The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010-2017

Impact of COVID-19 on antibiotic usage in primary care: a retrospective analysis

The COVID-19 pandemic has contributed to many changes in the medical practice, including a wider access to tele-consultations. It not only influenced the type of treatment but also shed light on mistakes often made by doctors, such as the abuse of antibiotics. This study aimed to evaluate the antibiotic treatment, and the impact of the COVID-19 pandemic on antibiotic prescribing during a GP's visit. The retrospective medical history analysis involved data from a first-contact medical center (Pantamed, Olsztyn, Poland), from 1 January 2018 to 31 May 2023. Quantities of prescribed antibiotics were assessed and converted into the so-called active list for a given working day of adult patients (> 18 years of age). Statistical analysis based on collective data was performed. During the COVID-19 pandemic, a decline in the number of medical consultations has been observed, both remotely via tele-medicine and in personal appointments, compared to the data from before the pandemic: n = 95,251 versus n = 79,619. Also, during the COVID-19 pandemic, there was a decrease in the total amount of prescribed antibiotics relative to the data before the pandemic (2.44 vs. 4.54; p > 0.001). The decrease in the quantities of prescribed antibiotics did not depend on the way doctor consultations were provided. The COVID-19 pandemic has contributed to changing the family doctors' management of respiratory infections. The ability to identify the etiological agent-the SARS-COV2 virus-contributed to the reduction of the antibiotics use.

Influvac Tetra: clinical experience on safety, efficacy, and immunogenicity

INTRODUCTION

This paper summarizes the safety and immunogenicity data of Influvac Tetra across all age groups starting from 6 months of age, obtained during its clinical development program.

AREAS COVERED

The article covers the clinical development program of Influvac Tetra based on five registration studies that included different age groups, different comparators, and participants from Europe and Asia. Safety and immunogenicity were assessed in all studies and in one study, the efficacy of Influvac Tetra was assessed.

EXPERT OPINION

Seasonal influenza is a vaccine-preventable disease that can cause serious complications. Several types of influenza vaccines are available, including egg-based (standard dose, high dose, and adjuvanted), cell-based, and recombinant. The COVID-19 pandemic has stimulated innovation in the development such as mRNA vaccines. However, these vaccines are still in development and the true value still has to be proven. Regardless of the type of vaccine, it is also important to increase overall vaccination coverage. ECDC recommends that EU Member States implement action plans and policies aimed at reaching 75% coverage in at-risk groups and healthcare workers. Even so, vaccine coverage is still far from recommended.

Vaccination to Reduce Antimicrobial Resistance Burden-Data Gaps and Future Research

Antimicrobial resistance (AMR) poses an immediate danger to global health. If unaddressed, the current upsurge in AMR threatens to reverse the achievements in reducing the infectious disease-associated mortality and morbidity associated with antimicrobial treatment. Consequently, there is an urgent need for strategies to prevent or slow the progress of AMR. Vaccines potentially contribute both directly and indirectly to combating AMR. Modeling studies have indicated significant gains from vaccination in reducing AMR burdens for specific pathogens, reducing mortality/morbidity, and economic loss. However, quantifying the real impact of vaccines in these reductions is challenging because many of the study designs used to evaluate the contribution of vaccination programs are affected by significant background confounding, and potential selection and information bias. Here, we discuss challenges in assessing vaccine impact to reduce AMR burdens and suggest potential approaches for vaccine impact evaluation nested in vaccine trials.

Antibiotic persistence and its impact on the environment

From boon molecules to molecules contributing to rising concern has been the sojourn of antibiotics. The problem of antibiotic contamination has gotten worse due to antibiotics' pervasive use in every aspect of the environment. One such consequence of pollution is the increase in infections with antibiotic resistance. All known antimicrobials being used for human benefit lead to their repetitive and routine release into the environment. The misuse of antibiotics has aggravated the situation to a level that we are short of antibiotics to treat infections as organisms have developed resistance against them. Overconsumption is not just limited to human health care, but also occurs in other areas such as aquaculture, livestock, and veterinary applications for the purpose of improving feed and meat products. Due to their harmful effects on non-target species, the trace level of antibiotics in the aquatic ecosystem presents a significant problem. Since the introduction of antibiotics into the environment is more than their removal, they have been given the status of persistent pollutants. The buildup of antibiotics in the environment threatens aquatic life and may lead to bacterial strains developing resistance. As newer organisms are becoming resistant, there exists a shortage of antibiotics to treat infections. This has presented a very critical problem for the health-care community. Another rising concern is that the development of newer drug molecules as antibiotics is minimal. This review article critically explains the cause and nature of the pollution and the effects of this emerging trend. Also, in the latter sections, why we need newer antibiotics is questioned and discussed.

Association between seasonal influenza vaccination and antimicrobial use in Japan from the 2015-16 to 2020-21 seasons: from the VENUS study

BACKGROUND

Seasonal influenza vaccination might be considered an antimicrobial resistance (AMR) countermeasure because it can reduce unnecessary antimicrobial use for acute respiratory infection by mitigating the burden of such diseases.

OBJECTIVES

To examine the association between seasonal influenza vaccination and antimicrobial use (AMU) in Japan at the community level and to examine the impact of influenza vaccination on the frequency of unnecessary antimicrobial prescription for upper respiratory infection.

METHODS

For patients who visited any healthcare facility in one of the 23 wards of Tokyo, Japan, due to upper respiratory infection and who were aged 65 years or older, we extracted data from the Vaccine Effectiveness, Networking, and Universal Safety (VENUS) study database, which includes all claims data and vaccination records from the 2015-16 to 2020-21 seasons. We used the average treatment effect (ATE) with 1:1 propensity score matching to examine the association of vaccination status with frequency of antibiotic prescription, frequency of healthcare facility consultation, risk of admission and risk of death in the follow-up period of the same season (from 1 January to 31 March).

RESULTS

In total, 244 642 people were enrolled. Matched data included 101 734 people in each of the unvaccinated and vaccinated groups. The ATE of vaccination was -0.004 (95% CI -0.006 to -0.002) for the frequency of antibiotic prescription, -0.005 (-0.007 to -0.004) for the frequency of healthcare facility consultation, -0.001 (-0.002 to -0.001) for the risk of admission and 0.00 (0.00 to 0.00) for the risk of death.

CONCLUSIONS

Our results suggest that seasonal influenza vaccination is associated with lower frequencies of unnecessary antibiotic prescription and of healthcare facility consultation.

The burden of influenza and the role of influenza vaccination in adults aged 50-64 years: A summary of available evidence

Influenza is a vaccine-preventable disease and a global public health problem. Although most national influenza vaccination recommendations focus on subjects aged ≥65 years, an extensive burden of influenza has also been reported in those aged ≥50 years and is exacerbated by immune system aging. The main purpose of this review is to provide an overview of the burden of influenza and its potential prevention within the 50-64 age-group. These subjects account for a large proportion of the workforce, and play a central economic and social role. Individuals aged 50-64 years had a 3-times higher rate of hospitalization and a 9-fold higher mortality rate attributable to influenza than those aged 18-49-years, generating higher influenza-related hospitalization costs. Available data suggest that including healthy subjects aged 50-64 years in influenza vaccination recommendations would allow a broader population to be reached, reducing the economic and social burden of influenza.

COVID-19 and Outpatient Antibiotic Prescriptions in the United States: A County-Level Analysis

Background

Declines in outpatient antibiotic prescribing were reported during the beginning of the coronavirus disease 2019 (COVID-19) pandemic in the United States; however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear.

Methods

This was an ecological study using random-effects panel regression of monthly reported COVID-19 county case and antibiotic prescription data, controlling for seasonality, urbanicity, health care access, nonpharmaceutical interventions (NPIs), and sociodemographic factors.

Results

Antibiotic prescribing fell 26.8% in 2020 compared with prior years. Each 1% increase in county-level monthly COVID-19 cases was associated with a 0.009% (95% CI, 0.007% to 0.012%; P < .01) increase in prescriptions per 100 000 population dispensed to all ages and a 0.012% (95% CI, -0.017% to -0.008%; P < .01) decrease in prescriptions per 100 000 children. Counties with schools open for in-person instruction were associated with a 0.044% (95% CI, 0.024% to 0.065%; P < .01) increase in prescriptions per 100 000 children compared with counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children.

Conclusions

The positive association of COVID-19 cases with prescribing for all ages and the negative association for children indicate that increases in prescribing occurred primarily among adults. The rarity of bacterial coinfection in COVID-19 patients suggests that a fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, possibly due to the prevention of other upper respiratory infections. The strongest predictors of prescribing were prior years' prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices.

Global antibiotic use during the COVID-19 pandemic: analysis of pharmaceutical sales data from 71 countries, 2020-2022

BACKGROUND

Despite bacterial coinfection rates of less than 10%, antibiotics are prescribed to an estimated 75% of patients with COVID-19, potentially exacerbating antimicrobial resistance. We estimated the associations of COVID-19 cases and vaccinations with global antibiotic sales during the first two years of the COVID-19 pandemic.

METHODS

We obtained monthly data on broad-spectrum antibiotic sales volumes (cephalosporins, penicillins, macrolides, and tetracyclines) in 71 countries during March 2020-May 2022 from the IQVIA MIDAS® database. These data were combined with country-month-level COVID-19 case and vaccination data from Our World in Data. We used least squares (pooled) and fixed-effects panel data regression models, accounting for country characteristics, to estimate the associations between antibiotic sales volumes and COVID-19 cases and vaccinations per 1000 people.

FINDINGS

Sales of all four antibiotics fell sharply during April and May 2020, followed by a gradual rise to near pre-pandemic levels through May 2022. In fixed-effects regression models, a 10% increase in monthly COVID-19 cases was associated with 0.2%-0.3% higher sales of cephalosporins, 0.2%-0.3% higher sales of penicillins, 0.4%-0.6% higher sales of macrolides, and 0.3% higher sales of all four antibiotics combined per 1000 people. Across continents, a 10% increase in monthly COVID-19 cases was associated with 0.8%, 1.3%, and 1.5% higher macrolides sales in Europe, North America, and Africa respectively. Sales of other antibiotics across continent were also positively associated with COVID-19 cases, although the estimated associations were smaller in magnitude. No consistent associations were observed between antibiotic sales and COVID-19 vaccinations. Results from pooled regression analysis were similar to those from the fixed-effects models.

INTERPRETATION

Antibiotic sales were positively associated with COVID-19 cases globally during 2020-2022. Our findings underline that antibiotic stewardship in the context of COVID-19 remains essential.

FUNDING

Bill & Melinda Gates Foundation.

Available evidence and potential for vaccines for reduction in antibiotic prescriptions

Bacterial antibiotic resistance is a public health issue. It means that drugs become ineffective, infections persist and have a huge impact on the health of patients and their spreading increases. To address a complex threat such as bacterial antibiotic resistance different and integrated approaches are needed including discovery of new antibiotics, improvement of diagnostics tools and improvement of antibiotic stewardship. Absolutely relevant are prevention of infections as well as decrease in the use of antibiotics. Vaccines are an important tool in the fight against bacterial antibiotic resistance and can help prevent it in several ways. Indeed, vaccines are highly effective in preventing diseases that might otherwise require the use of antibiotics to treat symptoms and associated complications. Preventing infections through vaccination helps reduce the need for and widespread and inappropriate use of antibiotics, including for secondary bacterial infections.

Clinical and economic burden of physician-diagnosed influenza in adults during the 2017/2018 epidemic season in Spain

BACKGROUND

Influenza is an acutely debilitating respiratory infection, contributing significantly to outpatient visits and hospitalizations. Spain lacks comprehensive and updated data on the burden of influenza, particularly in the outpatient setting. Our study aimed to fill this gap by estimating the clinical and economic burden of physician-diagnosed influenza cases in adults from four Spanish regions, stratified by age groups and presence of comorbidities.

METHODS

A retrospective cost-of-illness study was conducted using data from an electronic medical records database from the National Healthcare Service (NHS) of four Spanish regions for individuals aged ≥ 18 years diagnosed for influenza during the 2017/2018 epidemic season. Health resource utilization and related cost data were collected, including primary care visits, referrals to other specialists, visits to the emergency department, hospitalizations, and prescribed medicines.

RESULTS

The study reported a total of 28,381 patients aged ≥ 18 years diagnosed with influenza, corresponding to 1,804 cases per 100,000 population. Most patients were aged < 65 years: 60.5% (n = 17,166) aged 18-49 and 26.3% (n = 7,451) 50-64 years. A total of 39.2% (n = 11,132) of patients presented a comorbidity. Cardiovascular diseases were the most common comorbidity reported along with influenza. The mean healthcare cost per case was estimated at €235.1 in population aged 18-49 years, increasing by 1.7 and 4.9 times in those aged 50-64 (€402.0) and ≥ 65 (€1,149.0), respectively. The mean healthcare cost per case was 3.2 times higher in patients with comorbidities. The total healthcare cost of medically attended influenza cases was mainly driven by primary care (45.1%) and hospitalization (42.0%). Patients aged 18-64 years old accounted for 61.9% of the costs of medically attended influenza. Irrespective of age, patients with comorbidities accounted for 67.1% of costs.

CONCLUSIONS

Season 2017/2018 was associated with a considerable burden of influenza in Spain, which increased with age and presence of comorbidities. Individuals with comorbidities accounted for most of the costs of influenza. Results suggest that population aged 18-64 years old is generating the highest share of costs to the NHS when all healthcare costs are considered. Preventive strategies targeting subjects with comorbidities, regardless of age, should be warranted.

The value of vaccines

Optimizing vaccine spending depends on recognizing the full value of vaccination (VoV). Existing taxonomies of such value are not comprehensive because they are not guided by general theories. I rely on two such theories: subjective-value theory claims that what has value is determined by what people actually or ideally want in life. A welfarist theory of government states that a fundamental objective of government is to promote social value (or social welfare). These jointly imply that any aspect of life that individuals actually or ideally value and that could be negatively affected by vaccine-preventable diseases (and therefore positively affected by preventive vaccines) is an element of VoV. I build a more comprehensive-value taxonomy than currently exists based on this implication.

Temporal Association between Influenza Vaccination Coverage and Ambulatory Antibiotic Use in Children

In this population-based retrospective cohort study, increased influenza vaccination coverage was temporally associated with a reduction in ambulatory antibiotic use in children. After adjustment for yearly vaccine effectiveness, antibiotic prescription rate declined by 3/1000 person-months for each 1% increase in influenza vaccination coverage between 2012 and 2017 in South Carolina (P < 0.001).

Antibiotic Resistance Patterns and Association with the Influenza Season in the United States: A Multicenter Evaluation Reveals Surprising Associations Between Influenza Season and Resistance in Gram-negative Pathogens

Background

Viral infections are often treated with empiric antibiotics due to suspected bacterial coinfections, leading to antibiotic overuse. We aimed to describe antibiotic resistance (ABR) trends and their association with the influenza season in ambulatory and inpatient settings in the United States.

Methods

We used the BD Insights Research Database to evaluate antibiotic susceptibility profiles in 30-day nonduplicate bacterial isolates collected from patients >17 years old at 257 US healthcare institutions from 2011 to 2019. We investigated ABR in Gram-positive (Staphylococcus aureus and Streptococcus pneumoniae) and Gram-negative (Enterobacterales [ENT], Pseudomonas aeruginosa [PSA], and Acinetobacter baumannii spp [ACB]) bacteria expressed as the proportion of isolates not susceptible ([NS], intermediate or resistant) and resistance per 100 admissions (inpatients only). Antibiotics included carbapenems (Carb), fluoroquinolones (FQ), macrolides, penicillin, extended-spectrum cephalosporins (ESC), and methicillin. Generalized estimating equations models were used to evaluate monthly trends in ABR outcomes and associations with community influenza rates.

Results

We identified 8 250 860 nonduplicate pathogens, including 154 841 Gram-negative Carb-NS, 1 502 796 Gram-negative FQ-NS, 498 012 methicillin-resistant S aureus (MRSA), and 44 131 NS S pneumoniae. All S pneumoniae rates per 100 admissions (macrolide-, penicillin-, and ESC-NS) were associated with influenza rates. Respiratory, but not nonrespiratory, MRSA was also associated with influenza. For Gram-negative pathogens, influenza rates were associated with the percentage of FQ-NS ENT, FQ-NS PSA, and Carb-NS ACB.

Conclusions

Our study showed expected increases in rates of ABR Gram-positive and identified small but surprising increases in ABR Gram-negative pathogens associated with influenza activity. These insights may help inform antimicrobial stewardship initiatives.

Unnecessary antibiotic treatment of children hospitalised with respiratory syncytial virus (RSV) bronchiolitis: risk factors and prescription patterns

OBJECTIVES

Respiratory syncytial virus (RSV) is a leading cause of respiratory tract infections, especially in young children. Antibiotics are often unnecessarily prescribed for the treatment of RSV. Such treatments affect antibiotic resistance in future bacterial infections of treated patients and the general population. This study aimed to understand risk factors for and patterns of unnecessary antibiotic prescription in children with RSV.

METHODS

In a single-centre, retrospective study in Israel, we obtained data for children aged ≤2 years (n = 1016) hospitalised for RSV bronchiolitis during 2008-2018 and ascertained not to have bacterial co-infections. Antibiotic misuse was defined as prescription of antibiotics during hospitalisation of the study population. Demographic and clinical variables were assessed as predictors of unnecessary antibiotic treatment in a multivariable logistic regression model.

RESULTS

The unnecessary antibiotic treatment rate of children infected with RSV and ascertained not to have a bacterial co-infection was estimated at 33.4% (95% CI 30.5-36.4%). An increased likelihood of antibiotic misuse was associated with drawing bacterial cultures and with variables indicative of a severe patient status such as lower oxygen saturation, higher body temperature, tachypnoea and prior recent emergency room visit. Older age and female sex were also associated with an increased likelihood of unnecessary antibiotic treatment.

CONCLUSIONS

Unnecessary antibiotic treatment in RSV patients was very common and may be largely attributed to physicians' perception of patients' severity. Improving prescription guidelines, implementing antibiotic stewardship programmes and utilising decision support systems may help achieve a better balance between prescribing and withholding antibiotic treatment.

Trend of antibiotic consumption and its association with influenza-like illnesses in France between 2004 and 2018

BACKGROUND

Antibiotic consumption has been reported to be driven by the treatment of respiratory tract infections. Our objectives were to describe the trend of antibiotic consumption in France compared with that of other European countries; to describe the evolution of each antibiotic class in France; and to explore the relationship between antibiotic consumption and incidence of influenza-like illnesses.

METHODS

In this observational study, antibiotic consumption was reported as defined daily doses per 1000 inhabitants per day in the community and hospital sectors in descriptive and graphical formats, using data from the European Surveillance of Antimicrobial Consumption Network database. The total consumption and the consumption of different classes of antibiotics in France according to time and influenza-like illnesses were studied using multiple linear regression models.

RESULTS

The total consumption of antibiotics in France was constant over the 15 years. It was driven by the community sector (92.8%) and was higher than the consumption of other European Union countries (P-value < 0.001). The beta-lactam penicillins were the most consumed antibiotic class and the only class that increased with time. The multiple linear regression models showed a positive correlation between antibiotic consumption in the community sector and incidence of influenza-like illnesses [B = 0.170, 95% CI (0.088-0.252)]. Similar significant results were shown between other antibiotic classes used in the management of influenza-like illnesses (other beta-lactams, and macrolides, lincosamides and streptogramins) and influenza-like illnesses.

CONCLUSION

Our results suggest that antibiotics used in the management of respiratory tract infections might be involved in the irrational use of antibiotics.

Antimicrobial resistance and COVID-19: Intersections and implications

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.

Associations between private vaccine and antimicrobial consumption across Indian states, 2009-2017

Vaccines can reduce antibiotic use and, consequently, antimicrobial resistance by averting vaccine-preventable and secondary infections. We estimated the associations between private vaccine and antibiotic consumption across Indian states during 2009-2017 using monthly and annual consumption data from IQVIA and employed fixed-effects regression and the Arellano-Bond Generalized Method of Moments (GMM) model for panel data regression, which controlled for income and public sector vaccine use indicators obtained from other sources. In the annual data fixed-effects model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.22% increase in antibiotic consumption per 1000 people (P < 0.001). In the annual data GMM model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.2% increase in private antibiotic consumption (P < 0.001). In the monthly data GMM model, private vaccine consumption was negatively associated with antibiotic consumption when 32, 34, 35, and 44-47 months had elapsed after vaccine consumption, with a positive association with lags of fewer than 18 months. These results indicate vaccine-induced longer-term reductions in antibiotic use in India, similar to findings of studies from other low- and middle-income countries.