incidence of antimicrobial resistance poses collateral damage to the current status of the COVID-19 (coronavirus disease 2019) pandemic. There has been a rapid increase in multidrug-resistant organisms (MDROs), including extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae, carbapenem-resistant New Delhi metallo-β-lactamase (NDM)-producing Enterobacterales, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), pan-echinocandin-resistant Candida glabrata and multi-triazole-resistant Aspergillus fumigatus. The cause is multifactorial and is particularly related to high rates of antimicrobial agent utilisation in COVID-19 patients with a relatively low rate of co- or secondary infection. Appropriate prescription and optimised use of antimicrobials according to the principles of antimicrobial stewardship as well as quality diagnosis and aggressive infection control measures may help prevent the occurrence of MDROs during this pandemic.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antibiotic Prescriptions for Children With Community-acquired Pneumonia: Findings From Italy

INTRODUCTION AND OBJECTIVE

Community-acquired pneumonia (CAP) is one of the most common reasons of prescribing antibiotics for children, often with overuse of broad-spectrum antibiotics. The aim of this study is to describe the antibiotic prescriptions for Italian children with CAP, at the primary care level.

STUDY DESIGN

Retrospective cohort study conducted among children 3 months-14 years of age with CAP, enrolled in Pedianet (http://www.pedianet.it) from January 1, 2009 to December 31, 2018. Antibiotic treatment was defined as narrow-spectrum (NS-ABT) if amoxicillin and broad-spectrum (BS-ABT) if amoxicillin/clavulanic acid, cephalosporins or any combination. Crude and adjusted logistic regressions for the odds of receiving NS-ABT were conducted (all episodes of CAP and per patient). A P value <0.05 was considered statistically significant.

RESULTS

Among 9691 CAP, 7260 episodes from 6409 children followed by 147 pediatricians were analyzed. The 16.7% of CAP [1216/7260, 95% confidence interval (CI): 15.9%-17.6%] received an NS-ABT while 53.3% (3863/7260, 95% CI: 52%-54.4%) received BS-ABTs and 30% (2181/7260, 95% CI: 28.9%-31.1%) macrolides. Within 10 years, a slight but increasing trend of NS-ABT prescription was observed (P < 0.001). Factors independently associated with reduced odds of receiving an NS-ABT compared with BS-ABT including macrolides were being older than 5 years [odds ratio (OR) 0.45, 95% CI: 0.39-0.52], living in Central/Southern Italy (OR 0.13, 95% CI: 0.10-0.16) and being exposed to ABT 3 months before (OR 0.61, 95% CI: 0.53-0.70). These findings were confirmed comparing NS-ABT versus BS-ABT excluding macrolides (n = 5079) and when the analysis was limited to index CAP.

CONCLUSION

Our findings report a very limited prescription of narrow-spectrum antibiotics for Italian children with CAP.

Gradual decline in outpatient antibiotic prescriptions in paediatrics: A data warehouse-based 11-year cohort study

AIM

To describe trends in antibiotic (AB) prescriptions in children in primary care over 11 years, using a large data warehouse.

METHODS

A retrospective cohort study assessed outpatient AB prescriptions 2007-2017, using the Massachusetts Health Disparities Repository. The evolution of paediatric outpatient AB prescriptions was assessed using time-series analyses through annual per cent change (APC) for the population and for children with or without comorbid condition.

RESULTS

About 25 000 children were followed in primary care with 31 248 AB prescriptions reported in the data warehouse. The youngest children had more AB prescriptions. Penicillins were prescribed most frequently (46%), then macrolides (28%). One third of children had comorbid conditions, receiving significantly more antibiotics (30.3 vs 21.0 AB/100 child-years, relative risk: 1.43, 95% CI: 1.40, 1.46). Overall AB prescription decreased over the period (APC = -5.34%, 95% CI: -7.10, -3.54), with similar trends for penicillins (APC = -5.49; 95% CI: -8.27, -2.62) and macrolides (APC = -6.46; 95% CI: -8.37, -4.58); antibiotic prescribing declined more in children with comorbid conditions.

CONCLUSION

Outpatient AB prescribing decline was gradual and consistent in paediatrics over the period. Prescription differences persisted between age groups, conditions and indication. The availability of routine care data through data warehouse fosters the surveillance automation, providing inexpensive fast tools to design appropriate antimicrobial stewardship.

Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation

Respiratory tract infections (RTIs) account for a large part of antibiotic prescriptions in primary care. However, guidelines advise restrictive antibiotic prescribing for RTIs. Only in certain circumstances, depending on, e.g., comorbidity, are antibiotics indicated. Most studies on guideline adherence do not account for this. We aimed to assess guideline adherence for antibiotic prescribing for RTIs as well as its variation between general practices (GPs), accounting for patient characteristics. We used data from electronic health records of GPs in the Netherlands. We selected patients who consulted their GP for acute cough, rhinitis, rhinosinusitis or sore throat in 2014. For each disease episode we assessed whether, according to the GP guideline, there was an indication for antibiotics, using the patient's sociodemographic characteristics, comorbidity and co-medication. We assessed antibiotic prescribing for episodes with no or an unsure indication according to the guidelines. We analysed 248,896 episodes. Diagnoses with high rates of antibiotic prescribing when there was no indication include acute tonsillitis (57%), strep throat (56%), acute bronchitis (51%) and acute sinusitis (48%). Prescribing rates vary greatly between diagnoses and practices. Reduction of inappropriate antibiotic prescribing remains a key target to tackle antimicrobial resistance. Insight into reasons for guideline non-adherence may guide successful implementation of the variety of interventions already available for GPs and patients.

Does shared decision-making reduce antibiotic prescribing in primary care?

Background

Increasing antibiotic resistance is recognized as a major threat to global health and is related to antibiotic prescription rates in primary care. Shared decision-making (SDM), the process in which patients and doctors participate together in making decisions, is argued to possibly promote more appropriate use of antibiotics and reduce prescribing. However, it is unknown whether in practice fewer antibiotics are prescribed where more SDM takes place.

Objectives

To investigate whether more SDM is related to less antibiotic prescribing and whether this relationship differs between subgroups of patients (male/female and age groups).

Patients and methods

A questionnaire survey was conducted among 2670 members of the Dutch Health Care Consumer Panel to measure SDM (response rate 45%). Average practice-level SDM scores were calculated for 15 general practices. Data from routine electronic health records of 8192 adult patients of these general practices participating in the Nivel Primary Care Database were used to assess relevant illness episodes (acute cough, acute rhinosinusitis and urinary tract infection), the indication for antibiotics and antibiotic prescriptions. Logistic multilevel regression analyses were performed to investigate the relationship between practice-level SDM and patient-level antibiotic prescriptions.

Results

In practices where more SDM takes place, general practitioners prescribed fewer antibiotics for adult patients under the age of 40 years in preference-sensitive situations (i.e. situations in which antibiotics could be considered according to clinical guidelines).

Conclusions

SDM can be a framework to reduce the prescribing of antibiotics and thus to control antibiotic resistance.

Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care

INTRODUCTION

One way to slow the spread of resistant bacteria is by improved stewardship of antibiotics: using them more carefully and reducing the number of prescriptions. With an estimated 7%-10% of antibiotic prescriptions globally originating from dental practices and up to 80% prescribed unnecessarily, dentistry has an important role to play. To support the design of new stewardship interventions through knowledge transfer between contexts, this study aimed to identify factors associated with the decision to prescribe antibiotics to adults presenting with acute conditions across primary care (including dentistry).

METHODS

Two reviews were undertaken: an umbrella review across primary healthcare and a systematic review in dentistry. Two authors independently selected and quality assessed the included studies. Factors were identified using an inductive thematic approach and mapped to the Theoretical Domains Framework (TDF). Comparisons between dental and other settings were explored. Registration number: PROSPERO_CRD42016037174.

RESULTS

Searches identified 689 publications across primary care and 432 across dental care. Included studies (nine and seven, respectively) were assessed as of variable quality. They covered 46 countries, of which 12 were low and middle-income countries (LMICs). Across the two reviews, 30 factors were identified, with 'patient/condition characteristics', 'patient influence' and 'guidelines & information' the most frequent. Two factors were unique to dental studies: 'procedure possible' and 'treatment skills'. No factor related only to LMICs.

CONCLUSIONS

A comprehensive list of factors associated with antibiotic prescribing to adults with acute conditions in primary care settings around the world has been collated and should assist theory-informed design of new context-specific stewardship interventions.

Antibiotic Prescribing in Outpatient Children: A Cohort From a Clinical Data Warehouse

AIM

To characterize antibiotic (ab) prescriptions in children.

METHODS

Evaluation of outpatient ab prescriptions in a 3-year cohort of children in primary care using a data warehouse (Massachusetts Health Disparities Repository) by comorbid conditions, demographics, and clinical indication.

RESULTS

A total of 15 208 children with nearly 120 000 outpatient visits were included. About one third had a comorbid condition (most commonly asthma). Among the 30 000 ab prescriptions, first-line penicillins and macrolides represented the most frequent ab (70%), followed by cephalosporins (16%). Comorbid children had 54.3 ab prescriptions/100 child-years versus 38.8 in children without comorbidity; ab prescription was higher in urinary tract infections (>60% of episodes), otitis, lower respiratory tract infections (>50%), especially in comorbid children and children under 2 year old. Ab prescriptions were significantly associated with younger age, emergency room visit, comorbid children, and acute infections.

DISCUSSION

A clinical data warehouse could help in designing appropriate antimicrobial stewardship programs and represent a potential assessment tool.

Potential for reducing inappropriate antibiotic prescribing in English primary care

Objectives

To identify and quantify inappropriate systemic antibiotic prescribing in primary care in England, and ultimately to determine the potential for reduction in prescribing of antibiotics.

Methods

Primary care data from 2013-15 recorded in The Health Improvement Network (THIN) database were used. Potentially inappropriate prescribing events in the database were identified by: (i) comparing prescribing events against treatment guidelines; (ii) comparing actual proportions of consultations resulting in prescription for a set of conditions with the ideal proportions derived from expert opinion; and (iii) identifying high prescribers and their number of prescriptions above an age- and body-system-specific benchmark.

Results

Applying the most conservative assumptions, 8.8% of all systemic antibiotic prescriptions in English primary care were identified as inappropriate, and in the least conservative scenario 23.1% of prescriptions were inappropriate. All practices had non-zero reduction potentials, ranging from 6.4% to 43.5% in the middle scenario. The four conditions that contributed most to inappropriate prescribing were sore throat (23.0% of identified inappropriate prescriptions), cough (22.2%), sinusitis (7.6%) and acute otitis media (5.7%). One-third of all antibiotic prescriptions lacked an informative diagnostic code.

Conclusions

This work demonstrates (i) the existence of substantial inappropriate antibiotic prescribing and (ii) poor diagnostic coding in English primary care. All practices (not just the high prescribers) should engage in efforts to improve antimicrobial stewardship. Better diagnostic coding, more precise prescribing guidelines and a deeper understanding of appropriate long-term uses of antibiotics would allow identification of further potential for reductions.

Cross-national comparison of paediatric antibiotic use in Norway, Portugal and Hungary

A cross-national comparison was performed on paediatric (0-19 years) antibiotic use in Hungary, Norway and Portugal to explore and compare the scale and pattern of paediatric antibiotic use in these three European countries. Ambulatory care systemic antibiotic use (ATC: J01) was retrieved from national databases for year 2014. The main outcome measure was number of antibacterial packages per child inhabitant per year (packages/child/year) and was further stratified by age groups. Paediatric antibiotic use peaked in Hungary with 1.3 packages/child/year, followed by Portugal (0.8) and Norway (0.3). This ranking was retained and was most prominent in the 5- to 9-year and 10- to 14-year age groups. The pattern of antibiotic use in different paediatric age groups varied also substantially between countries. Narrow-spectrum penicillins were much commonly used in Norway in all paediatric age subgroups in comparison with Hungary and Portugal. Newer, broad-spectrum cephalosporins and macrolides were widely prescribed for Hungarian and Portuguese children in all paediatric subgroups in contrast to Norway, while tetracyclines were commonly prescribed for Norwegian adolescents. The scale and pattern of paediatric antibiotic use in Hungary and Portugal were very different compared with Norway. The high antibiotic exposure and the high consumption of broad-spectrum penicillins begin in childhood in Hungary and Portugal which underpins the responsibility of paediatric GPs.

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.

Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections

Respiratory viral infections are associated with a wide range of acute syndromes and infectious disease processes in children and adults worldwide. Many viruses are implicated in these infections, and these viruses are spread largely via respiratory means between humans but also occasionally from animals to humans. This article is an American Society for Microbiology (ASM)-sponsored Practical Guidance for Clinical Microbiology (PGCM) document identifying best practices for diagnosis and characterization of viruses that cause acute respiratory infections and replaces the most recent prior version of the ASM-sponsored Cumitech 21 document, Laboratory Diagnosis of Viral Respiratory Disease, published in 1986. The scope of the original document was quite broad, with an emphasis on clinical diagnosis of a wide variety of infectious agents and laboratory focus on antigen detection and viral culture. The new PGCM document is designed to be used by laboratorians in a wide variety of diagnostic and public health microbiology/virology laboratory settings worldwide. The article provides guidance to a rapidly changing field of diagnostics and outlines the epidemiology and clinical impact of acute respiratory viral infections, including preferred methods of specimen collection and current methods for diagnosis and characterization of viral pathogens causing acute respiratory tract infections. Compared to the case in 1986, molecular techniques are now the preferred diagnostic approaches for the detection of acute respiratory viruses, and they allow for automation, high-throughput workflows, and near-patient testing. These changes require quality assurance programs to prevent laboratory contamination as well as strong preanalytical screening approaches to utilize laboratory resources appropriately. Appropriate guidance from laboratorians to stakeholders will allow for appropriate specimen collection, as well as correct test ordering that will quickly identify highly transmissible emerging pathogens.

Point-of-care CRP matters: normal CRP levels reduce immediate antibiotic prescribing for acutely ill children in primary care: a cluster randomized controlled trial

OBJECTIVE

Antibiotics are prescribed too often in acutely ill children in primary care. We examined whether a Point-of-Care (POC) C-reactive Protein (CRP) test influences the family physicians' (FP) prescribing rate and adherence to the Evidence Based Medicine (EBM) practice guidelines.

DESIGN

Cluster randomized controlled trial.

SETTING

Primary care, Flanders, Belgium.

INTERVENTION

Half of the children with non-severe acute infections (random allocation of practices to perform POC CRP or not) and all children at risk for serious infection were tested with POC CRP.

SUBJECTS

Acutely ill children consulting their FP.

MAIN OUTCOME MEASURE

Immediate antibiotic prescribing.

RESULTS

2844 infectious episodes recruited by 133 FPs between 15 February 2013 and 28 February 2014 were analyzed. A mixed logistic regression analysis was performed. Compared to episodes in which CRP was not tested, the mere performing of POC CRP reduced prescribing in case EBM practice guidelines advise to prescribe antibiotics (adjusted odds ratio (aOR) 0.54 (95% Confidence Interval (CI) 0.33-0.90). Normal CRP levels reduced antibiotic prescribing, regardless of whether the advice was to prescribe (aOR 0.24 (95%CI 0.11-0.50) or to withhold (aOR 0.31 (95%CI 0.17-0.57)). Elevated CRP levels did not increase antibiotic prescribing.

CONCLUSION

Normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing. Key points What is previously known or believed on this topic •Antibiotics are prescribed too often for non-severe conditions. Point-of-care (POC) C-reactive Protein (CRP) testing without guidance does not reduce immediate antibiotic prescribing in acutely ill children in primary care. What this research adds •FPs clearly consider CRP once available: normal CRP levels discourage immediate antibiotic prescribing, even when EBM practice guidelines advise differently. Most likely, a normal CRP convinces FPs to withhold antibiotics when guidelines go against their own gut feeling. •Future research should focus on whether POC CRP can effectively identify children that benefit from antibiotics more accurately, without increasing the risks of under-prescribing.

Switching Between Antibiotics Among Danish Children 0-4 Years of Age: A Nationwide Drug Utilization Study

BACKGROUND

In Denmark, the use of amoxicillin is widespread among children, despite phenoxymethylpenicillin being recommended as first-line therapy. The reason for this apparent discrepancy is not fully understood. We aimed at evaluating prescribing patterns of antibiotics among Danish children 0-4 years of age, with emphasis on incidence of treatment episodes, choice of initial antibiotic treatment and switching patterns between different types of antibiotics.

METHODS

We identified all children ≤4 years of age who filled a prescription of antibiotics from 2000 to 2015 according to the nationwide Danish National Prescription Registry. We estimated the incidence rate of episodes treated with antibiotics and the choice of initial antibiotic treatment over time. Further, we assessed the cumulative risk of switching within 0-3 days after initiating therapy.

RESULTS

We identified 3,481,684 antibiotic treatment episodes issued to 0- to 4-year-olds from 2000 to 2015. The incidence rate was stable until 2011 both among children 0-1 years of age (approximately 880/1000) and among children 2-4 years of age (approximately 610/1000), after which it dropped. Phenoxymethylpenicillin and, increasingly, amoxicillin were most frequently used as initial treatments (39% vs. 44%). Few switched from amoxicillin (1%) or phenoxymethylpenicillin (4.7%) within the first 3 days. Of those who switched from phenoxymethylpenicillin, 64% received amoxicillin as second-line treatment.

CONCLUSIONS

The incidence of episodes treated with antibiotics among Danish children 0-4 years of age has decreased considerably since 2011. In contrast to guideline recommendations, amoxicillin is the most frequently used initial treatment. Early switching between antibiotics is uncommon. Initiatives should address the extensive use of amoxicillin.

Diagnostic value of signs, symptoms and diagnostic tests for diagnosing pneumonia in ambulant children in developed countries: a systematic review

Identifying a child with pneumonia in the large group of children with acute respiratory tract infections can be challenging for primary care physicians. Knowledge on the diagnostic value of specific signs and symptoms may guide future decision rules and guidelines for clinicians. We aimed to identify and systematically review available evidence for the diagnostic value of signs, symptoms, and additional tests to diagnose pneumonia in children in an ambulatory setting in developed countries. We conducted a systematic review, searching in the electronic databases of PubMed and Embase. Quality assessment of studies was done using the QUADAS-2 criteria. After data extraction from selected studies, we calculated and summarized test characteristics (sensitivity, specificity, negative and positive predictive values) of all available signs, symptoms, additional laboratory tests, and chest ultrasonography. The original search yielded 4665 records, of which 17 articles were eligible for analysis: 12 studies on signs and symptoms, 4 on additional laboratory tests, and 6 on ultrasonography. All included studies were performed in a secondary care setting. Risk of bias was present in the majority of studies in the domain of patient selection. Prevalence of pneumonia varied from 3.4% to 71.7%. The diagnostic value of the available 27 individual signs and symptoms to identify pneumonia was low. In a low prevalence setting, (4 studies, pneumonia prevalence <10%) clinically ill appearance of the child and oxygen saturation <94% can aid a physician. In a high prevalence setting (10 studies, pneumonia >10%), additional diagnostic tests such as oxygen saturation, C-reactive protein, and white blood cell count are more promising. Chest ultrasonography showed high diagnostic value in settings with higher prevalence of pneumonia. Single signs and symptoms from medical history and physical examination or individual additional diagnostic tests are insufficient to diagnose pneumonia in ambulant children. Very few diagnostic studies are conducted in settings with low prevalence of pneumonia. Future research in low prevalence settings should focus on the diagnostic value of the combination of clinical features and additional testing possibly using meta-analysis of individual data.

Current pharmacotherapeutic options for pediatric lower respiratory tract infections with a focus on antimicrobial agents

Introduction: Antibiotics are frequently prescribed to children in the community and in nosocomial settings, mainly because of lower respiratory tract infections(LRTIs), which include influenza, bronchitis, bronchiolitis, pneumonia, and tuberculosis, in addition to bronchiectasis and cystic fibrosis lung disease. It is important to note, however, that more than 50% of these prescriptions are unnecessary or inappropriate. Areas covered: The current choice of antimicrobial therapy for etiological agents of LRTIs is examined and discussed considering each type of LRTI. Expert opinion: There is a clear need for the appropriate utilization of antibiotics in children. Therefore, accurate drug selection and choice of best dosage and duration of the antibacterial treatment are important to optimize the treatment of LRTIs. It's fundamental to bear in mind that children differ from adults in how LRTIs manifest and evolve not only because of the diversity in the immunological profiles but also the fundamental age-related differences in absorption, distribution, metabolism, and elimination of drugs. Since comprehensive antibiotic guideline recommendations for the treatment of pediatric LRTIs are generally lacking, there is an undeniable need for the introduction of pediatric antimicrobial stewardship programmes in both community and hospital settings.

Knowledge, attitude, perception and practice regarding antimicrobial use in upper respiratory tract infections in Qatar: a systematic review

OBJECTIVE

To explore the knowledge, attitude, perception and practice towards antimicrobial use in upper respiratory tract infections in patients visiting healthcare settings in Qatar.

DESIGN

Systematic review was performed using a predetermined protocol and in accordance with standardized reporting guidelines. MEDLINE, PubMed, EMBASE, Global Health and PsycINFO were searched for relevant published studies using relevant MESH terms and keywords.

SETTING

All healthcare settings in Qatar including both inpatient and ambulatory care.

PARTICIPANTS

All published articles exploring the antimicrobial use in upper respiratory tract infections at any health setting in Qatar were considered for inclusion in the study. No age, gender or population were excluded.

MAIN OUTCOME MEASURES

The outcome of interest was antimicrobial use in upper respiratory tract infections in Qatar. We included all related studies to explore the knowledge, attitude, perception and practice for patients visiting all health care settings.

RESULTS

Three articles were included, one in a primary care setting, one in a secondary care setting and one in the private sector. Overprescribing was noted in all settings. Our findings demonstrate low expectations to receive antibiotics, among the Qatari population, in primary care (28.1%). In fact, the majority of patients would be satisfied with reassurance rather than receiving antimicrobials. Many patients were satisfied with explanation from physicians and counselling. Private sector registered high prevalence of antimicrobial misuse for respiratory tract infections in which 85% deemed inappropriate. This finding was also noted at a medical intensive care unit which showed high antimicrobial use (76%) and respiratory tract infections accounted for 57% of prescriptions.

CONCLUSION

Studies are needed to determine factors and population-based rates of antimicrobial use in all healthcare settings. There is also a need for interventional programs for both physicians and public on appropriate use of antimicrobials to combat global antimicrobial resistance.

Assessing the Quality of the Management of Tonsillitis among Australian Children: A Population-Based Sample Survey

OBJECTIVE

The aims of this study were twofold: (1) to design and validate a set of clinical indicators of appropriate care for tonsillitis and (2) to measure the level of tonsillitis care that is in line with guideline recommendations in a sample of Australian children.

STUDY DESIGN

A set of tonsillitis care indicators was developed from available national and international guidelines and validated in 4 stages. This research used the same design as the CareTrack Kids study, which was described in detail elsewhere.

SETTING

Samples of patient records from general practices, emergency departments, and hospital admissions were assessed.

SUBJECTS AND METHODS

Patient records of children aged 0 to 15 years were assessed for the presence of, and adherence to, the indicators for care delivered in 2012 and 2013.

RESULTS

Eleven indicators were developed. The records of 821 children (mean age, 5.0 years; SD, 4.0) with tonsillitis were screened. The reviewers conducted 2354 eligible indicator assessments across 1127 visits. Adherence to 6 indicators could be assessed and ranged from 14.3% to 73.2% (interquartile range 31.5% to 72.2%).

CONCLUSION

Our main findings are consistent with the international literature: the treatment of many children who present with confirmed or suspected tonsillitis is inconsistent with current guidelines. Future research should consider how the indicators could be applied in a structured and automated manner to increase the reliability and efficiency of record reviews and help raise clinicians' awareness of appropriate tonsillitis management.

Point-of-care C-reactive protein to assist in primary care management of children with suspected non-serious lower respiratory tract infection: a randomised controlled trial

Background

Overprescription of antibiotics for lower respiratory tract infections (LRTIs) in children is common, partly due to diagnostic uncertainty, in which case the addition of point-of-care (POC) C-reactive protein (CRP) testing can be of aid.

Aim

To assess whether use of POC CRP by the GP reduces antibiotic prescriptions in children with suspected non-serious LRTI.

Design & setting

An open, pragmatic, randomised controlled trial in daytime general practice and out-of-hours services.

Method

Children between 3 months and 12 years of age with acute cough and fever were included and randomised to either use of POC CRP or usual care. Antibiotic prescription rates were measured and compared between groups using generalising estimating equations.

Results

There was no statistically significant reduction in antibiotic prescriptions in the GP use of CRP group (30.9% versus 39.4%; odds ratio [OR] 0.6; 95% confidence interval [CI] = 0.29 to 1.23). Only the estimated severity of illness was related to antibiotic prescription. Forty-six per cent of children had POC CRP levels <10mg/L.

Conclusion

It is still uncertain whether POC CRP measurement in children with non-serious respiratory tract infection presenting to general practice can reduce the prescription of antibiotics. Until new research provides further evidence, POC CRP measurement in these children is not recommended.

Outpatient antibiotic use in Dutch infants after 10-valent pneumococcal vaccine introduction: a time-series analysis

OBJECTIVE

This population-based cohort study assesses the impact of switching from a 7-valent pneumococcal conjugate vaccine (PCV) to a 10-valent PCV on outpatient antibiotic use in Dutch infants, and whether geographical vaccination coverage modifies this association.

SETTING AND PARTICIPANTS

We extracted 2006-2013 anonymised antibiotic purchase data of 255 154 Dutch infants aged below 2 years from Achmea Health, a health insurance fund covering 28% of the national population.

DESIGN AND MAIN OUTCOME MEASURE

Changes in monthly antibiotic use from 2006-2011 (PCV7) to 2011-2013 (PCV10) were estimated using time-series analysis accounting for seasonality and autocorrelation. Interaction terms for vaccination coverage (categorised into seven groups) and period were added to the model to test whether this association was vaccination coverage-dependent.

RESULTS

275 337 antibiotic courses were used by 119 078 infants (461 352 person-years). PCV10 introduction was associated with a modest 1.6% overall reduction in antibiotic use (purchase rate ratio: 0.98, 95% CI: 0.98 to 0.99). Our model showed a significant difference in time trend in antibiotic use after PCV10 introduction (p=0.0084) with an increase in prescriptions in the PCV7 period (slope: 0.0023/month, 95% CI: -0.0001 to 0.0047) versus a decline in the PCV10 period (slope: -0.0089/month, 95% CI: -0.0150 to -0.0029). There was no evidence that PCV vaccination coverage affected this association, but since the largest rate ratios were observed in municipalities with the lowest vaccine coverage and had very wide accompanying CIs, our study might have insufficient power to detect such an association.

CONCLUSIONS

Switching from PCV7 to PCV10 was associated with a modest decline in outpatient antibiotic use in Dutch infants.

Quality of antibiotic prescribing of Swiss primary care physicians with high prescription rates: a nationwide survey

Objectives

To assess the quality of antibiotic prescribing of Swiss primary care physicians with high prescription rates.

Methods

In January 2015, we mailed a structured questionnaire to 2900 primary care physicians in Switzerland. They were included in a nationwide pragmatic randomized controlled trial on routine antibiotic prescription monitoring and feedback based on health insurance claims data. We asked them to record the diagnosis and antibiotic treatment for 44 consecutive patients with the most common conditions associated with antibiotic prescribing in primary care. We evaluated if the disease-specific antibiotic prescribing and the proportion of non-recommended antibiotics used, in particular quinolones, were within 'acceptable ranges' using adapted European Surveillance of Antimicrobial Consumption (ESAC) quality indicators.

Results

Two hundred and fifty physicians (8.6%) responded, providing 9961 patient records. Responders were similar to the entire physician population. Overall, antibiotics were prescribed to 32.1% of patients. For tonsillitis/pharyngitis, acute otitis media, acute rhinosinusitis and acute bronchitis the acceptable maximum of antibiotic prescriptions was exceeded by 24.4%, 49.6%, 27.4% and 11.5%, respectively. The proportion of non-recommended antibiotics was for all diagnoses above the recommended maximum of 20% (31.5%-88.7% across all conditions). Quinolones were prescribed to 37.2% of women with urinary tract infections, substantially exceeding the recommended maximum of 5%.

Conclusions

Antibiotic prescribing quality of Swiss primary care physicians with high prescription rates is low according to the indicators used, with substantial overtreatment of tonsillitis/pharyngitis, acute rhinosinusitis, acute otitis media and acute bronchitis. Routine nationwide and continuous monitoring of antibiotic use and specific interventions are warranted to improve prescribing in primary care.

Recent Anti-Microbial Exposure Is Associated with More Complications after Elective Surgery

BACKGROUND

Recent anti-microbial exposure has been associated with poor outcomes after infection in a mixed population. We hypothesized that recent anti-microbial exposure would be associated with poor outcomes of elective surgery.

METHODS

From August 2015 to August 2016, all elective surgical patients were questioned prospectively about anti-microbial exposure during the prior three months. Multivariable models were used to calculate risk-adjusted odds ratios for anti-microbial exposure controlling for surgeon influence. Primary outcomes were any serious complication, any complication, any infection, and surgical site infection. Secondary outcomes were length of stay, C. difficile infection, and death. A separate analysis of patients excluding those having colorectal surgery who had undergone an oral antibiotic bowel preparation also was performed.

RESULTS

Ninety-four percent of eligible patients (n = 1,538) answered the exposure question, with a three-month anti-microbial exposure rate of 34.1%. Colorectal surgery patients had the highest exposure rate, whereas hernia patients had the lowest. Exposed patients had higher rates of any complication, any infection, and surgical site infection, as well as a median two-day longer hospital stay. There were no differences in C. difficile infection or death between the groups. After risk adjustment, anti-microbial exposure was independently associated with any serious complication for all patients as well as with complications and infection in patients having an operation other than colorectal surgery.

CONCLUSION

Recent anti-microbial exposure is associated with more complications of elective surgery. Anti-microbial drug-induced alterations in microbiome-related inflammatory responses may play a role, highlighting an opportunity for pre-surgical intervention in this at-risk population.

Age-Specific Antibiotic Prescribing and Adherence to Guidelines in Pediatric Patients in Primary Care

BACKGROUND

Most antibiotics in children are used to treat viral and self-limiting conditions. This study aims to compare physicians' adherence to guidelines on antibiotic prescribing in fever and in ear and respiratory infections to children in different age groups in the Netherlands.

METHODS

Data were used from the NIVEL Primary Care Database. For all pediatric episodes of fever, acute otitis media (AOM), streptococcal pharyngitis (strep throat), sinusitis, acute tonsillitis, acute bronchitis/bronchiolitis and pneumonia in 2012, we determined whether national guidelines were followed with regard to whether an antibiotic was prescribed, and the type of antibiotic.

RESULTS

For diagnoses that generally do not require antibiotics, more prescriptions were found in adolescents' episodes compared with children 0-4 and 5-11 years of age, respectively, (bronchitis: 52.0% versus 42.4% and 42.7%, and fever: 16.8% versus 9.0% and 14.2%). The same was true for diagnoses that require antibiotics (strep throat: 76.5% versus 55.0% and 49.5%, pneumonia: 71.6% versus 60.2% and 69.8% and tonsillitis: 57.8% versus 54.8% and 49.7%), except for AOM (43.9% versus 52.4% and 39.6%). First-choice amoxicillin was prescribed more frequently in children 0-4 years of age than in age groups 5-11 and 11-17 years (AOM: 88.0% versus 83.2% and 81.8%, and pneumonia:74.7% versus 57.2% and 53.8%). First-choice narrow-spectrum penicillins were prescribed more often in adolescents than in age groups 0-4 and 5-11 years (strep throat: 72.0% versus 63.6%, and 60.9% and tonsillitis: 67.9% versus 33.1 and 45.9%).

CONCLUSIONS

Concerning adherence patterns include high antibiotic rates for bronchitis, particularly in adolescents, and underuse of narrow-spectrum penicillins in the 0-4 years group.

Patient, Provider, and Practice Characteristics Associated with Inappropriate Antimicrobial Prescribing in Ambulatory Practices

OBJECTIVE

To reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.

DESIGN, SETTING, AND PARTICIPANTS

Data for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.

METHODS

Prescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.

RESULTS

The overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).

CONCLUSIONS

Our results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.

Infect Control Hosp Epidemiol 2018;39:307–315

Is there a conflict between general practitioners applying guidelines for antibiotic prescribing and including their patients' preferences?

OBJECTIVES

One perceived barrier to guideline adherence is the existence of conflicting patient preferences. We examined whether patient preferences influence the prescription of antibiotics in general practice, and how this affects guideline adherence. We hypothesized that preferences play a larger role in prescribing antibiotics if the guideline allows for preferences to be taken into account, ie, if prescribing antibiotics is an option which can be considered rather than a clear recommendation to prescribe or not. We included three guidelines: acute cough, acute rhinosinusitis, and urinary tract infections.

METHODS

Data from NIVEL (the Netherlands Institute for Health Services Research) Primary Care Database (NIVEL-PCD) were used to assess antibiotic indications and prescriptions. These data were combined with a questionnaire among members of NIVEL's Dutch Health Care Consumer Panel to examine patient preferences. According to NIVEL-PCD, 286 of these members contacted their general practitioner (GP) in 2015 for acute cough, acute rhinosinusitis or urinary tract infections. A logistic multilevel regression analysis was performed to test our hypothesis.

RESULTS

Patient preferences do play a role in GPs' prescribing of antibiotics only in situations where, in accordance with the guideline, their use is an option which could be considered (interaction between indication and preference: p=0.049). If patients ask for antibiotics themselves in such situations, then GPs prescribe antibiotics more often.

CONCLUSION

Patient preferences only play a role if the guideline provides room to take preferences into account. Therefore, our results do not suggest a conflict between applying guidelines and including patient preferences. Further research is recommended to examine this possible conflict in other situations.

Assessment of prescribing practices at the primary healthcare facilities in Botswana with an emphasis on antibiotics: Findings and implications

BACKGROUND AND AIMS

Inappropriate drug prescribing has increased especially in developing countries where systems for monitoring medicine use are not well developed. This increases the rate of antimicrobial resistance. The study aim was to assess the prescribing patterns among urban primary health facilities in Botswana to provide future guidance including developing future quality indicators.

METHODS

Retrospective data from patients' records between January and December 2013 in 19 clinics were collected in a cross-sectional study. The WHO/International Network for Rational Use of Drugs indicators were used to assess prescribing patterns in the study clinics.

RESULTS

Average number of drugs per prescription was 2.8; 78.6% of the prescribed antibiotics were by International Non-proprietary Name and 96.1% complied with the Botswana Essential Drugs List. Overall rate of antibiotic prescribing was high (42.7%) with 14.7%, 5.9% and 1.3% of prescriptions having two, three and four antibiotics, respectively. Systemic antibiotics (JO1C) accounted for 45.4% of prescribed antibiotics of which amoxicillin accounted for 28.4% and metronidazole 14.4% of all antibiotic prescriptions. There was low use of co-amoxiclav (0.3% of all antibiotic prescriptions). Third generation cephalosporins and macrolides accounted for 9.8% and 6.2% of antibiotic prescriptions respectively, with no prescribing of fluoroquinolones. The majority of indications (87%) for antibiotic prescriptions were according to ICD classification.

CONCLUSIONS

While most indications for antibiotic prescriptions were based on signs and symptoms according to ICD, antibiotic prescribing rates were high with some conditions not requiring antibiotics because they are viral infections. There is a need to further improve prescribing practices through induction and training of in-service prescribers. An effective management tool for monitoring antibiotic prescribing practices at Primary Health Care facilities should be designed and implemented, including developing robust quality indicators.

Treatment of Community-Acquired Pneumonia: Are All Countries Treating Children in the Same Way? A Literature Review

Background

Pneumonia represents an important threat to children's health in both developed and developing countries. In the last 10 years, many national and international guidelines on the treatment of pediatric CAP have been published, in order to optimize the prescription of antibiotics and limit their cost and side effects. However, the practical implementation of these guidelines is still limited.

Main Text

We analyzed the current recommendations for the therapy of pediatric community-acquired pneumonia (CAP) that all converge on the identification of aminopenicillins and beta-lactams as the optimal treatment for CAP. We also conducted a review of the current literature on antibiotic regimens used for pediatric CAP to identify the current state of guidelines implementation in different settings. We selected 37 studies published from 2010 to 2016, including both retrospective and prospective studies, mainly cross-sectional and hospital based. The results show a global heterogeneity in the antibiotics prescription for pediatric CAP, with application of guidelines varying from 0% to more than 91% and with important differences even within the same country.

Conclusions

Our review has demonstrated that the implementation of the guidelines is still limited but also that achieving the optimal prescription is possible and can be done in both developed and developing countries.

Trends in Antibiotic Use by Birth Season and Birth Year

OBJECTIVES

We examined 2 birth cohort effects on antibiotic prescribing during the first year of life (henceforth, infancy) in Denmark: (1) the birth season effect on timing and overall occurrence of antibiotic prescribing, and (2) the birth year effect amid emerging nationwide pneumococcal vaccination programs and changing prescribing guidelines.

METHODS

We linked data for all live births in Denmark from 2004 to 2012 (N = 561 729) across the National Health Service Prescription Database, Medical Birth Registry, and Civil Registration System. Across birth season and birth year cohorts, we estimated 1-year risk, rate, and burden of redeemed antibiotic prescriptions during infancy. We used interrupted time series methods to assess prescribing trends across birth year cohorts. Graphical displays of all birth cohort effect data are included.

RESULTS

The 1-year risk of having at least 1 redeemed antibiotic prescription during infancy was 39.5% (99% confidence interval [CI]: 39.3% to 39.6%). The hazard of a first prescription increased with age throughout infancy and varied by season; subsequently, Kaplan-Meier-derived risk functions varied by birth season cohort. After rollout of a first vaccination program and new antibiotic prescribing guidelines, 1-year risk decreased by 4.4% over 14 months (99% CI: 3.4% to 5.5%); it decreased again after rollout of a second vaccination program by 6.9% over 3 years (99% CI: 4.4% to 9.3%).

CONCLUSIONS

In Denmark, birth season and birth year cohort effects influenced timing and risk of antibiotic prescribing during infancy. Future studies of antibiotic stewardship, effectiveness, and safety in children should consider these cohort effects, which may render some children inherently more susceptible than others to downstream antibiotic effects.

Characterisation of antibiotic prescriptions for acute respiratory tract infections in Danish general practice: a retrospective registry based cohort study

Inappropriate use of antibiotics is contributing to the increasing rates of antimicrobial resistance. Several Danish guidelines on antibiotic prescribing for acute respiratory tract infections in general practice have been issued to promote rational prescribing of antibiotics, however it is unclear if these recommendations are followed. We aimed to characterise the pattern of antibiotic prescriptions for patients diagnosed with acute respiratory tract infections, by means of electronic prescriptions, labeled with clinical indications, from Danish general practice. Acute respiratory tract infections accounted for 456,532 antibiotic prescriptions issued between July 2012 and June 2013. Pneumonia was the most common indication with 178,354 prescriptions (39%), followed by acute tonsillitis (21%) and acute otitis media (19%). In total, penicillin V accounted for 58% of all prescriptions, followed by macrolides (18%) and amoxicillin (15%). The use of second-line agents increased with age for all indications, and comprised more than 40% of the prescriptions in patients aged >75 years. Women were more often prescribed antibiotics regardless of clinical indication. This is the first Danish study to characterise antibiotic prescription patterns for acute respiratory tract infections by data linkage of clinical indications. The findings confirm that penicillin V is the most commonly prescribed antibiotic agent for treatment of patients with an acute respiratory tract infection in Danish general practice. However, second-line agents like macrolides and amoxicillin with or without clavulanic acid are overused. Strategies to improve the quality of antibiotic prescribing especially for pneumonia, acute otitis media and acute rhinosinusitis are warranted.

Better adherence to guidelines for prescribing antibiotics for different respiratory tract infections are warranted in Danish general practice. The over-use of antibiotics, particularly so-called ‘second-line’ agents such as amoxicillin, increases resistance and may lead to a potentially catastrophic scenario where antibiotics are no longer effective. Exactly how widespread the over-use of antibiotics is for different infections, however, is not clear. Rune Aabenhus at the University of Copenhagen and co-workers analyzed primary care data regarding antibiotic prescriptions for acute respiratory tract infections including pneumonia and ear infections in Denmark. They found that penicillin V—the current recommended first-line drug in Scandinavian countries—accounted for 58 per cent of prescriptions, a figure which should be improved. Amoxicillin and macrolides were over-prescribed, particularly in elderly patients. The team also call for further analysis of prescriptions given by out-of-hours clinics.

A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic

BACKGROUND:

Inappropriate use of antimicrobial agents is the major cause for the development of resistance. Thus, it is important to include outpatient clinics in the development of antibiotic stewardship program.

METHODS:

We report a multifaceted approach to decrease inappropriate antibiotic use in upper respiratory tract infections (URTIs) in an outpatient pediatric clinic. The interventions included educational grand round, academic detailing, and prospective audit and feedback and peer comparison.

RESULTS:

During the study period, a total of 3677 outpatient clinic visits for URTIs were evaluated. Of all the included patients, 12% were <1 year of age, 42% were 1–5 years, and 46% were >5 years of age. Of the total patients, 684 (17.6%) received appropriate antibiotics, 2812 (76.4%) appropriately did not receive antibiotics, and 217 (6%) inappropriately received antibiotics. The monthly rate of prescription of inappropriate antibiotics significantly decreased from 12.3% at the beginning of the study to 3.8% at the end of the study (P < 0.0001). Antibiotic prescription among those who had rapid streptococcal antigen test (RSAT) was 40% compared with 78% among those who did not have RSAT (P < 0.0001).

CONCLUSIONS:

The combination of education and academic detailing is important to improve antibiotic use.

Assessing the quality of paediatric antibiotic prescribing by community paediatricians: a database analysis of prescribing in Lombardy

OBJECTIVE

To evaluate the quality of paediatricians' antibiotic prescribing using administrative databases.

METHODS

The data source was the database of reimbursed prescriptions of the Lombardy Region, Italy. Children 1-13 years were included. An index prescription was defined as the first antibiotic prescription during a year period (2011) that occurred without previous, recent, antibiotic prescriptions or hospital or emergency department admissions. The A indicator was the percentage of children, cared for by paediatricians, receiving amoxicillin at the index prescription (minimum target 50%). The B indicator was the percentage of children receiving exclusively non-penicillin antibiotics in unrelated infection episodes (maximum target 10%). Indicators were evaluated for each prescriber and geographical area.

RESULTS

Overall 424 280 children (cared for by 1164 paediatricians) received an index prescription and were included in the study. Amoxicillin alone was prescribed at the index prescription only to 23.6% of children (7.9%-46.3% within different areas of the region).The percentage of paediatricians who reached the target for the quality indicators was low (12.8% A indicator; 54.0% B indicator; 11.3% both). Almost half of the paediatricians (44.5%) showed inadequate quality of antibiotic prescribing, failing to reach the target for both indicators. Quality of prescribing was about four times worse in high prescribers and younger paediatricians. A geographical cluster of paediatricians reaching the target for both indicators was identified. These paediatricians had, for several years, previously been involved in educational programme.

CONCLUSIONS

Quality of prescribing was generally unsatisfactory, but increased in a group of paediatricians previously involved in educational interventions and increased with increasing age. Further studies are warranted in order to validate these promising indicators as a benchmarking tool in other studies, when diagnosis is unknown.