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Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine 2023; 98:104864. [PMID: 37950997 PMCID: PMC10663680 DOI: 10.1016/j.ebiom.2023.104864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). METHODS We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. FINDINGS We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. INTERPRETATION A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. FUNDING The Wellcome Trust, grant agreement number 215490/Z/19/Z.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel Cadarette
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Centre for Child Health Research, Medical School, University of Western Australia, Nedlands, Western Australia, Australia.
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Saleh HA, Borg MA, Stålsby Lundborg C, Saliba-Gustafsson EA. General Practitioners', Pharmacists' and Parents' Views on Antibiotic Use and Resistance in Malta: An Exploratory Qualitative Study. Antibiotics (Basel) 2022; 11:661. [PMID: 35625305 PMCID: PMC9137633 DOI: 10.3390/antibiotics11050661] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement.
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Affiliation(s)
- Hager Ali Saleh
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden; (H.A.S.); (C.S.L.)
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, MSD 2090 Msida, Malta;
- Faculty of Medicine and Surgery, University of Malta, MSD 2080 Msida, Malta
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden; (H.A.S.); (C.S.L.)
| | - Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden; (H.A.S.); (C.S.L.)
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Machowska A, Marrone G, Saliba-Gustafsson P, Borg MA, Saliba-Gustafsson EA, Stålsby Lundborg C. Impact of a Social Marketing Intervention on General Practitioners' Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta. Antibiotics (Basel) 2021; 10:371. [PMID: 33807404 PMCID: PMC8066227 DOI: 10.3390/antibiotics10040371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners' (GPs') antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs' antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs' antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.
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Affiliation(s)
- Anna Machowska
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Gaetano Marrone
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Peter Saliba-Gustafsson
- Center for Molecular Medicine at BioClinicum, Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden;
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, MSD 2090 Msida, Malta;
- Faculty of Medicine and Surgery, University of Malta, MSD 2090 Msida, Malta
| | - Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
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Saliba-Gustafsson EA, Nyberg A, Borg MA, Rosales-Klintz S, Stålsby Lundborg C. Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta. PLoS One 2021; 16:e0246782. [PMID: 33571265 PMCID: PMC7877739 DOI: 10.1371/journal.pone.0246782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta. METHODS Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour. FINDINGS We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed. CONCLUSION This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment. TRIAL REGISTRATION NUMBER NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.
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Affiliation(s)
- Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Anna Nyberg
- Faculty of Social Sciences, Stockholm University, Stockholm, Sweden
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Senia Rosales-Klintz
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
- Unit of Surveillance and Response Support (SRS), European Centre for Disease Prevention and Control, Solna, Sweden
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
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Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Orsini N, Borg MA, Stålsby Lundborg C. Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study. BMJ Open 2019; 9:e032704. [PMID: 31857311 PMCID: PMC6937012 DOI: 10.1136/bmjopen-2019-032704] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To identify factors that influence general practitioners' (GPs') oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta. DESIGN Repeated, cross-sectional surveillance. SETTING Maltese general practice; both public health centres and private GP clinics. PARTICIPANTS 30 GPs registered on the Malta Medical Council's Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods. OUTCOME MEASURES The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated. RESULTS The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95% CI 1.22 to 4.26), GP age with GPs ≥60 being the most likely (OR 34.7, 95% CI 14.14 to 84.98), patient age with patients ≥65 being the most likely (OR 2.3, 95% CI 1.71 to 3.18), number of signs and/or symptoms with patients having ≥4 being the most likely (OR 9.6, 95% CI 5.78 to 15.99), fever (OR 2.6, 95% CI 2.08 to 3.26), productive cough (OR 1.3, 95% CI 1.03 to 1.61), otalgia (OR 1.3, 95% CI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95% CI 1.57 to 3.05), regular clients (OR 1.3, 95% CI 1.05 to 1.66), antibiotic requests (OR 4.8, 95% CI 2.52 to 8.99) and smoking (OR 1.4, 95% CI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95% CI 0.26 to 0.41), sore throat (OR 0.6, 95% CI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95% CI 0.23 to 0.36) or dyspnoea (OR 0.6, 95% CI 0.41 to 0.83) were less likely to receive an antibiotic prescription. CONCLUSION Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription. TRIAL REGISTRATION NUMBER NCT03218930.
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Affiliation(s)
- Erika A Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Dunberger Hampton
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Peter Zarb
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
| | - Nicola Orsini
- Department of Global Public Health, Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
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Saliba-Gustafsson EA, Röing M, Borg MA, Rosales-Klintz S, Lundborg CS. General practitioners' perceptions of delayed antibiotic prescription for respiratory tract infections: A phenomenographic study. PLoS One 2019; 14:e0225506. [PMID: 31756197 PMCID: PMC6874332 DOI: 10.1371/journal.pone.0225506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/06/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta. METHODS This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach. FINDINGS General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"-maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"-reaching a compromise and providing treatment just in case, (C) "The Comforter"-providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"-empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"-retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon. CONCLUSIONS In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required. TRIAL REGISTRATION NUMBER NCT03218930.
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Affiliation(s)
- Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Marta Röing
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Senia Rosales-Klintz
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
- Unit of Surveillance and Response Support, European Centre for Disease Prevention and Control, Solna, Sweden
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
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