Regulating the use of antibiotics in the community

Oral healthcare seeking behavior of Malaysian adults in urban and rural areas: findings from the National Health and Morbidity Survey 2019

BACKGROUND

The development and implementation of appropriate strategies to enhance oral health in the community can be aided by an understanding of oral healthcare seeking behavior among urban and rural populations. The purpose of this study was to identify the factors associated with oral healthcare seeking behavior of the Malaysians in urban and rural locations who self-reported dental problems.

METHODS

The National Health and Morbidity Survey 2019, a cross-sectional nationwide household survey that focused on non-institutionalised Malaysians, provided the data for this study on adults in Malaysia who were 18 years of age and older. A two-stage stratified random sampling technique was employed to ensure national representativeness. Data was collected using a multilingual (Malay and English), structured, and validated questionnaire via face-to-face interviews from July to October 2019. The dependent variable was oral healthcare seeking behavior (sought oral healthcare and self-medication). Independent variables were predisposing, enabling and health needs factor based on Andersen's Behavioral Model. Descriptive statistics were used to describe the characteristics and oral healthcare seeking behavior of the respondents. The relationship between the independent and dependent variables were investigated using multivariable logistic regression analysis.

RESULTS

The analysis comprised a total of 10,134 respondents, representing about 18.2 million Malaysian adults aged 18 and above. The overall prevalence of Malaysian adults who self-reported dental problems was low (5.5%) and was slightly higher in the rural than urban population. Almost half sought treatment from healthcare practitioners, and almost a quarter self-medicated. Ethnicity was associated with seeking healthcare and self-medication among urban dwellers. Among the rural population, income level was associated with seeking healthcare while education level was associated with self-medication.

CONCLUSION

Disparities in oral healthcare seeking behaviors exist between Malaysians living in urban and rural areas. Future policies should adopt focused strategies that concentrate on oral healthcare accessibility and health literacy of the vulnerable and rural populations to achieve the best oral healthcare for this population group.

Self-Medication With Antibiotics: An Element Increasing Resistance

Self-medication refers to the consumption of drugs such as antibiotics by individuals based on their own experience and knowledge, without consulting a doctor either for diagnosis or prescription. The inappropriate use of antibiotics is the primary source of antibiotic resistance (AR) development in microorganisms. As a result, some specific types of microorganisms that are naturally resistant to antibiotics have become considerably more common. Self-medication poses a danger to the advantages of antibiotics since it results in financial burdens on low and middle-income countries (LMICs), management failures, the evolution of antibiotic-resistant bacterial serotypes, and a higher risk of contamination of the general population by such tensions. Antibiotic misuse puts patients at risk for adverse drug reactions, false symptom relief, and the rise of drug-resistant microorganisms. It carries many health risks, chiefly in LMICs. These risks are linked to various factors, including a shortage of medical experts, low-level healthcare facilities, unregulated medication delivery, and negative public perceptions of doctors. The primary issue with self-medication is that majority of the population is uninformed of the harmful consequences of antibiotic resistance and how they might donate to it by self-diagnosing and self-treating with antibiotics. Antibiotic self-medication remains a common practice in society, and educational attainment significantly affects the frequency of this behavior. The article aims to educate the people by showing the development and plausible future to decrease antibiotic misuse. It also tells about the various challenges and prevention of this preceding problem.

An Overview of Antimicrobial Stewardship Optimization: The Use of Antibiotics in Humans and Animals to Prevent Resistance

Antimicrobials are a type of agent widely used to prevent various microbial infections in humans and animals. Antimicrobial resistance is a major cause of clinical antimicrobial therapy failure, and it has become a major public health concern around the world. Increasing the development of multiple antimicrobials has become available for humans and animals with no appropriate guidance. As a result, inappropriate use of antimicrobials has significantly produced antimicrobial resistance. However, an increasing number of infections such as sepsis are untreatable due to this antimicrobial resistance. In either case, life-saving drugs are rendered ineffective in most cases. The actual causes of antimicrobial resistance are complex and versatile. A lack of adequate health services, unoptimized use of antimicrobials in humans and animals, poor water and sanitation systems, wide gaps in access and research and development in healthcare technologies, and environmental pollution have vital impacts on antimicrobial resistance. This current review will highlight the natural history and basics of the development of antimicrobials, the relationship between antimicrobial use in humans and antimicrobial use in animals, the simplistic pathways, and mechanisms of antimicrobial resistance, and how to control the spread of this resistance.

To give or not to give antibiotics is not the only question

In a 1945 Nobel Lecture, Sir Alexander Fleming warned against the overuse of antibiotics, particularly in response to public pressure. In the subsequent decades, evidence has shown that bacteria can become resistant to almost any available molecule. One key question is how the emergence and dissemination of resistant bacteria or resistance genes can be delayed. Although some clinicians remain sceptical, in this Personal View, we argue that the prescription of fewer antibiotics and shorter treatment duration is just as effective as longer regimens that remain the current guideline. Additionally, we discuss the fact that shorter antibiotic treatments exert less selective pressure on microorganisms, preventing the development of resistance. By contrast, longer treatments associated with a strong selective pressure favour the emergence of resistant clones within commensal organisms. We also emphasise that more studies are needed to identify the optimal duration of antibiotic therapy for common infections, which is important for making changes to the current guidelines, and to identify clinical biomarkers to guide antibiotic treatment in both hospital and ambulatory settings.

Microbial Resistance Movements: An Overview of Global Public Health Threats Posed by Antimicrobial Resistance, and How Best to Counter

Antibiotics changed medical practice by significantly decreasing the morbidity and mortality associated with bacterial infection. However, infectious diseases remain the leading cause of death in the world. There is global concern about the rise in antimicrobial resistance (AMR), which affects both developed and developing countries. AMR is a public health challenge with extensive health, economic, and societal implications. This paper sets AMR in context, starting with the history of antibiotics, including the discovery of penicillin and the golden era of antibiotics, before exploring the problems and challenges we now face due to AMR. Among the factors discussed is the low level of development of new antimicrobials and the irrational prescribing of antibiotics in developed and developing countries. A fundamental problem is the knowledge, attitude, and practice (KAP) regarding antibiotics among medical practitioners, and we explore this aspect in some depth, including a discussion on the KAP among medical students. We conclude with suggestions on how to address this public health threat, including recommendations on training medical students about antibiotics, and strategies to overcome the problems of irrational antibiotic prescribing and AMR.

Online availability of fish antibiotics and documented intent for self-medication

Self-medication and antibiotic utilization without healthcare oversight may lead to delayed appropriate treatment, transmission of communicable infections, untoward adverse events, and contribute to antimicrobial resistance. Previous data suggest people obtain over-the-counter (OTC) animal antibiotics for their personal use. This study examined the availability of OTC fish antibiotics online and the documented intent for self-medication. The authors conducted a web-based cross-sectional study using Google search engine to identify vendor websites selling fish antibiotics in the United States. Vendor websites were included if product information, consumer reviews, and comments were publicly available. Nine fish antibiotics were chosen due to their possibility of having consequences to human misuse. The cost and availability of fish antibiotics was recorded. The proportion of reviews and comments related to human consumption was calculated. Consumer review traffic based on “likes” and “dislikes” received was compared between human- and non-human consumption-related reviews. Selected fish antibiotics were purchased and evaluated for physical appearance and compared to FDA-approved available equivalents. We found 24 website vendors with online ordering available for OTC fish antibiotics. Cost varied significantly by antibiotic and quantity ranging from USD $8.99 to $119.99. There were 2,288 reviews documented for the 9 selected antibiotics being sold. Among consumer reviews, 2.4% were potentially associated with human consumption. Human consumption-related reviews constituted 30.2% of all “likes” received and 37.5% of all “dislikes” received. Human consumption-related reviews received an average of 9.2 likes compared to 0.52 likes for non-human consumption-related reviews. The 8 fish antibiotics purchased were consistent with FDA-approved equivalents in physical appearance. Although infrequent, antibiotics intended for fish use are being purchased online without a prescription for self-medication to circumvent professional medical care. Reviews related to human consumption generate significant online traffic compared to reviews unrelated to human consumption.

Dispensing of non-prescribed antibiotics in Jordan

OBJECTIVE

Current regulations in Jordan state that antibiotics cannot be sold without a medical prescription. This study aimed to assess the percentage of pharmacies that dispense antibiotics without a medical prescription in the Kingdom of Jordan and identify and highlight the extent and seriousness of such practices among Jordanian pharmacies.

METHODS

A prospective study was performed, and five different clinical scenarios were simulated at pharmacies investigated including sore throat, otitis media, acute sinusitis, diarrhea, and urinary tract infection in childbearing-aged women. Three levels of demand were used to convince the pharmacists to sell an antibiotic.

RESULTS

A total of 202 total pharmacies in Jordan were visited in the present study. The majority of pharmacies (74.3%) dispensed antibiotics without prescription with three different levels of demand. The percentage of pharmacies dispensing antibiotics without a prescription for the sore throat scenario was 97.6%, followed by urinary tract infection (83.3%), diarrhea (83%), and otitis media (68.4%). The lowest percentage of antibiotic dispensing was for the acute sinusitis simulation at 48.5%. Among the pharmacies that dispensed antibiotics, the pharmacists provided an explanation as the number of times per day the drug should be taken in 95.3% of the cases, explained the duration of treatment in 25.7%, and inquired about allergies prior to the sale of the antibiotic in only 17.3%. Only 52 pharmacies (25.7%) refused to dispense any kind of antibiotics, the majority (61.5%) of this refusal response came from acute sinusitis cases, while the minority (2.4%) came from the sore throat cases.

CONCLUSION

The results of this study demonstrate that antibiotics continue to be dispensed without prescription in Jordan in violation with national regulations regarding this practice. The findings of this study could provide a layout for governmental health authorities to implement strict enfrorcment of national regulations regarding antibiotic dispensing in order to avoid the serious complications that could arise in the future as a result of such practices.

Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: a cross sectional study

BACKGROUND

Antibiotics sales without medical prescriptions are increasingly recognized as sources of antimicrobial misuse that can exacerbate the global burden of antibiotic resistance. We aimed to determine the percentage of pharmacies who sell antibiotics without medical prescriptions, examining the potential associated risks of such practice in Riyadh, Saudi Arabia, by simulation of different clinical scenarios.

METHODS

A cross sectional study of a quasi-random sample of pharmacies stratified by the five regions of Riyadh. Each pharmacy was visited once by two investigators who simulated having a relative with a specific clinical illness (sore throat, acute bronchitis, otitis media, acute sinusitis, diarrhea, and urinary tract infection (UTI) in childbearing aged women).

RESULTS

A total of 327 pharmacies were visited. Antibiotics were dispensed without a medical prescription in 244 (77.6%) of 327, of which 231 (95%) were dispensed without a patient request. Simulated cases of sore throat and diarrhea resulted in an antibiotic being dispensed in (90%) of encounters, followed by UTI (75%), acute bronchitis (73%), otitis media (51%) and acute sinusitis (40%). Metronidazole (89%) and ciprofloxacin (86%) were commonly given for diarrhea and UTI, respectively, whereas amoxicillin/clavulanate was dispensed (51%) for the other simulated cases. None of the pharmacists asked about antibiotic allergy history or provided information about drug interactions. Only 23% asked about pregnancy status when dispensing antibiotics for UTI-simulated cases.

CONCLUSIONS

We observed that an antibiotic could be obtained in Riyadh without a medical prescription or an evidence-based indication with associated potential clinical risks. Strict enforcement and adherence to existing regulations are warranted.

Treatment of infection: a cross-sectional survey of antibiotic drug utilisation in the Ramallah district of Palestine

Objective

To characterise the use of antibiotics in outpatients treated for infection in the Ramallah district of Palestine.

Setting

A purposive sample of general and specialist outpatient clinics in the public and private sector in Ramallah.

Method

A prospective, cross-sectional survey over 3 months (February-May 2000) of patients diagnosed with infection, conducted through questionnaires to treating physicians (n = 25) and patients (n = 575).

Key findings

Infection associated with the respiratory tract was the most common type of infection diagnosed, accounting for over 80% of all infections, followed by urinary tract infection and otitis media (14% and 10%, respectively). Amoxicillin was the antibiotic prescribed most often, prescribed for 44% of all patients and for infection of all types and across all age groups. A wide variety of other antibiotics was prescribed, and in the private sector there was more use of newer, more expensive antibiotics. Antibiotic use was rated as appropriate in only 35% of patients, with inappropriate prescribing largely resulting from inappropriate indication (73%) and to a lesser extent choice of drug (17%) or cost (9%). Duration of therapy was seldom specified by the prescriber and depended on pack size dispensed. Seventy-six per cent of patients followed up at 1 week had recovered partially or completely, but lack of compliance was noted in 30%.

Conclusions

There was considerable evidence of inappropriate use of antibiotics, including prescribing for likely self-limiting or non-bacterial infection and failure to specify duration of therapy. A number of patients failed to complete the course. Strategies to promote optimal antibiotic use should be targeted initially to respiratory tract infection, and both physicians and patients require educational input. The community pharmacist can play a lead role on account of both drug expertise and ability to advise health professionals and patients.

Long-term Symptom Recovery and Health-Related Quality of Life in Patients With Mild-to-Moderate-Severe Community-Acquired Pneumonia

STUDY OBJECTIVES

The long-term outcomes of patients with community-acquired pneumonia (CAP) in terms of symptom resolution and health-related quality of life (HRQL) is unknown. Our objective was to determine the rate of symptom resolution using validated patient-based outcome measures, and to assess HRQL 18 months after the episode.

PARTICIPANTS

Patients were recruited from a group enrolled in a randomized trial comparing two durations of treatment for CAP. Between 2000 and 2003, we included 102 adults with a mild-to-moderate-severe CAP (pneumonia severity index, < or = 110).

INTERVENTIONS

CAP-related symptoms were assessed until month 18 using the CAP score. The CAP score was divided into respiratory and well-being sections to assess the recovery of respiratory and well-being symptoms separately. The HRQL was assessed at 18 months using the Medical Outcomes Study 36-item short form (SF-36) questionnaire and compared to a Dutch reference group.

RESULTS

Respiratory symptoms resolved within 14 days, while the well-being symptoms resolved more slowly. Taking the prepneumonia status into account, patients recovered fully from pneumonia after 6 months. Patients with comorbid conditions had significantly more symptoms prepneumonia and during follow-up than patients without comorbidities, but at all time points the proportion of patients that reached > or = 80% of the prepneumonia health level did not depend on comorbidity, age, or etiology. SF-36 scores at 18 months were significantly impaired in four of the eight dimensions for patients with comorbid illness, but did not differ from the reference population for patients without comorbid illness.

CONCLUSION

Patients with mild-to-moderate-severe CAP recover fully from pneumonia after 6 months. The presence of symptoms beyond 28 days and any impairment in HRQL were found to reflect age and comorbidity rather than the persistent effects of the pneumonia itself.

Age-related changes in consultations and antibiotic prescribing for acute respiratory infections, 1995–2000. Data from the UK General Practice Research Database

BACKGROUND

International studies using data aggregated for all ages have shown decreasing rates of general practice consultations for acute respiratory infections with fewer antibiotic prescriptions issued per consultation. The occurrence of different respiratory infections varies widely at different ages but we do not know whether prescribing has reduced equally in all age groups.

OBJECTIVE

We aimed to determine how reductions in consultation rates and antibiotic prescribing varied with age for different respiratory infections.

METHODS

Data were abstracted from the General Practice Research Database for 108 general practices in the UK (mean registered population 642 685). We estimated age-specific changes between 1995 and 2000 in consultation rates, and the proportion of consultations resulting in an antibiotic prescription for 'all respiratory infections' and for 'sore throat', 'ear infection', 'bronchitis' and 'chest infection'.

RESULTS

Consultation rates for 'all respiratory infections' declined in all age groups with the greatest decreases in children aged 1-4 years (41%), 5-10 year olds (53%) and 11-16 year olds (54%), whereas at 75-84 years the reduction was 28%. The pattern of greater reductions in children held for each separate condition even though the age of peak incidence varied. The relative reduction in antibiotic prescribing was greatest at 1-4 years (18%), 5-10 years (17%) and 11-16 years (17%), compared with 5% at 75-84 years. Antibiotic prescribing decreased most for sore throat and this was observed at all ages particularly in 5-10 year olds (relative reduction, 32%).

CONCLUSIONS

School age children account for the greatest reduction in consultations for acute respiratory infection. School age and preschool children account for the greatest reductions in antibiotic prescribing during the consultation. The rapid changes in consultation rates are unexplained.

Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study

OBJECTIVE

To compare the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.

DESIGN

Randomised, double blind, placebo controlled non-inferiority trial.

SETTING

Nine secondary and tertiary care hospitals in the Netherlands.

PARTICIPANTS

Adults with mild to moderate-severe community acquired pneumonia (pneumonia severity index score < or = 110).

INTERVENTIONS

Patients who had substantially improved after three days' treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (n = 63) or placebo (n = 56) three times daily for five days.

MAIN OUTCOME MEASURES

The primary outcome measure was the clinical success rate at day 10. Secondary outcome measures were the clinical success rate at day 28, symptom resolution, radiological success rates at days 10 and 28, and adverse events.

RESULTS

Baseline characteristics were comparable, with the exception of symptom severity, which was worse in the three day treatment group. In the three day and eight day treatment groups the clinical success rate at day 10 was 93% for both (difference 0.1%, 95% confidence interval--9% to 10%) and at day 28 was 90% compared with 88% (difference 2.0%,--9% to 15%). Both groups had similar resolution of symptoms. Radiological success rates were 86% compared with 83% at day 10 (difference 3%,--10% to 16%) and 86% compared with 79% at day 28 (difference 6%,--7% to 20%). Six patients (11%) in the placebo group and 13 patients (21%) in the active treatment group reported adverse events (P = 0.1).

CONCLUSIONS

Discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days' treatment.

Community consumption of antibacterial drugs within the Jordanian population: sources, patterns and appropriateness

This study is the first of its type to evaluate sources, patterns and appropriateness of antibacterial drug consumption within the Jordanian population. It uses a structured random interview to customers arriving at community pharmacy stores seeking antibacterial medication for systemic infections. Dispensed antibacterial drugs belonged to eight different main classes of systemically used antibacterial drugs in accordance with the Anatomical Therapeutic Chemical (ATC) classification system. Just less than one-half of all dispensed antibacterial drugs were without a prescription (46%), either via self-medication (23.2%) or pharmacist recommendation (23.1%). Inappropriateness in use was seen in 29.9% and 34% of the prescribed and non-prescribed (over-the-counter) antibacterial drugs, respectively. No uniformity in the treatment profile of the different treated complaints was seen. Our study shows great misuse and abuse of antibacterial drugs and hence there is a need to force regulations to control community use of antibacterial drugs and to increase awareness of the consequences of their inappropriate and uncontrolled use.

Antimicrobial resistance determinants and future control

At the beginning of the 21st century, antimicrobial resistance is common, has developed against every class of antimicrobial drug, and appears to be spreading into new clinical niches. We describe determinants likely to influence the future epidemiology and health impact of antimicrobial-resistant infections. Understanding these factors will ultimately optimize preventive strategies for an unpredictable future.

Antibiotic prescription in primary health care: clinical and economic perspectives (Catalonia, Spain)

OBJECTIVE

To quantify clinical inappropriateness of antibiotic prescription and its costs in primary health care.

METHODS

2470 cases of infectious disease during 1998 were analysed.

RESULTS

Of all cases, 69.9% did not require antibiotic treatment. Global clinical inappropriateness amounted to 43.7%, rising to 56.7% with the introduction of economic criteria. Treatment unnecessary but antibiotic provided (27.9%) represented the most important category. Costs of inappropriateness reached 68.4% of the estimated total cost.

CONCLUSION

Appropriate antibiotic use should be focused on reducing antibiotic prescription when not indicated and restraining the use of penicillins maintaining restrictive and adequate health policies, and also achieving co-responsibility from the general population.

Prevalence and identification of tetracycline-resistant oral bacteria in children not receiving antibiotic therapy

The prevalence of tetracycline-resistant oral bacteria in healthy 4- and 6-year-old children who had not received antibiotics during the 3 months prior to sampling was investigated. Of the 47 children sampled, 46 harboured tetracycline-resistant bacteria. The median proportion of cultivable anaerobic and aerobic oral bacteria resistant to tetracycline was 1.1% and the MIC50 of these was 64 microg ml(-1). The majority (56%) of tetracycline-resistant bacteria were resistant to at least one other antibiotic, usually erythromycin. The most commonly identified tetracycline-resistant bacteria were the oral streptococci (65%), the next most prevalent groups were Veillonella spp. (10%) and Neisseria spp. (9%). The most frequently identified tetracycline resistance determinant was tet(M). The results of this study have shown that tetracycline-resistant oral bacteria were widespread amongst the children studied.

What are the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection in a mixed private/public Asian setting?

OBJECTIVES

To examine the non-biomedical reasons which make family doctors over-prescribe antibiotics for upper respiratory tract infection (URTI) in a mixed private/public Asian setting.

METHODS

The questionnaire was sent to the members of the Hong Kong College of Family Physicians between August and December 2001.

RESULTS

A total of 801 family doctors completed a postal questionnaire with an overall response rate of 65.0. A significant number of respondents (21.8) felt they might be prescribing antibiotics too often for URTI but the majority of them felt they were using antibiotics just a bit too often. Doctors who were older, more senior or in private practice were more likely to feel that they might be prescribing antibiotics too often. More than 50 of respondents thought that to satisfy the patient or his/her carer and fear of medicolegal problem if the patient deteriorates would make them very likely or likely to over-prescribe antibiotics for patients with URTIs. Public doctors might over-prescribe in order to save time, whereas private doctors might do so in order to keep patients in their practice.

CONCLUSION

The results showed that doctors with certain characteristics are more likely to over-prescribe antibiotics. Factors, other than biomedical ones, may play important roles in doctor's prescription of antibiotics for URTI.

A simple intervention to improve hospital antibiotic prescribing

OBJECTIVE

To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 x 6 cm laminated card suitable for clipping to a hospital identification badge.

INTERVENTION

Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 x 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff.

DESIGN

We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs.

MAIN OUTCOME MEASURES

Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins.

RESULTS

For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards.

CONCLUSION

The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

Moving from recommendation to implementation and audit: part 1. Current recommendations and programs: a critical commentary

Growing concern over the spread of resistance to antibiotics and other antimicrobials has prompted a plethora of recommendations for its control. Strategic programs for resistance containment have been initiated in various countries, particularly in Western Europe and North America. The World Health Organization and the European Union have responded to the need for international action by publishing guidance and encouraging collaboration. These recommendations rightly focus on controlling resistance in the community. They agree on the importance of surveillance of resistance patterns and antibiotic usage and the need to encourage judicious antibiotic usage (especially through education of prescribers and the public). Yet there remains a pressing need for the implementation of effective actions to address these issues. Important considerations given less attention include infection prevention (e.g. through immunization), the use of rapid diagnostic tests to reduce antibiotic usage, audit of implemented actions, and the provision of feedback. Furthermore, research is necessary to fill the substantial gaps in our knowledge. Notably, the reversibility or containment of resistance with the optimization of antibiotic usage has yet to be definitely established. For now, antimicrobial management programs should focus on ensuring the most appropriate use of antimicrobials rather than simply on limiting choices. Finally, developed countries must recognize that a truly global approach to resistance containment will require greater support for developing countries.

Antibiotic prescribing decisions of generalists and infectious disease specialists: thresholds for adopting new drug therapies

The objective of this study was to examine whether physicians are willing to continue to use older antibiotics in the face of drug resistance in order to preserve newer antibiotics forfuture use. The study was a national sample of 398 generalist physicians and 429 infectious disease (ID) specialists. Clinical vignettes prompted respondents to select the level of resistance to a hypothetical older antibiotic at which they would prefer a newer antibiotic without any current resistance in the treatment of a patient with pneumococcalpneumonia. Vignettes varied in the site of care of the patient as a proxyfor variation in disease severity. Respondents significantly reduced their threshold for switching to a newer antibiotic as disease severityincreased. Generalists were more responsive to disease severity than LD specialists. Thus, the adoption of recommendations to limit overuse of newer antibiotics may be variable across clinical settings and providers, reducing the impact of these recommendations on emerging resistance.

The future challenges facing the development of new antimicrobial drugs

The emergence of resistance to antibacterial agents is a pressing concern for human health. New drugs to combat this problem are therefore in great demand, but as past experience indicates, the time for resistance to new drugs to develop is often short. Conventionally, antibacterial drugs have been developed on the basis of their ability to inhibit bacterial multiplication, and this remains at the core of most approaches to discover new antibacterial drugs. Here, we focus primarily on an alternative novel strategy for antibacterial drug development that could potentially alleviate the current situation of drug resistance--targeting non-multiplying latent bacteria, which prolong the duration of antimicrobial chemotherapy and so might increase the rate of development of resistance.

Superbugs II: how should economic evaluation be conducted for interventions which aim to contain antimicrobial resistance?

To date, there has been little examination of the problems associated with conducting economic evaluation for interventions designed to contain antimicrobial resistance. There are two quite different types of intervention aimed at containing antimicrobial resistance: interventions which are designed to avoid the emergence of resistant organisms; and interventions that are designed to avoid the transmission of resistance organisms. Four aspects of economic evaluation where the ease of assessment might be expected to differ across evaluations for these different types of intervention are examined: problems associated with the identification of diffuse impacts, problems associated with comparing current and future impacts, problems associated with uncertainty, and problems associated with difficulties in measurement and valuation. The paper suggests that it may be much easier to conduct rigorous economic evaluations for interventions designed to avoid transmission of resistance, than for those intended to avoid emergence. Unfortunately, the transmission policies, which are likely to be the easiest to evaluate, are not likely to produce an optimal long-term outcome given the apparent irreversibility of much resistance and the potentially severe harms which could be imposed as a result. Given the desirability of avoiding a scenario where, in the evidence-based medicine culture, the most rigorously evaluated policies are followed even though they may be less important, there is the need to consider carefully what, and how, economic evaluation should be conducted in the area of antimicrobial resistance. It is suggested that research should focus on the use of modelling as a means of evaluating optimal policy responses and on trying to resolve some of the difficulties associated with measurement and valuation.

Over-the-counter acquisition of antibiotics in the Maltese general population

Few studies have studied the frequency of over-the-counter acquisition of antibiotics in western countries. In order to provide an insight into these practices in Malta, attitudes towards antibiotic use in the general public were researched through a structured interview. Nineteen percent admitted that they took antibiotics without prescription and 11% of parents replied that they had given antibiotics to their children without prescription. These antibiotics were mainly self-administered for upper respiratory tract symptoms, particularly sore throat, with community pharmacies being the major source in more than 85% of cases. The study indicates the need for an educational campaign on proper antibiotic use amongst the Maltese general public.

Antibacterial prescribing and antibacterial resistance in English general practice: cross sectional study

OBJECTIVE

To quantify the relation between community based antibacterial prescribing and antibacterial resistance in community acquired disease.

DESIGN

Cross sectional study of antibacterial prescribing and antibacterial resistance of routine isolates within individual practices and primary care groups.

SETTING

405 general practices (38 groups) in south west and north west England.

MAIN OUTCOME MEASURES

Correlation between antibacterial prescribing and resistance for urinary coliforms and Streptococcus pneumoniae.

RESULTS

Antibacterial resistance in urinary coliform isolates is common but the correlation with prescribing rates was relatively low for individual practices (ampicillin and amoxicillin r(s)=0.20, P=0.001; trimethoprim r(s)=0.24, P=0.0001) and primary care groups (ampicillin and amoxicillin r(s)=0.44, P=0.05; trimethoprim r(s)=0.31, P=0.09). Regression coefficients were also low; a practice prescribing 20% less ampicillin and amoxicillin than average would have about 1% fewer resistant isolates (0.94/100; 95% confidence interval 0.02 to 1.85). Resistance of S pneumoniae to both penicillin and erythromycin remains uncommon, and no clear relation with prescribing was found.

CONCLUSIONS

Routine microbiological isolates should not be used for surveillance of antibacterial resistance in the community or for monitoring the outcome of any change in antibacterial prescribing by general practitioners. Trying to reduce the overall level of antibiotic prescribing in UK general practice may not be the most effective strategy for reducing resistance in the community.

Pathways for inappropriate dispensing of antibiotics for rhinosinusitis: a randomized trial

We evaluated the extent of and factors that determine the inappropriate use of antibiotics that are obtained without a physician's prescription. Ninety-eight Greek pharmacists were visited by actress-researchers who played clients requesting antibiotics without a physician's prescription. Pharmacists were randomly challenged in a scenario that involved simulated cases of acute uncomplicated rhinosinusitis with either low fever (38.5 degrees C) or high fever (40 degrees C). Antibiotics were offered by 34 (69%) of 49 pharmacists who were presented with the high-fever scenario and by 42 (86%) of 49 pharmacists who were presented with the low-fever scenario (risk difference, 16.3%; P = .05). Thirty-two (65%) and 35 (71%) pharmacists in the high- and low-fever study arms, respectively, agreed to sell the actress-researchers broad-spectrum antibiotics. Only 28 (57%) and 17 (35%) pharmacists, respectively, recommended that the patient visit a physician (P = .03). Inappropriate recommendations regarding antibiotic use were very common in the studied setting. Antibiotics were more likely to be offered to persons who did not have a prescription when they were less likely to be clinically indicated.

Antibiotic prescribing by single handed general practitioners: secondary analysis of data

AIM

To determine the contribution of various doctor and patient factors on the frequency of antibiotic prescribing.

METHODS

Secondary analyses of data on 155 single handed general practitioners.

RESULTS

Three variables explained 25% of variation in antibiotic prescribing. Doctors qualified from the Indian subcontinent issued more antibiotics than U.K.-qualified doctors. Patients from the non-manual social class were issued fewer antibiotics than those from the manual class and the most deprived patients received significantly more antibiotics.

CONCLUSION

Very little of prescribing of antibiotics by doctors is explained by these doctor-patient factors. Prescribing is a complex process and the search for factors must continue in order to address the rising antibiotic resistance.

Rationalised prescribing for community acquired pneumonia: a closed loop audit

AIMS

To audit the management of community acquired pneumonia before and after the introduction of a protocol. To determine the aetiology of pneumonia using routine investigations and polymerase chain reaction (PCR).

METHODS

Retrospective and prospective audit following the introduction of a management protocol. Prospective cases were investigated routinely and with PCR on blood and nasopharyngeal aspirate.

RESULTS

There was a significant increase in rational prescribing following introduction of the protocol with 75% of children receiving intravenous penicillin or erythromycin compared with 26% beforehand. Of 89 children in the prospective group, 51 microbiological diagnoses were achieved in 48 children. Seven children had Streptococcus pneumoniae infection, 14 had Mycoplasma infection, six had pertussis, and one had Chlamydia pneumoniae infection. Twenty three children had a viral cause of which respiratory syncytial virus was commonest.

CONCLUSIONS

Introduction of the protocol led to improved prescribing. PCR increased the diagnostic yield and the results support the management protocol.

The millennium bugs--the need for and development of new antibacterials

Global antibacterial resistance is becoming an increasing public health problem. Bacteria resistant to almost all of the available antibacterials have been identified. The pharmaceutical industry and fledgling biotechnology companies are responding to the threat of antibiotic resistance with renewed efforts to discover novel antibacterials in attempts to overcome bacterial resistance. Both short term and long term strategies are being vigorously pursued. Short-term efforts are focused on developing novel antibacterial agents with a narrow spectrum of action to combat the problem of gram-positive resistant bacteria. Long-term approaches include the use of microbial genomic sequencing techniques to discover novel agents active against potentially new bacterial targets. Better use of existing agents using pharmacodynamic data to optimise antibiotic regimens is increasingly being addressed and the hope is that such measures will prevail until the newer agents are available.

Antibiotic use in developing countries

Antimicrobials have been used successfully for over 6 decades, but genes expressing resistance to them have emerged in strains of bacteria and have disseminated through the global ecosystem to reach infecting microorganisms, produce disease, and seriously interfere with therapy, allowing infections to progress and kill despite antibiotic administration. The upsurge in prevalence of such resistance genes in the bacterial population that colonize and infect humans involves two processes, emergence and dissemination, in both of which there have been contributions from the developing world, where resistance is common and increasing. The emergence of pneumococcal isolates noted in Papua New Guinea and later in South Africa that 1 decade later spread to most of the world and the intercontinental spread between the United States and Venezuela of a new gentamicin resistance gene carried on an epidemic plasmid are examples of the ability of bacteria to travel freely, without regard to borders. Complex societal issues such as the misuse of antibiotics by physicians, pharmacists, and the public; the suboptimal quality of the drugs (emergence); and conditions such as crowding, lack of hygiene, poor or nonexistent hospital infection control practices, or insufficient surveillance (dissemination) play a largely unmeasured role that requires study and solutions. In the meantime, we may intervene to delay the emergence of resistance and to limit its spread by promoting the judicious use of antibiotics both at the local level as well as from multinational organized cooperative efforts. Education and improvement of surveillance and socioeconomic conditions are integral parts of any solution strategy.

[The economic impact of inadequate prescriptions]

The impact of antibiotic therapy has gone to considerable expense. The review of literature demonstrates that an optimal use of economical resources can be achieved by an improvement of medical prescriptions. This improvement of prescriptions can be obtained for prophylaxy and for curative therapy. Cost savings can be as high as one-year budget for the recruitment of an infectious diseases consultant.

Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support

As part of our integrated hospital information system (the HELP system), we developed computer-assisted decision support programs for antimicrobial prescribing that are available at bedside terminals throughout our 520-bed community hospital. Recently, options have been added to allow direct physician order entry of anti-infective agents in the shock-trauma intensive care unit (STRICU). Physicians prescribed the computer-suggested regimens for 46% but followed the suggested dose and interval for 93% of the orders during a 1-year study period. In comparison to a 2-year pre-intervention period, improved drug selection and reductions in adverse drug events and costs were seen. Antimicrobial resistance patterns for nosocomial gram-negative isolates remained stable or improved in the STRICU over an 11-year period of computer-assisted antibiotic management. We conclude that strategies for optimizing antimicrobial prescribing have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns, use of local antimicrobial susceptibility patterns to inform empiric drug selection, and reduced "tonnage" of antibiotic use.

Antibiotic use in humans and bacterial resistance

As with any public health problem, the evolution of antibacterial resistance must be viewed from a perspective of risk, and analysed in terms of probabilities within the populations. It is necessary to be able to predict the risk of antibacterial resistance, in the future, and two main strategies have recently been developed in mathematical models that may help to evaluate these risks. It is also important to understand how antibiotics are used and how their use affects the evolution of antibacterial resistance. Understanding the epidemiology of antibacterial resistance will enable us to develop preventive strategies to limit existing resistance and to avoid the emergence of new strains of resistant bacteria.