Appropriateness of intended antibiotic prescribing using clinical case vignettes in primary care, and related factors

BACKGROUND

Factors associated with the appropriateness of antibiotic prescribing in primary care have been poorly explored. In particular, the impact of computerised decision-support systems (CDSS) remains unknown.

OBJECTIVES

We aim at investigating the uptake of CDSS and its association with physician characteristics and professional activity.

METHODS

Since May 2022, users of a CDSS for antibiotic prescribing in primary care in France have been invited, when registering, to complete three case vignettes assessing clinical situations frequently encountered in general practice and identified as at risk of antibiotic misuse. Appropriateness of antibiotic prescribing was defined as the rate of answers in line with the current guidelines, computed by individuals and by specific questions. Physician's characteristics associated with individual appropriate antibiotic prescribing (< 50%, 50-75% and > 75% appropriateness) were identified by multivariate ordinal logistic regression.

RESULTS

In June 2023, 60,067 physicians had registered on the CDSS. Among the 13,851 physicians who answered all case vignettes, the median individual appropriateness level of antibiotic prescribing was 77.8% [Interquartile range, 66.7%-88.9%], and was < 50% for 1,353 physicians (10%). In the multivariate analysis, physicians' characteristics associated with appropriateness were prior use of the CDSS (OR = 1.71, 95% CI 1.56-1.87), being a general practitioner vs. other specialist (OR = 1.34, 95% CI 1.20-1.49), working in primary care (OR = 1.14, 95% CI 1.02-1.27), mentoring students (OR = 1.12, 95% CI 1.04-1.21) age (OR = 0.69 per 10 years increase, 95% CI 0.67-0.71).

CONCLUSION

Individual appropriateness for antibiotic prescribing was high among CDSS users, with a higher rate in young general practitioners, previously using the system. CDSS could improve antibiotic prescribing in primary care.

Global hierarchical meta-analysis to identify the factors for controlling effects of antibiotics on soil microbiota

It is widely known that antibiotics can affect the structure and function of soil microbial communities, but the specific degree of impact and controlled factors on different indicators remain inconclusive. We conducted a multiple hierarchical mixed effects meta-analysis on 2564 observations that were extracted from 60 publications, to comprehensively assess the impact of antibiotics on soil microbiota. The results showed that antibiotics had significant negative effects on soil microbial biomass, α-diversity and soil enzyme activity. Under neutral initial soil, when soil was derived from agricultural land or had a fine-textured, the negative impacts of antibiotics on soil microbial community were exacerbated. Both single and mixed additions of antibiotics had significant inhibitory effects on soil microbial enzyme activities. The Random Forest model predicted the following key moderators involved in the effects of antibiotics on the soil microbiome, and antibiotics type, soil texture were key moderators on the severity of soil microbial biomass changes. Soil texture, temperature and single or combined application constitute of antibiotics were the main drivers of effects on soil enzyme activities. The reported results can be helpful to assess the ecological risk of antibiotics in a soil environment and provides a scientific basis for the rational of antibiotics use in the soil environment.

Antimicrobial prescription pattern and appropriateness for respiratory tract infection in outpatients: a systematic review and meta-analysis

BACKGROUND

Millions of people die every year as a result of antimicrobial resistance worldwide. An inappropriate prescription of antimicrobials (e.g., overuse, inadequate use, or a choice that diverges from established guidelines) can lead to a heightened risk of antimicrobial resistance. This study aimed to determine the rate and appropriateness of antimicrobial prescriptions for respiratory tract infections.

METHODS

This review was conducted in accordance with the PRISMA guidelines. Web of Science, PubMed, ProQuest Health and Medicine, and Scopus were searched between October 1, 2023, and December 15, 2023, with no time constraints. Studies were independently screened by the first author and the co-authors. We included original studies reporting antimicrobial prescription patterns and appropriateness for respiratory tract infections. The quality of included studies' was assessed via the Joanna Briggs Institute's Critical Appraisal Checklists for Cross-Sectional Studies. The assessment of publication bias was conducted using a funnel plot and Egger's regression test. A random effect model was employed to estimate the pooled antibiotic prescribing and inappropriate rates. Subgroup analysis was conducted by country, study period, data source, and age group.

RESULTS

Of the total 1220 identified studies, 36 studies were included in the review. The antimicrobial prescribing rate ranged from 25% (95% CI 0.24-0.26) to 90% (95% CI 0.89-0.91). The pooled antimicrobial prescription rate was 66% (95% CI 0.57 to 0.73). Subgroup analysis by region revealed that the antimicrobial prescription rate was highest in Africa (79%, 95% CI 0.48-0.94) and lowest in Europe (47%, 95% CI 0.32-0.62). Amoxicillin and amoxicillin-clavulanate antimicrobials from the Access group, along with azithromycin and erythromycin from the Watch group, were the most frequently used antimicrobial agents. This study revealed that the major reasons for antimicrobial prescription were acute bronchitis, pharyngitis, sinusitis, and the common cold. The pooled inappropriate antimicrobial prescription rate was 45% (95% CI 0.38-0.52). Twenty-eight of the included studies reported that prescribing antimicrobials without proper indications was the main cause of inappropriate antimicrobial prescriptions. Additionally, subgroup analysis by region showed a higher inappropriate antimicrobial prescription rate in Asia at 49% (95% CI 0.38-0.60). The result of the funnel plot and Egger's tests revealed no substantial publication bias (Egger's test: p = 0.268).

CONCLUSION

The prescribing rate and inappropriate use of antimicrobials remain high and vary among countries. Further studies should be conducted to generate information about factors contributing to unnecessary antimicrobial prescriptions in outpatients.

SYSTEMATIC REVIEW REGISTRATION

Systematic review registration: CRD42023468353.

Evaluation of appropriateness of antibiotic prescribing in primary healthcare institutions in China using proxy indicator

Background

Our objectives were to develop a set of proxy indicators (PIs) suited for assessing antibiotic use appropriateness in China's primary healthcare institutions (PHIs), and assess performance scores of these PIs while exploring factors that influence the antibiotic appropriateness.

Methods

We selected potential PIs for the PHIs through a RAND-modified Delphi procedure, and assessed clinimetric properties, focusing on measurability, applicability, and potential for improvement. PIs with favorable clinimetric properties were used to evaluate antibiotic prescription appropriateness by calculating performance scores of each PI. Institutions were categorized into three clusters representing different levels of appropriateness. We used the chi-square test and an ordinal logistic regression model at PHI level to explore factors influencing antibiotic appropriateness.

Findings

Eighteen PIs were developed through two rounds of online surveys and one face-to-face meeting involving 20 stakeholders. All PIs met the clinimetric properties criteria and were used to analyze 209,662 antibiotic prescriptions across 269 PHIs. The percentage of PHIs meeting the target ranged from 3.1% to 69.3%, with 6 PIs below 10%. The appropriateness of antibiotic prescriptions was significantly associated with percentages of patients' gender of the PHIs.

Interpretation

The varied and suboptimal performance of the PIs indicated the need for diverse efforts to enhance the rational antibiotic use at PHI level. It was necessary to devise distinct sets of PIs for diverse settings in future endeavors.

Funding

This work was supported by the National Natural Science Foundation of China (grant numbers 72374009, 81973294).

Computational prediction of new therapeutic effects of probiotics

Probiotics are living microorganisms that provide health benefits to their hosts, potentially aiding in the treatment or prevention of various diseases, including diarrhea, irritable bowel syndrome, ulcerative colitis, and Crohn's disease. Motivated by successful applications of link prediction in medical and biological networks, we applied link prediction to the probiotic-disease network to identify unreported relations. Using data from the Probio database and International Classification of Diseases-10th Revision (ICD-10) resources, we constructed a bipartite graph focused on the relationship between probiotics and diseases. We applied customized link prediction algorithms for this bipartite network, including common neighbors, Jaccard coefficient, and Adamic/Adar ranking formulas. We evaluated the results using Area under the Curve (AUC) and precision metrics. Our analysis revealed that common neighbors outperformed the other methods, with an AUC of 0.96 and precision of 0.6, indicating that basic formulas can predict at least six out of ten probable relations correctly. To support our findings, we conducted an exact search of the top 20 predictions and found six confirming papers on Google Scholar and Science Direct. Evidence suggests that Lactobacillus jensenii may provide prophylactic and therapeutic benefits for gastrointestinal diseases and that Lactobacillus acidophilus may have potential activity against urologic and female genital illnesses. Further investigation of other predictions through additional preclinical and clinical studies is recommended. Future research may focus on deploying more powerful link prediction algorithms to achieve better and more accurate results.

Claiming or abdicating medical authority: Treatment recommendation actions, doctor-patient relationship, and antibiotic overprescription in Chinese paediatrics

Antibiotic overprescription in China has long been considered a problem on the supply side, linked to the financial incentives of physicians. Based on the conversation analysis of 187 video-recorded naturally occurring medical consultations in Chinese paediatric primary care settings, this study finds that the driving force behind the problem of antibiotic overprescription in China has changed. Physicians use a low-authority communication style to recommend treatment, displaying a low level of medical authority and a willingness to accommodate caregivers' preferences in antibiotic prescribing decisions. The problem is now attributed to physician-caregiver interaction, doctor-patient relationship and the antibiotic-saturated prescribing culture. Practice implications involve deepening the understanding of the evolving nature of the antibiotic overprescription problem in China, building trust between physicians and patients/caregivers in order to facilitate the physicians' role as the gatekeeper of antibiotics and providing training programmes to help physicians develop effective communication skills.

Assessing the Appropriateness of Antimicrobial Prescribing in the Community Setting: A Scoping Review

Background

This scoping review examined the concept and scope of appropriateness of antimicrobial prescribing in the community setting and how it has been measured.

Methods

Utilizing the Joanna Briggs Institute's methodology, we appraised peer-reviewed articles and unpublished studies, focusing on the US, UK, Canada, and Australia, with no limit to date.

Results

Four basic components of antimicrobial prescribing to be evaluated during assessment of antimicrobial appropriateness in the community setting were identified: diagnosis for infection or indication for antimicrobial therapy, choice of antimicrobial therapy, dosing, and duration of therapy. The benchmark for definition of appropriateness is crucial in assessing antimicrobial prescribing appropriateness. The use of recommended guidelines as a benchmark is the standard for appropriate antimicrobial therapy, and when necessary, susceptibility testing should be explored.

Conclusions

Studies evaluating the appropriateness of antimicrobial prescribing should assess these components of antimicrobial prescribing, and this should be clearly stated in the aim and objectives of the study.

Outpatient Antibiotic Prescribing Patterns in Children among Primary Healthcare Institutions in China: A Nationwide Retrospective Study, 2017-2019

There is scarce evidence to demonstrate the pattern of antibiotic use in children in China. We aimed to describe antibiotic prescribing practices among children in primary healthcare institutions (PHIs) in China. We described outpatient antibiotic prescriptions for children in PHIs from January 2017 to December 2019 at both the national and diagnostic levels, utilizing the antibiotic prescribing rate (APR), multi-antibiotic prescribing rate (MAPR), and broad-spectrum prescribing rate (BAPR). Generalized estimating equations were adopted to analyze the factors associated with antibiotic use. Among the total 155,262.2 weighted prescriptions for children, the APR, MAPR, and BAPR were 43.5%, 9.9%, and 84.8%. At the national level, J01DC second-generation cephalosporins were the most prescribed antibiotic category (21.0%, N = 15,313.0), followed by J01DD third-generation cephalosporins (17.4%, N = 12,695.8). Watch group antibiotics accounted for 55.0% of the total antibiotic prescriptions (N = 52,056.3). At the diagnostic level, respiratory tract infections accounted for 67.4% of antibiotic prescriptions, among which prescriptions with diagnoses classified as potentially bacterial RTIs occupied the highest APR (55.0%). For each diagnostic category, the MAPR and BAPR varied. Age, region, and diagnostic categories were associated with antibiotic use. Concerns were raised regarding the appropriateness of antibiotic use, especially for broad-spectrum antibiotics.

Adverse drug reactions and hospital admissions: Large case-control study of patients aged 65-100 years using linked English primary care and hospital data

BACKGROUND

Adverse drug reactions (ADRs) are common and a leading cause of injury. However, information on ADR risks of individual medicines is often limited. The aim of this hypothesis-generating study was to assess the relative importance of ADR-related and emergency hospital admission for large group of medication classes.

METHODS

This study was a propensity-matched case-control study in English primary care. Data sources were Clinical Practice Research Databank and Aurum with longitudinal, anonymized, patient level electronic health records (EHRs) from English general practices linked to hospital records. Cases aged 65-100 with ADR-related or emergency hospital admission were matched to up to six controls by age, sex, morbidity and propensity scores for hospital admission risk. Medication groups with systemic administration as listed in the British National Formulary (used by prescribers for medication advice). Prescribing in the 84 days before the index date was assessed. Only medication groups with 50+ cases exposed were analysed. The outcomes of interest were ADR-related and emergency hospital admissions. Conditional logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CI).

RESULTS

The overall population included 121 546 cases with an ADR-related and 849 769 cases with emergency hospital admission. The percentage of hospitalizations with an ADR-related code for admission diagnosis was 1.83% and 6.58% with an ADR-related code at any time during hospitalization. A total of 137 medication groups was included in the main ADR analyses. Of these, 13 (9.5%) had statistically non-significant adjusted ORs, 58 (42.3%) statistically significant ORs between 1.0 and 1.5, 37 (27.0%) between 1.5-2.0, 18 (13.1%) between 2.0-3.0 and 11 (8.0%) 3.0 or higher. Several classes of antibiotics (including penicillins) were among medicines with largest ORs. Evaluating the 14 medications most often associated with ADRs, a strong association was found between the number of these medicines and the risk of ADR-related hospital admission (adjusted OR of 7.53 (95% CI 7.15-7.93) for those exposed to 6+ of these medicines).

CONCLUSIONS AND RELEVANCE

There is a need for a regular systematic assessment of the harm-benefit ratio of medicines, harvesting the information in large healthcare databases and combining it with causality assessment of individual case histories.

Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing?

BACKGROUND

There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis.

METHODS

A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics.

RESULTS

Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics.

CONCLUSIONS

Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.

Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019

Background

The appropriateness of antibiotic use for acute respiratory infections (ARIs) in Chinese primary healthcare facilities (PHFs) remained uncertain. We aimed to evaluate to what degree antibiotic prescribing for ARIs were aligned with guideline recommendations in primary settings across China.

Methods

We collected outpatient prescriptions from 262 Chinese PHFs in 27 cities of six provinces between 2017 and 2019. The appropriate antibiotic prescribing was defined as prescribing antibiotic classes that were recommended by Chinese clinical guidelines, if patients were prescribed antibiotics. We evaluated the magnitude of antibiotics prescribed for acute upper respiratory infections (AURIs), acute bronchitis, and community-acquired pneumonia (CAP) and their appropriateness.

Findings

Overall, 55.1% (87,684/159,150), 66.8% (30,836/46,153), and 68.5% (4615/6733) of outpatients with AURIs, acute bronchitis, and CAP treated at PHFs in China were prescribed with antibiotics. Of all antibiotic prescriptions, only 20.0% (17,542/87,684), 18.6% (5724/30,836) and 69.6% (3211/4615) used antibiotic classes that were recommended by the guidelines for AURIs, acute bronchitis, and CAP, respectively. Patients residing in the Chinese central region (17.0%, 15.4%, 69.3% for AURIs, acute bronchitis, and CAP, respectively) were less likely to be prescribed with antibiotics that were appropriately selected.

Interpretation

Unnecessary antibiotics were widely prescribed for patients with AURIs or acute bronchitis and most patients with ARIs did not receive guideline-recommended antibiotic classes in Chinese PHFs. Interventions to promote evidence-based treatment and the appropriate use of antibiotics are urgently needed at the primary level across China.

Funding

This work was supported by the National Natural Science Foundation of China [grant number 72074007, 81973294].

Antibiotic prescribing in remote versus face-to-face consultations for acute respiratory infections in primary care in England: an observational study using target maximum likelihood estimation

Background

The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Although the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing.

Methods

In this cohort study, we used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote versus face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 and March 2022. Eligibility criteria were applied at both practice-level and patient-level. 400 practices in England were sampled at random and then 600,000 patients were randomly sampled from the eligible patients (whose sex was recorded). Consultations for acute respiratory infections were identified. All antibiotic prescriptions were included, with the exception of antituberculosis drugs and antileprotic drugs, as identified through chapter 5.1 of the British National Formulary. The CPRD Aurum data was linked to the COVID-19 ONS infection survey by region. All analyses were done at the individual level. Repeated consultations from the same patient within 7 days were grouped together. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for infection type and patient-level, clinician-level and practice-level factors.

Findings

There were 45,997 ARI consultations (34,555 unique patients) within the study period, of which 28,127 were remote and 17,870 were face-to-face. For children, 48% of consultations were remote and, for adults, 66% were remote. For children, 42% of remote and 43% of face-to-face consultations led to an antibiotic prescription; the equivalent values for adults were 52% and 42%, respectively. After adjustment with TMLE, adults with a remote consultation had 23% (odds ratio [OR] 1.23, 95% CI: 1.18-1.29) higher chance of being prescribed antibiotics than if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI: 0.98-1.11).

Interpretation

The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health-care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes.

Funding

None.

Antibiotic-Prescribing Patterns Among Patients With Respiratory Symptoms in the Eastern Province, Kingdom of Saudi Arabia

Background Upper respiratory tract infections (URTIs) represent the most common diagnosis in ambulatory care settings. Some of these infections are properly treated with antibiotics, but evidence points to an inappropriate overuse of antibiotics in URTI management. This overuse is linked to antibiotic resistance, drug-related adverse effects, and increased costs. Objective This study evaluated the prevalence and predictors of antibiotic prescription for patients with URTI symptoms at the primary healthcare centers (PHCCs) and pediatric emergency department (ED) of the Maternity and Children Hospital (MCH) in Dammam, Saudi Arabia. Methods A prospective study was conducted in the PHCCs and pediatric ED of MCH. Trained physicians collected data on patients with URTI symptoms aged three years and older. Scores based on modified Centor criteria were calculated, and rapid antigen detection tests (RADTs) were conducted for all study participants. Results Out of 469 patients with a URTI, 141 (30.1%) received a prescription for an antibiotic, with a smaller proportion in the PHCCs (n=85; 24.4%) than in the pediatric ED (n=56; 46.3%). The main significant predictors of antibiotic prescription in terms of odds ratio (OR) and 95% confidence interval (95%CI) were a positive RADT result (OR=41.75, 95%CI=4.76-366.28), the presence of tonsillar exudate (OR=5.066, 95%CI=3.08-8.33), tender and/or swollen anterior cervical lymph nodes (OR=4.537, 95%CI=1.96-10.54), and fever (OR=3.519, 95%CI=2.33-5.31). A higher Centor score was also a predictor (2 to 5 vs. -1 to 1) (OR=2.72, 95%CI=1.8-4.12). The absence of a cough was not a significant predictor (OR=1.13, 95%CI=0.74-1.72). Conclusions Although a positive RADT increased the likelihood that a patient would be prescribed an antibiotic at the time of assessment, most antibiotic prescriptions were not justified. To control expenses, prevent adverse effects, and limit the spread of antibiotic resistance, efforts should be made to reduce unnecessarily high antibiotic usage.

The treatment of mild upper respiratory tract infections - a position paper with recommendations for best practice

Following the waning severity of COVID-19 due to vaccination and the development of immunity, the current variants of SARS-CoV-2 often lead to mild upper respiratory tract infections (MURTIs), suggesting it is an appropriate time to review the pathogenesis and treatment of such illnesses. The present article reviews the diverse causes of MURTIs and the mechanisms leading to symptomatic illness. Different symptoms of MURTIs develop in a staggered manner and require targeted symptomatic treatment. A wide variety of remedies for home treatment is available, including over-the-counter drugs and plant-derived substances. Recent pharmacological research has increased the understanding of molecular effects, and clinical studies have shown the efficacy of certain herbal remedies. However, the use of subjective endpoints in these clinical studies may suggest limited validity of the results. In this position paper, the importance of patient-centric outcomes, including a subjective perception of improved well-being, is emphasized. A best practice approach for the management of MURTIs, in which pharmacists and physicians create an improved multi-professional healthcare setting and provide healthcare education to patients, is proposed. Pharmacists act as first-line consultants and provide patients with remedies, considering the individual patient's preferences towards chemical or plant-derived drugs and providing advice for self-monitoring. Physicians act as second-line consultants if symptoms worsen and subsequently initiate appropriate therapies. In conclusion, general awareness of MURTIs should be increased amongst medical professionals and patients, thus improving their management.

Metagenomics reveals the abundance and accumulation trend of antibiotic resistance gene profile under long-term no tillage in a rainfed agroecosystem

Widespread soil resistance can seriously endanger sustainable food production and soil health. Conservation tillage is a promising practice for improving soil structure and health. However, the impact of long-term no-tillage on the presence of antibiotic resistance genes in agricultural soils remains unexplored. Based on the long-term (>11 yr) tillage experimental fields that include both conservation tillage practices [no tillage (ZT)] and conventional tillage practices [plough tillage (PT)], we investigated the accumulation trend of antibiotic resistance genes (ARGs) in farmland soils under long-term no-tillage conditions. We aimed to provide a scientific basis for formulating agricultural production strategies to promote ecological environment safety and human health. In comparison to PT, ZT led to a considerable reduction in the relative abundance of both antibiotic resistance genes and antibiotic target gene families in the soil. Furthermore, the abundance of all ARGs were considerably lower in the ZT soil. The classification of drug resistance showed that ZT substantially decreased the relative abundance of Ethambutol (59.97%), β-lactams (44.87%), Fosfomycin (35.82%), Sulfonamides (34.64%), Polymyxins (33.67%), MLSB (32.78%), Chloramphenicol (28.57%), Multi-drug resistance (26.22%), Efflux pump (23.46%), Aminoglycosides (16.79%), Trimethoprim (13.21%), Isoniazid (11.34%), Fluoroquinolone (6.21%) resistance genes, compared to PT soil. In addition, the abundance of the bacterial phyla Proteobacteria, Actinobacteria, Acidobacteria, and Gemmatimonadetes decreased considerably. The Mantel test indicated that long-term ZT practices substantially increased the abundance of beneficial microbial flora and inhibited the enrichment of ARGs in soil by improving soil microbial diversity, metabolic activity, increasing SOC, TN, and available Zn, and decreasing pH. Overall, long-term no-tillage practices inhibit the accumulation of antibiotic resistance genes in farmland soil, which is a promising agricultural management measure to reduce the accumulation risk of soil ARGs.

The impact of COVID-19 on antibiotic prescribing in primary care in England: Evaluation and risk prediction of appropriateness of type and repeat prescribing

BACKGROUND

This study aimed to predict risks of potentially inappropriate antibiotic type and repeat prescribing and assess changes during COVID-19.

METHODS

With the approval of NHS England, we used OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system and selected patients prescribed antibiotics from 2019 to 2021. Multinomial logistic regression models predicted patient's probability of receiving inappropriate antibiotic type or repeat antibiotic course for each common infection.

RESULTS

The population included 9.1 million patients with 29.2 million antibiotic prescriptions. 29.1% of prescriptions were identified as repeat prescribing. Those with same day incident infection coded in the EHR had considerably lower rates of repeat prescribing (18.0%) and 8.6% had potentially inappropriate type. No major changes in the rates of repeat antibiotic prescribing during COVID-19 were found. In the 10 risk prediction models, good levels of calibration and moderate levels of discrimination were found.

CONCLUSIONS

Our study found no evidence of changes in level of inappropriate or repeat antibiotic prescribing after the start of COVID-19. Repeat antibiotic prescribing was frequent and varied according to regional and patient characteristics. There is a need for treatment guidelines to be developed around antibiotic failure and clinicians provided with individualised patient information.

A scoping review and behavioural analysis of factors underlying overuse of antimicrobials

Background

Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved.

Objectives

To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science.

Methods

We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines.

Results and conclusions

From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.

Determinants of inappropriate antibiotic prescription in primary care in developed countries with general practitioners as gatekeepers: a systematic review and construction of a framework

OBJECTIVES

This study aimed to identify determinants of inappropriate antibiotic prescription in primary care in developed countries and to construct a framework with the determinants to help understand which actions can best be targeted to counteract development of antimicrobial resistance (AMR).

DESIGN

A systematic review of peer-reviewed studies reporting determinants of inappropriate antibiotic prescription published through 9 September 2021 in PubMed, Embase, Web of Science and the Cochrane Library was performed.

SETTING

All studies focusing on primary care in developed countries where general practitioners (GPs) act as gatekeepers for referral to medical specialists and hospital care were included.

RESULTS

Seventeen studies fulfilled the inclusion criteria and were used for the analysis which identified 45 determinants of inappropriate antibiotic prescription. Important determinants for inappropriate antibiotic prescription were comorbidity, primary care not considered to be responsible for development of AMR and GP perception of patient desire for antibiotics. A framework was constructed with the determinants and provides a broad overview of several domains. The framework can be used to identify several reasons for inappropriate antibiotic prescription in a specific primary care setting and from there, choose the most suitable intervention(s) and assist in implementing them for combatting AMR.

CONCLUSIONS

The type of infection, comorbidity and the GPs perception of a patient's desire for antibiotics are consistently identified as factors driving inappropriate antibiotic prescription in primary care. A framework with determinants of inappropriate antibiotic prescription may be useful after validation for effective implementation of interventions for decreasing these inappropriate prescriptions.

PROSPERO REGISTRATION NUMBER

CRD42023396225.

Antibiotic prescribing trends in primary care 2014-2022

Antimicrobial resistance (AMR) is a global healthcare challenge that governments and health systems are tackling primarily through antimicrobial stewardship (AMS). This should, improve antibiotic use, avoid inappropriate prescribing, reduce prescription numbers, aligning with national/international AMS targets. In primary care in the United Kingdom (UK) antibiotics are mainly prescribed for patients with urinary and respiratory symptoms (22.7% and 46% of all antibiotic prescriptions respectively). This study aimed to capture the time-series trends (2014-2022) for commonly prescribed antibiotics for respiratory and urinary tract infections in primary care in England. Trends for Amoxicillin, Amoxicillin sodium, Trimethoprim, Clarithromycin, Erythromycin, Erythromycin ethylsuccinate, Erythromycin stearate, Doxycycline hyclate, Doxycycline monohydrate and Phenoxymethylpenicillin (Penicillin V) were determined. In doing so providing evidence regarding meeting UK antibiotic prescribing rate objectives (a 15% reduction in human antibiotic use 2019-2024). Time series trend analysis of 62,949,272 antibiotic prescriptions from 6,370 General Practices in England extracted from the National Health Service (NHS) Business Services Authority web portal were explored. With additional investigation of prescribing rate trends by quintiles of the Index of Multiple Deprivation (IMD). Overall, there is a downwards trend in antibiotic prescribing for those explored. There is an association between IMD, geographical location, and higher antibiotic prescribing levels (prescribing hot spots). England has a well-documented North-South divide of health inequalities, this is reflected in antibiotic prescribing. The corona virus pandemic (COVID-19) impacted on AMS, with a rise in doxycycline and trimethoprim prescriptions notable in higher IMD areas. Since then, prescribing appears to have returned to pre-pandemic levels in all IMDs and continued to decline. AMS efforts are being adhered to in primary care in England. This study provides further evidence of the link between locality and poorer health outcomes (reflected in higher antibiotic prescribing). Further work is required to address antibiotic use in hot spot areas.

Clinician acceptability of an antibiotic prescribing knowledge support system for primary care: a mixed-method evaluation of features and context

BACKGROUND

Overprescribing of antibiotics is a major concern as it contributes to antimicrobial resistance. Research has found highly variable antibiotic prescribing in (UK) primary care, and to support more effective stewardship, the BRIT Project (Building Rapid Interventions to optimise prescribing) is implementing an eHealth Knowledge Support System. This will provide unique individualised analytics information to clinicians and patients at the point of care. The objective of the current study was to gauge the acceptability of the system to prescribing healthcare professionals and highlight factors to maximise intervention uptake.

METHODS

Two mixed-method co-design workshops were held online with primary care prescribing healthcare professionals (n = 16). Usefulness ratings of example features were collected using online polls and online whiteboards. Verbal discussion and textual comments were analysed thematically using inductive (participant-centred) and deductive perspectives (using the Theoretical Framework of Acceptability).

RESULTS

Hierarchical thematic coding generated three overarching themes relevant to intervention use and development. Clinician concerns (focal issues) were safe prescribing, accessible information, autonomy, avoiding duplication, technical issues and time. Requirements were ease and efficiency of use, integration of systems, patient-centeredness, personalisation, and training. Important features of the system included extraction of pertinent information from patient records (such as antibiotic prescribing history), recommended actions, personalised treatment, risk indicators and electronic patient communication leaflets. Anticipated acceptability and intention to use the knowledge support system was moderate to high. Time was identified as a focal cost/ burden, but this would be outweighed if the system improved patient outcomes and increased prescribing confidence.

CONCLUSION

Clinicians anticipate that an eHealth knowledge support system will be a useful and acceptable way to optimise antibiotic prescribing at the point of care. The mixed method workshop highlighted issues to assist person-centred eHealth intervention development, such as the value of communicating patient outcomes. Important features were identified including the ability to efficiently extract and summarise pertinent information from the patient records, provide explainable and transparent risk information, and personalised information to support patient communication. The Theoretical Framework of Acceptability enabled structured, theoretically sound feedback and creation of a profile to benchmark future evaluations. This may encourage a consistent user-focused approach to guide future eHealth intervention development.

Financial incentives and antibiotic prescribing patterns: Evidence from dispensing physicians in a public healthcare system

To ensure sufficient access to healthcare in remote areas, some countries allow physicians to directly dispense prescribed drugs through on-site pharmacies. Depending on the medication prescribed, this may pose a significant financial incentive for physicians to over-prescribe. This study, therefore, explored the effect of on-site pharmacies on antibiotic dispensing in a social health insurance system. Investigating physicians' prescribing behavior is especially relevant in the case of antibiotics, as over-utilization expedites antimicrobial resistance, leading to the development of untreatable bacterial infections. The empirical analysis was based on comprehensive administrative data on 13,741 antibiotic prescriptions issued by all 4044 public general practitioners (GPs) in Austria between 2016 and 2019. Switches from dispensing to non-dispensing status (and vice versa) were exploited in a difference-in-difference framework to mitigate a potential selection bias. GPs with the right to dispense over the entire observed period were used as the control group, and those who had either lost or gained the right to dispense as the treatment group. The results from a log-linear mixed model show that not currently operating an on-site pharmacy is associated with a 9.2% lower dispensing rate (i.e., antibiotics per 1000 yearly consultations). The results are robust to potential differences between GPs who switch from dispensing to non-dispensing and those who switch from non-dispensing to dispensing, to potential patient sorting, and to different functional forms. A prescribing effect interpretation (i.e., financial incentives give rise to more prescriptions for antibiotics) explains the observed volume effect provided that the share of unfilled antibiotic prescriptions issued by non-dispensing physicians does not exceed 4%.

A review of evidence for pneumococcal vaccination in adults at increased risk of pneumococcal disease: risk group definitions and optimization of vaccination coverage in the United Kingdom

INTRODUCTION

Pneumococcal disease (PD) significantly contributes to morbidity and mortality, carrying substantial economic and public health burden. This article is a targeted review of evidence for pneumococcal vaccination in the UK, the definitions of groups at particular risk of PD and vaccine effectiveness.

AREAS COVERED

Relevant evidence focusing on UK data from surveillance systems, randomized controlled trials, observational studies and publicly available government documents is collated and reviewed. Selected global data are included where appropriate.

EXPERT OPINION

National vaccination programs have reduced the incidence of vaccine-type PD, despite the rising prominence of non-vaccine serotypes in the UK. The introduction of higher-valency conjugate vaccines provides an opportunity to improve protection against PD for adults in risk groups. Several incentives are in place to encourage general practitioners to vaccinate risk groups, but uptake is low-suboptimal particularly among at-risk individuals. Wider awareness and understanding among the public and healthcare professionals may increase vaccination uptake and coverage. National strategies targeting organizational factors are urgently needed to achieve optimal access to vaccines. Finally, identifying new risk factors and approaches to risk assessment for PD are crucial to ensure those at risk of PD can benefit from pneumococcal vaccination.

Coping with ‘the grey area’ of antibiotic prescribing: a theory-informed qualitative study exploring family physician perspectives on antibiotic prescribing

Background

Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms.

Methods

Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20^th percentile versus “medium” defined as 40^th to 60^th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved.

Results

Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty.

Conclusions

Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01806-8.

Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework

INTRODUCTION

Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis.

METHODS AND ANALYSIS

We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.

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.

Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing

BACKGROUND

There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians.

METHODS

Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012-2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk-based prescribing. Poisson regression models with random effect for clinicians were fitted.

RESULTS

6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection-related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk-based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year.

CONCLUSIONS

The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing.

Improving patient care pathways in otitis externa

INTRODUCTION

Referrals for otitis externa (OE) have dramatically increased but the reasons for this remain unclear. We aim to characterize management of patients both pre- and post-referral to identify areas of improvement at the primary-secondary care interface.

METHODS

Questionnaire study from consultant-led research clinic specifically set up to prospectively analyse OE referrals at a tertiary referral centre for Otolaryngology.

RESULTS

Sixty-two patients were included; 63% female, median age 57 years. One was excluded (clinically not OE). Most patients had multiple primary care visits before referral (average 4 GP; 2 practice nurse). Sixty per cent had received oral antibiotics (16% multiple classes). Eighteen per cent had never had ear drops. Thirty-nine per cent were not advised to keep ears dry. Twenty-one per cent had dermatitis; 13% contact allergy, 30% systemic allergy, 5% diabetes. Less than 10% had narrow canals. Thirty-six per cent had active discharge but <7% needed a wick. Approximately 75% appear suitable for community aural care clinics.

CONCLUSIONS

OE occurs most commonly in female patients, often with associated risk factors. Patients often consult primary care several times prior to referral. Lifestyle advice and ototopical drops are frequently overlooked; instead, often inappropriately treated with oral antibiotics. Most ears were anatomically normal, and community aural care clinics may have a role in more timely and accessible treatment.

Chronic diseases and compliance with provincial guidelines for outpatient antibiotic prescription in cases of otitis media and respiratory infections: a population-based study of linked data in Quebec, Canada, 2010-2017

BACKGROUND

In Quebec, antibiotic use is higher among outpatients with chronic diseases. We sought to measure compliance with provincial guidelines for the treatment of otitis media and common respiratory infections, and to measure variations in compliance according to the presence of certain chronic diseases.

METHODS

We conducted a population-based study of linked data on antibiotic dispensing covered by the public drug insurance plan between April 2010 and March 2017. We included patients who had consulted a primary care physician within 2 days before being dispensed an antibiotic for an infection targeted by provincial guidelines, including bronchitis in patients with chronic obstructive pulmonary disease, otitis media, pharyngitis, pneumonia and sinusitis. We computed proportions of prescriptions compliant with guidelines (use of recommended antibiotic for children, and use of recommended antibiotic and dosage for adults) by age group (children or adults) and chronic disease (respiratory, cardiovascular, diabetes, mental disorder or none). We measured the impact of chronic diseases on compliance using robust Poisson regression.

RESULTS

We analyzed between 14 677 and 198 902 prescriptions for each infection under study. Compliance was greater than 87% among children, but was lower among children with asthma (proportion ratios between 0.97 and 1.00). In adults, the chosen antibiotic was compliant for at least 73% of prescriptions, except for pharyngitis (≤ 61%). Accounting for dosage lowered compliance to between 31% and 61%. Compliance was lower in the presence of chronic diseases (proportion ratios between 0.94 and 0.98).

INTERPRETATION

It is possible that prescribing noncompliant prescriptions was sometimes appropriate, but the high frequency of noncompliance suggests room for improvement. Given that variations associated with chronic diseases were small, disease-specific guidelines for antibiotic prescriptions are likely to have a limited impact on compliance.

Impacts of farmland application of antibiotic-contaminated manures on the occurrence of antibiotic residues and antibiotic resistance genes in soil: A meta-analysis study

A meta-analysis of 94 published studies was conducted to explore the impacts of farmland application of antibiotic-contaminated manures on antibiotic concentrations and ARG abundances in manure-amended soil. Forty-nine antibiotics were reported, in which chlortetracycline, oxytetracycline, doxycycline, tetracycline, enrofloxacin, ciprofloxacin and norfloxacin were the most prevalent and had relatively high concentrations. The responses of ARG and mobile genetic element (MGE) abundances to farmland application of antibiotic-contaminated manures varied considerably under different management strategies and environmental settings. On average, compared to unamended treatments, farmland application of antibiotic-contaminated manures significantly increased the total ARG and MGE abundances by 591% and 351%, respectively (P < 0.05). Of all the included ARG classes, the largest increase was found for sulfonamide resistance genes (1121%), followed by aminoglycoside (852%) and tetracycline (763%) resistance genes. Correlation analysis suggested that soil organic carbon (SOC) was significantly negatively correlated with antibiotic concentrations in manured soil (P < 0.05) due to the formation of covalent bonds and nonextractable residues. Soil silt content was significantly positively correlated with antibiotic concentration (P < 0.05), which was attributed to greater sorption capacities. The ARG abundances were significantly positively correlated with soil silt content, antibiotic concentrations, mean annual temperature, SOC, MGEs and soil pH (P < 0.05), suggesting that changes in these factors may shape the ARG profiles. Collectively, these findings advanced our understanding of the occurrence of antibiotics and ARGs in manure-amended soil and potential factors affecting them and will contribute to better management of these contaminants in future agricultural production.

After-hours consultations and antibiotic prescribing for self-limiting upper respiratory tract infections in primary-care practices

Objectives:

To determine the association between after-hours consultations and the likelihood of antibiotic prescribing for self-limiting upper respiratory tract infections (URTIs) in primary care practices.

Design:

A cross-sectional analysis using Australian national primary-care practice data (MedicineInsight) between February 1, 2016 and January 31, 2019.

Setting:

Nationwide primary-care practices across Australia.

Participants:

Adult and pediatric patients who visited primary care practices for first-time URTIs.

Methods:

We estimated the proportion of first-time URTI episodes for which antibiotic prescribing occurred on the same day (immediate prescribing) using diagnoses and prescription records in the electronic primary-care database. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the likelihood of antibiotic prescribing by the time of primary care visits were calculated using generalized estimating equations.

Results:

Among 357,287 URTI episodes, antibiotics were prescribed in 172,605 episodes (48.3%). After adjusting for patients’ demographics, practice characteristics, and seasons, we detected a higher likelihood of antibiotic prescribing on weekends compared to weekdays (OR, 1.42; 95% CI, 1.39–1.45) and on national public holidays compared to nonholidays (OR, 1.23; 95% CI, 1.17–1.29). When we controlled for patient presentation and diagnosis, the association between antibiotic prescribing and after-hours consultations remained significant: weekend versus weekdays (OR, 1.37; 95% CI, 1.33–1.41) and holidays versus nonholidays (OR, 1.10; 95% CI, 1.03–1.18).

Conclusions:

Primary-care consultations on weekends and public holidays were associated with a higher likelihood of immediate antibiotic prescribing for self-limiting URTIs in primary care. This finding might be attributed to lower resourcing in after-hours health care.

Using nasal sprays to prevent respiratory tract infections: a qualitative study of online consumer reviews and primary care patient interviews

OBJECTIVES

Nasal sprays could be a promising approach to preventing respiratory tract infections (RTIs). This study explored lay people's perceptions and experiences of using nasal sprays to prevent RTIs to identify barriers and facilitators to their adoption and continued use.

DESIGN

Qualitative research. Study 1 thematically analysed online consumer reviews of an RTI prevention nasal spray. Study 2 interviewed patients about their reactions to and experiences of a digital intervention that promotes and supports nasal spray use for RTI prevention (reactively: at 'first signs' of infection and preventatively: following possible/probable exposure to infection). Interview transcripts were analysed using thematic analysis.

SETTING

Primary care, UK.

PARTICIPANTS

407 online customer reviews. 13 purposively recruited primary care patients who had experienced recurrent infections and/or had risk factors for severe infections.

RESULTS

Both studies identified various factors that might influence nasal spray use including: high motivation to avoid RTIs, particularly during the COVID-19 pandemic; fatalistic views about RTIs; beliefs about alternative prevention methods; the importance of personal recommendation; perceived complexity and familiarity of nasal sprays; personal experiences of spray success or failure; tolerable and off-putting side effects; concerns about medicines; and the nose as unpleasant and unhygienic.

CONCLUSIONS

People who suffer disruptive, frequent or severe RTIs or who are vulnerable to RTIs are interested in using a nasal spray for prevention. They also have doubts and concerns and may encounter problems. Some of these may be reduced or eliminated by providing nasal spray users with information and advice that addresses these concerns or helps people overcome difficulties.

Study of the indications for macrolide prescriptions in a Colombian population

Introduction

The inappropriate use of antibiotics is associated with a greater risk for antimicrobial resistance, high health care costs, adverse events, and worse clinical outcomes.

Objective

To determine the prescription patterns and approved and nonapproved indications for macrolides in a group of patients from Colombia.

Materials and methods

This was a cross-sectional study on the indications for the use of macrolides in outpatients registered in a drug-dispensing database of approximately 8.5 million people affiliated with the Colombian health system. Sociodemographic, pharmacological, and clinical variables were considered.

Results

A total of 9.344 patients had received a macrolide prescription; their median age was 40.1 years (interquartile range: 27.1-53.3 years) and 58.3% were women. The most commonly prescribed macrolide was azithromycin (38.8%) most frequently for Helicobacter pylori infection (15.9%) and pneumonia treatment (15.8%). A total of 31.3% of the prescriptions were used for unapproved indications: common cold (7.8%), COVID-19 (4.0%), and acute bronchitis (3.5%). Residence in the Caribbean region (OR=1.17; 95%CI 1.05-1.31), dental prescriptions (OR=2.75; 95%CI 1.91-3.96), presence of chronic respiratory comorbidities (OR=1.30; 95%CI 1.08-1.56), and prescription of erythromycin (OR=3.66; 95%CI 3.24-4.14) or azithromycin (OR=2.15; 95%CI 1,92-2.41) were associated with a higher probability of macrolide use for unapproved indications while being 18-64 years old (OR=0.81; 95%CI 0.71-0.93) or 65 years or older (OR=0.77; 95%CI 0.63-0.94) and residing in Bogotá-Cundinamarca (OR=0.74; 95%CI 0.65-0.85) were associated with reduced risk.

Conclusions

Most patients received macrolides for respiratory tract infections; erythromycin and azithromycin were used for unapproved indications in people under 18 years of age and those with chronic respiratory diseases.

Patient perceptions of vulnerability to recurrent respiratory tract infections and prevention strategies: a qualitative study

OBJECTIVES

Respiratory tract infections (RTIs) are extremely common, usually self-limiting, but responsible for considerable work sickness absence, reduced quality of life, inappropriate antibiotic prescribing and healthcare costs. Patients who experience recurrent RTIs and those with certain comorbid conditions have higher personal impact and healthcare costs and may be more likely to suffer disease exacerbations, hospitalisation and death. We explored how these patients experience and perceive their RTIs to understand how best to engage them in prevention behaviours.

DESIGN

A qualitative interview study.

SETTING

Primary care, UK.

METHODS

23 participants who reported recurrent RTIs and/or had relevant comorbid health conditions were interviewed about their experiences of RTIs. Interviews took place as the COVID-19 pandemic began. Data were analysed using inductive thematic analysis.

RESULTS

Three themes were developed: Understanding causes and vulnerability, Attempting to prevent RTIs, Uncertainty and ambivalence about prevention, along with an overarching theme; Changing experiences because of COVID-19. Participants' understandings of their susceptibility to RTIs were multifactorial and included both transmission via others and personal vulnerabilities. They engaged in various approaches to try to prevent infections or alter their progression yet perceived they had limited personal control. The COVID-19 pandemic had improved their understanding of transmission, heightened their concern and motivation to avoid RTIs and extended their repertoire of protective behaviours.

CONCLUSIONS

Patients who experience frequent or severe RTIs are likely to welcome and benefit from advice and support regarding RTI prevention. To engage people effectively, those developing interventions or delivering health services must consider their beliefs and concerns about susceptibility and prevention.

The Impact of a Multifaceted Pharmacist-Led Antimicrobial Stewardship Program on Antibiotic Use: Evidence From a Quasi-Experimental Study in the Department of Vascular and Interventional Radiology in a Chinese Tertiary Hospital

Objective: The objective of the study was to assess the impact of multifaceted clinical pharmacist-led antimicrobial stewardship (AMS) program on the rational use of antibiotics for patients who receive vascular and interventional radiology therapies. Methods: A quasi-experimental retrospective intervention design with a comparison group was applied to the practice of antibiotic use in the department of vascular and interventional radiology in a Chinese tertiary hospital. We used difference-in-differences (DID) analysis to compare outcomes before and after the AMS intervention between the intervention group and control group, to determine whether intervention would lead to changes in irrationality of antibiotic prescribing, antibiotic utilization, cost of antibiotics, and length of hospital stay. Results: The DID results showed that the intervention group was associated with a reduction in the average consumption of antibiotics (p = 0.017) and cost of antibiotics (p = 0.006) and cost per defined daily dose (DDD) (p = 0.000). There were no significant differences in the mean change of total costs and length of stay between the two groups (p > 0.05). The average inappropriate score of perioperative antimicrobial prophylaxis in the intervention group declined by 0.23, while it decreased by 0.02 in the control group [0.21 (95% CI, -0.271 to -0.143); p = 0.000]. The average inappropriate score of non-surgical antimicrobial prophylaxis in the intervention group declined by 0.14, while it increased by 0.02 in the control group [0.16 (95% CI, -0.288 to -0.035); p = 0.010]. The average inappropriate score of the therapeutic use of antibiotics in the intervention group declined by 0.07, while it decreased by 0.01 in the control group [0.06 (95% CI, -0.115 to -0.022); p = 0.003]. Conclusions: This study provides evidence that implementation of AMS interventions was associated with a marked reduction of antibiotic use, cost of antibiotics, and irrationality of antibiotic prescribing in China.

Factors associated with the appropriateness of antibiotics prescribed in French general practice: a cross-sectional study using reimbursement databases

OBJECTIVES

Identifying characteristics associated with the appropriateness of antibiotic prescriptions is useful to guide antibiotic stewardship interventions. Proxy indicators estimating the appropriateness of antibiotic prescriptions at the general practitioner (GP) level have recently been validated. Our objectives were to identify (a) clusters of GPs according to their appropriateness score based on these proxy indicator results, and (b) GPs', patients' and practices' characteristics associated with inappropriate prescriptions.

METHODS

We conducted a cross-sectional observational study analysing antibiotics prescribed by GPs in one large French region in 2019, using the Health Insurance databases. We identified clusters of GPs according to their appropriateness score calculated from ten proxy indicators' results. We then analysed the association between the clusters with more inappropriate practices compared with the one with less inappropriate practices, and GPs', patients', and practices' characteristics. We performed bivariate and multivariable analyses using logistic polytomous regressions.

RESULTS

We included 4819 GPs who were grouped into three clusters. GPs who belong to the clusters with more inappropriate practices were more likely to practice in certain geographical area, to be male, not to have a particular medical practice, to be practicing for longer, to have more patients and consultations, to have a higher proportion of elderly patients, and to prescribe more drugs, more antibiotics and a higher proportion of broad-spectrum antibiotics.

CONCLUSION

We identified clusters of practice as well as factors associated with the appropriateness of antibiotic prescriptions, using routinely collected data. This might help to guide antibiotic stewardship interventions.

Non-prescriptionxx antibiotic use for people aged 15 years or older for cough in China: a community-based survey

BACKGROUND

Non-prescription antibiotic use at community is a main driver of antimicrobial resistance. Cough is a common condition and prevalent in all townships, including China. This study aims to investigate the non-prescription antibiotic use for cough in China and explore to which extent antibiotic use knowledge was correctly instructed in communities.

METHODS

A probability-proportionate-to-size sampling method was adopted to survey from all 14 townships in Yiwu city, China. All participants were investigated by face-to-face interview on Portable Android Devices. The continuous variables were presented by mean and standard deviation or medium and inter-quartile range (IQR). The categorical variables were presented using percentage or constituent ratio. Chi-square test for univariate analysis and logistic regression for multivariate analysis were conducted to assess the odds ratios and 95% confidence intervals, respectively.

RESULTS

A total of 3034 respondents across all the 14 townships and the 50 natural villages/streets completed all key items of the questionnaire. Of 2400 (79.10%) respondents stated that they experienced cough in the past 12 months with the medium age of 36.5 (IQR: 26-49) and 12.21% (293/2400) respondents had the non-prescription antibiotic use behavior. Among those 293 respondents, the proportion of non-prescription antibiotic use for cough peaked at around 16% among people aged 30-39 years old. The major sources of antibiotics were pharmacy (77.70%) and/or family storage (43.92%).

CONCLUSIONS

Non-prescription antibiotics use for cough is prevalent in the community, especially among people in their thirties. Strengthened drug purchase regulation and well-trained professional pharmacists would be promising alternatives to ameliorate AMR. Moreover, penetrating antibiotics knowledge to common citizens and is an urgent task to alleviate antimicrobial resistance. Therefore, proactive policies and regulations should be made to improve current situations.

Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan

Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians' preferred sources of information and evaluate physicians' awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers' views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.

The Safety of Delayed Versus Immediate Antibiotic Prescribing for Upper Respiratory Tract Infections

Background

This study aimed to evaluate the clinical safety of delayed antibiotic prescribing for upper respiratory tract infections (URTIs), which is recommended in treatment guidelines for less severe cases.

Methods

Two population-based cohort studies used the English Clinical Practice Research Databank and Welsh Secure Anonymized Information Linkage, containing electronic health records from primary care linked to hospital admission records. Patients with URTI and prescriptions of amoxicillin, clarithromycin, doxycycline, erythromycin, or phenoxymethylpenicillin were identified. Patients were stratified according to delayed and immediate prescribing relative to URTI diagnosis. Outcome of interest was infection-related hospital admission after 30 days.

Results

The population included 1.82 million patients with an URTI and antibiotic prescription; 91.7% had an antibiotic at URTI diagnosis date (immediate) and 8.3% had URTI diagnosis in 1–30 days before (delayed). Delayed antibiotic prescribing was associated with a 52% increased risk of infection-related hospital admissions (adjusted hazard ratio, 1.52; 95% confidence interval, 1.43–1.62). The probability of delayed antibiotic prescribing was unrelated to predicted risks of hospital admission. Analyses of the number needed to harm showed considerable variability across different patient groups (median with delayed antibiotic prescribing, 1357; 2.5% percentile, 295; 97.5% percentile, 3366).

Conclusions

This is the first large population-based study examining the safety of delayed antibiotic prescribing. Waiting to treat URTI was associated with increased risk of hospital admission, although delayed antibiotic prescribing was used similarly between high- and low-risk patients. There is a need to better target delayed antibiotic prescribing to URTI patients with lower risks of complications.

Impact of guidelines on antibiotic prescribing approach in primary care-a 10-year study

BACKGROUND

Publication and implementation of clinical guidelines is an important educational measure that considerably helps physicians in choosing appropriate antimicrobial drug.

OBJECTIVES

To evaluate long-term changes in antimicrobial prescribing habits before and after publishing the guidelines and to determine the factors that influence physician's decision to prescribe an antimicrobial drug.

METHODS

The study among general practitioners in Primorsko-Goranska County was conducted in three periods (January 2009, January 2011 and April 2019) by using a structured questionnaire that included general data about the physician, questions about their habits in antibiotic prescribing, criteria that influenced decision to prescribe antibiotics and antimicrobial agent(s) preferred in treating common infections.

RESULTS

Concomitant chronic (non-pulmonary) disease was the most important factor influencing decision to prescribe an antimicrobial drug. Over 88% of physicians that completed the survey declared themselves as rational prescribers of antimicrobials but more than half of them (53.3%) sometimes prescribed an antibiotic even though it was not indicated compared to 75% of self-reported non-rational prescribers (P ˂ 0.05). Self-reported adherence to the guidelines increased from 34.6% in 2011 to 51.8% in 2019.

CONCLUSION

The research showed improvement in physicians' knowledge in choosing the right antibiotic based on the analysis of answers but indicated the necessity for improving communication skills and empowering physicians not to prescribe antibiotics 'just in case' because of diagnostic uncertainty or patient demand. Further qualitative research is needed to understand physicians' prescribing behaviour and decision-making processes in order to develop interventions that will effectively improve the use of antibiotics.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records

BACKGROUND

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing.

METHODS

This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing.

RESULTS

There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate.

CONCLUSIONS

We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

A Systematic Review of Antibiotic Prescription for Acute Otitis Externa

BACKGROUND

There is a perception among ear, nose, and throat (ENT) surgeons that oral antibiotics are over-prescribed for acute otitis externa (AOE), and the potential for topical therapy as first-line treatment is not fully realized in primary care. We evaluated the prescription rate of topical and oral antibiotics for AOE in primary care and in patients referred to the ENT emergency clinic.

METHODS

 A systematic review was performed by searching the MEDLINE, Embase, PubMed, and Google Scholar databases between January 1990 and October 2020. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. The outcome measures were the rate of topical and oral antibiotic prescriptions for AOE by primary care practitioners and the rate of oral antibiotic prescriptions that were not indicated.

RESULTS

Seven studies met the inclusion criteria. The overall quality of evidence was moderate. The rate of topical antibiotic prescriptions was between 77% and 95%, and oral antibiotics varied between 6% and 30% in patients that were managed only in primary care. Patients that were referred to an ENT emergency clinic had initially been treated by primary care practitioners with topical antibiotics in 14%-60% of cases and oral antibiotics in 16%-17%. The most commonly prescribed oral antibiotics were Amoxicillin and Co-amoxiclav (amoxicillin/clavulanic acid). No study had comprehensively reviewed the indication for oral antibiotics.

CONCLUSION

The rate of topical antibiotic prescriptions for AOE was high in primary care; however, the rate was frequently suboptimal in patients attending the ENT emergency clinic. Although the rate of oral antibiotic prescriptions was relatively low, the choice of antibiotic for empirical treatment frequently did not cover the typical bacteria in AOE. There is a need for improvement in primary care prescribing of topical therapy prior to referral to the ENT emergency clinic.

Shorter and longer courses of antibiotics for common infections and the association with reductions of infection-related complications including hospital admissions

BACKGROUND

Antimicrobial resistance is a serious global health concern that emphasises completing treatment course. Recently, the effectiveness of short versus longer antibiotic courses has been questioned. This study investigated the duration of prescribed antibiotics, their effectiveness and associated risk of infection-related complications.

METHODS

Clinical Practice Research Datalink identified 4 million acute infection episodes prescribed an antibiotic in primary care between January 2014 - June 2014, England. Prescriptions were categorised by duration. Risk of infection-related hospitalisations within 30 days was modelled overall and by infection type. Risk was assessed immediately after or within 30 days follow-up to measure confounders given similar and varying exposure respectively. An interaction term with follow-up time assessed whether hazards ratios (HR) remained parallel with different antibiotic durations.

RESULTS

The duration of antibiotic courses increased over the study period (5.2-19.1%); 6-7 days were most common (66.9%). Most infection-related hospitalisations occurred with prescriptions of 8-15 days (0.21%), accompanied by greater risk of infection-related complications compared to patients that received a short prescription (HR 1.75 [95% CI 1.54-2.00]). Comparing HRs in the first 5 days versus remaining follow-up showed longer antibiotic courses were no more effective than shorter courses (1.02 [95% CI 0.90-1.16] and 0.92 [95% CI 0.75-1.12]). No variation by infection-type was observed.

CONCLUSION

Equal effectiveness was found between shorter and longer antibiotic courses and the reduction of infection-related hospitalisations. Stewardship programmes should recommend shorter courses of antibiotics for acute infections. Further research is required for treating patients with a complex medical history.

Impact of influenza vaccination on amoxicillin prescriptions in older adults: A retrospective cohort study using primary care data

Background

Bacterial infections of the upper and lower respiratory tract are a frequent complication of influenza and contribute to the widespread use of antibiotics. Influenza vaccination may help reduce both appropriate and inappropriate prescribing of antibiotics. Electronic health records provide a rich source of information for assessing secondary effects of influenza vaccination.

Methods

We conducted a retrospective study to estimate effects of influenza vaccine on antibiotic (amoxicillin) prescription in the elderly based on data from the Clinical Practice Research Datalink. The introduction of UK policy to recommend the influenza vaccine to older adults in 2000 led to a substantial increase in uptake, creating a natural experiment. Of 259,753 eligible patients that were unvaccinated in 1999 and aged≥65y by January 2000, 88,519 patients received influenza vaccination in 2000. These were propensity score matched 1:1 to unvaccinated patients. Time-to-amoxicillin was analysed using the Prior Event Rate Ratio (PERR) Pairwise method to address bias from time-invariant measured and unmeasured confounders. A simulation study and negative control outcome were used to help strengthen the validity of results.

Results

Compared to unvaccinated patients, those from the vaccinated group were more likely to be prescribed amoxicillin in the year prior to vaccination: hazard ratio (HR) 1.90 (95% confidence interval 1.83, 1.98). Following vaccination, the vaccinated group were again more likely to be prescribed amoxicillin, HR 1.64 (1.58,1.71). After adjusting for prior differences between the two groups using PERR Pairwise, overall vaccine effectiveness was 0.86 (0.81, 0.92). Additional analyses suggested that provided data meet the PERR assumptions, these estimates were robust.

Conclusions

Once differences between groups were taken into account, influenza vaccine had a beneficial effect, lowering the frequency of amoxicillin prescribing in the vaccinated group. Ensuring successful implementation of national programmes of vaccinating older adults against influenza may help contribute to reducing antibiotic resistance.

Microbiological safety and antibiotic resistance risks at a sustainable farm under large-scale open-air composting and composting toilet systems

This study evaluated the microbial safety and antibiotic resistance risks of a sustainable ecological farm under large-scale open-air composting (OC) and green composting toilet systems (CT). Samples of livestock manure, compost, soil, vegetables, and rainwater were analysed to determine the best treatment of wastes and risk assessment of land application. Results showed that pathogenic bacteria (PB) in livestock manure was significantly greater than that in the surrounding topsoil, while the distribution of bacteria resistant to amoxicillin (AMX), tetracycline (TC), and amoxicillin-tetracycline (AMX- TC) was the opposite through long-term resistance selection pressure. E. coli and Enterococcus were the dominant pathogens in feces and surrounding soil, respectively, and AMX-resistant bacteria dominated soil, compost, and vegetable samples. Overall, while OC may significantly increase antibiotic resistance and effectively remove fecal PB, CT offers faster consumption with greater antibiotic resistant bacteria (ARB) removal but more PB. Moreover, PB and ARB were concentrated in mature compost, soil in planting areas, vegetables, and rainwater. In farm soil and vegetables, AMX-resistant and AMX-TC-resistant bacterial communities displayed similar composition. These findings may explain the main pathways of PB transmission, migration and accumulation of ARB in farms, and the potential risks to human health through the food chain.