Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines

More isn't always better: antibiotic duration after surgical decortication in pleural empyema

Background

While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists.

Methods

A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration.

Results

A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03).

Conclusions

Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.

Evaluating Antibiotic Treatment Guideline Adherence to Ongoing Antibiotic Stewardship in a Tertiary Care Setting: A Retrospective Observational Study

Antimicrobial resistance (AMR) is widely regarded as an increasing threat to global public health. Antibiotic treatment guidelines have been increasingly recognized as an effective tool to guide appropriate prescriptions and help curtail antibiotic resistance. The present study aimed to assess physician's adherence to hospital antibiotic treatment guideline recommendations in Nepal and determine predictive variables with a significant association. This was a retrospective, monocentric observational review to investigate the adherence to endorsed guidelines using the medical records of adults admitted to the hospital with a diagnosis of urinary tract infection (UTI), pneumonia, or skin and soft tissue infection (SSTI) from January 2018 to December 2019. Of the 2,077 medical records that were reviewed (954 UTI, 754 pneumonia, and 369 SSTI), 354 (17%) met the study inclusion criteria, which included 87 UTI, 180 pneumonia, and 87 SSTI patients. Among eligible patients with antibiotic prescriptions, the following were adherent to guideline recommendations: 33 (37.9%) UTI, 78 (43.3%) pneumonia, and 23 (26.4%) SSTI. The overall extent of adherence to hospital antibiotic treatment guidelines for the use of antibiotics among adult inpatients diagnosed with these common infections was 37.9%. Patients who received ceftriaxone (OR = 2.09, 95% CI = 1.18-3.71, p=0.012) and levofloxacin (OR = 4.63, 95% CI = 1.30-16.53, p=0.018) had significantly higher adherence to treatment guidelines. This study revealed a low adherence rate despite the availability of updated guidelines for antibiotic prescriptions. The findings confer an urgent need to confront antibiotic prescription patterns in such tertiary care centers for tailored interventions to improve adherence to antibiotic guidelines.

Implementation of a Taxonomy-Based Framework for the Selection of Appropriate Drugs and Outcomes for Real-World Data Signal Detection Studies

INTRODUCTION

For signal detection studies investigating either drug safety or method evaluation, the choice of drug-outcome pairs needs to be tailored to the planned study design and vice versa. While this is well understood in hypothesis-testing epidemiology, it should be as important in signal detection, but this has not widely been considered. There is a need for a taxonomy framework to provide guidance and a systematic reproducible approach to the selection of appropriate drugs and outcomes for signal detection studies either investigating drug safety or assessing method performance using real-world data.

OBJECTIVE

The aim was to design a general framework for the selection of appropriate drugs and outcomes for signal detection studies given a study design of interest. As a motivating example, we illustrate how the framework is applied to build a reference set for a study aiming to assess the performance of the self-controlled case series with active comparators.

METHODS

We reviewed criteria presented in two published studies which aimed to provide practical advice for choosing the appropriate signal evaluation methodology, and assessed their relevance for signal detection. Further characteristics specific to signal detection were added. The final framework is based on: the application of study design requirements, the database(s) of interest, and the clinical importance of the drug(s) and outcome(s) under consideration. This structure was applied by selecting drug-outcome pairs as a reference set (i.e. list of drug-outcome pairs classified as positive or negative controls) for which the method is expected to work well for a signal detection study aiming to assess the performance of self-controlled case series. Eight criteria were used, related to the application of self-controlled case series assumptions, choice of active comparators, coverage in the database of interest and clinical importance of the outcomes.

RESULTS

After application of the framework, two classes of antibiotics (seven drugs) were selected for the study, and 28 outcomes from all organ classes were chosen from the drug labels, out of the 273 investigated. In total, this corresponds to 104 positive controls (drug-outcome pairs) and 58 negative controls.

CONCLUSIONS

We proposed and applied a framework for the selection of drugs and outcomes for both drug safety signal detection and method assessment used in signal detection to optimise their performance given a study design. This framework will eliminate part of the bias relating to drugs and outcomes not being suited to the method or database. The main difficulty lies in the choice of the criteria and their application to ensure systematic selection, especially as some information remains unknown in signal detection, and clinical judgement was needed on occasions. The same framework could be adapted for other methods.

Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review

BACKGROUND

Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings.

METHODS

This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies.

RESULTS

Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability.

CONCLUSION

Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.

Medical treatment of pleural infection: antibiotic duration and corticosteroid usefulness

The data about the optimal duration of antibiotics and the usefulness of corticosteroids in the management of parapneumonic effusion and pleural infection are scarce. Two randomised controlled trials evaluating short antibiotic courses (ODAPE and SLIM) and another trial assessing the benefit from corticosteroid use (STOPPE) in this setting were recently published. The aim of this journal club is to present these trials and discuss their significance and limitations. ODAPE compared the efficacy and safety of a short (2 weeks) versus an extended (3 weeks) course of amoxicillin-clavulanate in community-acquired complicated parapneumonic effusions, while SLIM compared the efficacy and safety of short (14-21 days) versus longer (28-42 days) antibiotic courses in patients with community- or hospital-acquired pleural infection. STOPPE assessed the benefit from dexamethasone use in patients with community-acquired pneumonia and concomitant pleural effusion. Both ODAPE and SLIM found that shorter antibiotic courses produce less adverse events while being equally efficacious to the longer courses in a subgroup of patients, such as those with pleural infection that is stabilised with only medical treatment and does not require surgery. In contrast, STOPPE found no benefit from the use of dexamethasone in unselected patients with pneumonia and pleural effusion. Due to the significant limitations of these trials, further studies are required to confirm these findings.

Commentary on

Hassan M, et al. The Short versus Long Antibiotic Course for Pleural Infection Management (SLIM) randomised controlled open-label trial. ERJ Open Res 2023; 9: 00635-2022.Porcel JM, et al. Two vs. three weeks of treatment with amoxicillin-clavulanate for stabilized community-acquired complicated parapneumonic effusions. A preliminary non-inferiority, double-blind, randomized, controlled trial. Pleura Peritoneum 2020; 5: 20190027.Fitzgerald DB, et al. Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): a pilot randomized clinical trial. Am J Respir Crit Care Med 2022; 205: 1093-1101.

Inappropriate antibiotic prescribing and its determinants among outpatient children in 3 low- and middle-income countries: A multicentric community-based cohort study

BACKGROUND

Antibiotic resistance is a global public health issue, particularly in low- and middle-income countries (LMICs), where antibiotics required to treat resistant infections are not affordable. LMICs also bear a disproportionately high burden of bacterial diseases, particularly among children, and resistance jeopardizes progress made in these areas. Although outpatient antibiotic use is a major driver of antibiotic resistance, data on inappropriate antibiotic prescribing in LMICs are scarce at the community level, where the majority of prescribing occurs. Here, we aimed to characterize inappropriate antibiotic prescribing among young outpatient children and to identify its determinants in 3 LMICs.

METHODS AND FINDINGS

We used data from a prospective, community-based mother-and-child cohort (BIRDY, 2012 to 2018) conducted across urban and rural sites in Madagascar, Senegal, and Cambodia. Children were included at birth and followed-up for 3 to 24 months. Data from all outpatient consultations and antibiotics prescriptions were recorded. We defined inappropriate prescriptions as antibiotics prescribed for a health event determined not to require antibiotic therapy (antibiotic duration, dosage, and formulation were not considered). Antibiotic appropriateness was determined a posteriori using a classification algorithm developed according to international clinical guidelines. We used mixed logistic analyses to investigate risk factors for antibiotic prescription during consultations in which children were determined not to require antibiotics. Among the 2,719 children included in this analysis, there were 11,762 outpatient consultations over the follow-up period, of which 3,448 resulted in antibiotic prescription. Overall, 76.5% of consultations resulting in antibiotic prescription were determined not to require antibiotics, ranging from 71.5% in Madagascar to 83.3% in Cambodia. Among the 10,416 consultations (88.6%) determined not to require antibiotic therapy, 25.3% (n = 2,639) nonetheless resulted in antibiotic prescription. This proportion was much lower in Madagascar (15.6%) than in Cambodia (57.0%) or Senegal (57.2%) (p < 0.001). Among the consultations determined not to require antibiotics, in both Cambodia and Madagascar the diagnoses accounting for the greatest absolute share of inappropriate prescribing were rhinopharyngitis (59.0% of associated consultations in Cambodia, 7.9% in Madagascar) and gastroenteritis without evidence of blood in the stool (61.6% and 24.6%, respectively). In Senegal, uncomplicated bronchiolitis accounted for the greatest number of inappropriate prescriptions (84.4% of associated consultations). Across all inappropriate prescriptions, the most frequently prescribed antibiotic was amoxicillin in Cambodia and Madagascar (42.1% and 29.2%, respectively) and cefixime in Senegal (31.2%). Covariates associated with an increased risk of inappropriate prescription include patient age greater than 3 months (adjusted odds ratios (aOR) with 95% confidence interval (95% CI) ranged across countries from 1.91 [1.63, 2.25] to 5.25 [3.85, 7.15], p < 0.001) and living in rural as opposed to urban settings (aOR ranged across countries from 1.83 [1.57, 2.14] to 4.40 [2.34, 8.28], p < 0.001). Diagnosis with a higher severity score was also associated with an increased risk of inappropriate prescription (aOR = 2.00 [1.75, 2.30] for moderately severe, 3.10 [2.47, 3.91] for most severe, p < 0.001), as was consultation during the rainy season (aOR = 1.32 [1.19, 1.47], p < 0.001). The main limitation of our study is the lack of bacteriological documentation, which may have resulted in some diagnosis misclassification and possible overestimation of inappropriate antibiotic prescription.

CONCLUSION

In this study, we observed extensive inappropriate antibiotic prescribing among pediatric outpatients in Madagascar, Senegal, and Cambodia. Despite great intercountry heterogeneity in prescribing practices, we identified common risk factors for inappropriate prescription. This underscores the importance of implementing local programs to optimize antibiotic prescribing at the community level in LMICs.

Antibiotic Use for Febrile Children in a Tertiary Care Hospital's Outpatient Department: A Cross-Sectional Study

Background Irrational prescription of antibiotics is contributing to the antimicrobial resistance crisis in low and middle-income countries. Antibiotic stewardship programs need to be implemented to rationalize the use of antibiotics, but data on antibiotic prescriptions in pediatric outpatient departments is minimal. This study aimed to determine the frequency of antibiotic prescriptions in febrile children attending the Paediatric Outpatient Department (OPD) at Combined Military Hospital, Lahore, and observe the factors affecting the decision to prescribe antibiotics. Methodology A cross-sectional, descriptive study with non-probability sampling in the Department of Paediatrics at the Combined Military Hospital (CMH), Lahore, was conducted over two years. The confidence limit was 95%, and the anticipated population proportion was 32%. The primary outcome was the proportion of children aged two months to 10 years presenting to the OPD with fever who received antibiotics. Further analysis included the effect of patient-level risk factors on antibiotic prescription, especially in children with respiratory tract infections (RTIs). Results Of the 225 children analyzed, 137 (61%) received antibiotics. Of these antibiotic prescriptions, 123 (90%) were second-line antibiotics. Older age (odds ratio (OR) = 2.3, 1.18-4.46), high fever (OR = 2.48, 1.37-4.5), presenting in autumn and winter seasons (OR = 2.85, 1.53-5.3), ill appearance (OR = 2.71, 1.12-6.55), tachycardia (OR = 4.28, 1.22-15.01), and tachypnea (OR = 4.01, 1.14-14.12) were associated with increased likelihood of antibiotic prescription. Antibiotic prescriptions in children with RTIs were associated with lower RTI (OR = 12.96, 3.49-48.08), probable bacterial infection (OR = 12.37, 4.77-30.05), tachycardia (OR = 10.88, 1.28-92.24), tachypnea (OR = 14.73, 3.14-68.99), and increased work of breathing (OR = 7.8, 2.05-29.56). Conclusions The evidence of the widespread inappropriate use of antibiotics in OPDs, particularly for upper RTIs, highlights the need for an antibiotic stewardship program. Antibiotic overprescription promotes antibiotic resistance, prolonging illness and increasing healthcare costs.

New insights into the treatment of acute otitis media

INTRODUCTION

Acute otitis media (AOM) affects most (80%) children by 5 years of age and is the most common reason children are prescribed antibiotics. The epidemiology of AOM has changed considerably since the widespread use of pneumococcal conjugate vaccines, which has broad-reaching implications for management.

AREAS COVERED

In this narrative review, we cover the epidemiology of AOM, best practices for diagnosis and management, new diagnostic technology, effective stewardship interventions, and future directions of the field. Literature review was performed using PubMed and ClinicalTrials.gov.

EXPERT OPINION

Inaccurate diagnoses, unnecessary antibiotic use, and increasing antimicrobial resistance remain major challenges in AOM management. Fortunately, effective tools and interventions to improve diagnostic accuracy, de-implement unnecessary antibiotic use, and individualize care are on the horizon. Successful scaling of these tools and interventions will be critical to improving overall care for children.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

‘Brave Enough’: A Qualitative Study of Veterinary Decisions to Withhold or Delay Antimicrobial Treatment in Pets

Veterinarians sometimes prescribe antimicrobials even when they know or suspect that they are unnecessary. The drivers of this behaviour must be understood to design effective antimicrobial stewardship interventions. Semi-structured interviews were conducted with 22 veterinarians who treated companion animals in Australia. The Theory of Planned Behaviour was used to organise interview themes, focusing on a decision to withhold antimicrobial therapy in the absence of a clear indication. Many background factors influenced antimicrobial-withholding decisions, including the veterinarian’s communication skills, general attitudes towards antimicrobial resistance (AMR), habits and energy levels. Client awareness of AMR and the veterinarian–client relationship were also important. Beliefs about the consequences of withholding antimicrobials (behavioural beliefs) were dominated by fears of the animal’s condition deteriorating and of failing to meet client expectations. These fears, weighed against the seemingly distant consequences of AMR, were major barriers to withholding antimicrobials. Normative beliefs were primarily focused on the expected approval (or disapproval) of the client and of other veterinarians. Control beliefs about the difficulty of withholding antimicrobials centred around client factors, most importantly, their capacity to adequately monitor their animal, to pay for further investigations, or to undertake non-antimicrobial management, such as wound care, at home. The use of antimicrobials by companion animal veterinarians in the absence of a clear indication is often powerfully driven by behavioural beliefs, chiefly, fears of clinical deterioration and of failing to meet client expectations.

Re-examining advice to complete antibiotic courses: a qualitative study with clinicians and patients

BACKGROUND

Antibiotic treatment duration may be longer than sometimes needed. Stopping antibiotics early, rather than completing pre-set antibiotic courses, may help reduce unnecessary exposure to antibiotics and antimicrobial resistance (AMR).

AIM

To identify clinicians' and patients' views on stopping antibiotics when better (SAWB) for urinary tract infections (UTIs), and to explore comparisons with other acute infections.

DESIGN & SETTING

An exploratory qualitative study with general practice clinicians and patients in England.

METHOD

Primary care clinicians and patients who had recent UTI experience were recruited in England. Remote one-to-one interviews with clinicians and patients, and one focus group with patients, were conducted. Data were audiorecorded, transcribed, and analysed thematically.

RESULTS

Eleven clinicians (seven GPs) and 19 patients (14 with experience of recurrent and/or chronic UTIs) were included. All participants considered SAWB unfamiliar and contradictory to well-known advice to complete antibiotic courses, but were interested in the evidence for risks and benefits of SAWB. Clinicians were amenable if evidence and guidelines supported it, whereas patients were more averse because of concerns about the risk of UTI recurrence and/or complications and AMR. Participants viewed SAWB as potentially more appropriate for longer antibiotic courses and other infections (with longer courses and lower risk of recurrence and/or complications). Participants stressed the need for unambiguous advice and SAWB as part of shared decision making and personalised advice.

CONCLUSION

Patients were less accepting of SAWB, whereas clinicians were more amenable to it. Patients and clinicians require good evidence that this novel approach to self-determining antibiotic duration is safe and beneficial. If evidence based, SAWB should be offered with an explanation of why the advice differs from the 'complete the course' instruction, and a clear indication of when exactly to stop antibiotics should be given.

Effect of antibiotic-administration period on hepatic bile acid profile and expression of pharmacokinetic-related proteins in mouse liver, kidney, and brain capillaries

Antibiotic administration affects pharmacokinetics through changes in the intestinal microbiota, and bile acids are involved in this regulation. The purpose of the present study was to clarify the effect of different periods of antibiotic administration on the hepatic bile acid profile and expression of pharmacokinetic-related proteins in mouse liver, kidney, and brain capillaries. Vancomycin and polymyxin B were orally administered to mice for either 5- or 25-days. The hepatic bile acid profile of the 25-day treatment group was distinct. In the liver, the protein expression of cytochrome P450 (Cyp)3a11 showed the greatest reduction to 11.4% after the 5-day treatment and further reduced to 7.01% after the 25-day treatment. Similar reductions were observed for sulfotransferase 1d1, Cyp2b10, carboxylesterase 2e, UDP-glucuronosyltransferase (Ugt)1a5, and Ugt1a9. In the kidney and brain capillaries, no drug-metabolizing enzymes or drug transporters were changed with >1.5-fold or <0.66-fold statistical significance in either period. These results suggest that bile acids and metabolizing enzymes in the liver are affected in a period-dependent manner by antibiotic treatment, while the blood-brain barrier and kidneys are less affected. Drug-drug interactions of antibiotics via the intestinal microbiota should be considered by changing drug metabolism in the liver.

Antibiotic Prescription for Dental Procedures in Type 1 Diabetic Children

In diabetic patients, maintaining blood glucose levels as close to normal as possible is an objective in dental management especially in pediatric ones. Patients with poorly controlled diabetes are at greater risk of developing infections. Therefore, the prescription of antibiotics may be necessary for some dental procedures.

Aim

The aim is to optimize the benefit and minimize the risk of antibiotics in dental treatments performed in diabetic children.

Materials and methods

A cross-sectional approach was conducted on 155 type 1 diabetic children (72 controlled and 83 uncontrolled). The types of dental acts held for the study were pulpotomies, pulpectomies, pediatric crowns, scaling, and extraction. For the balanced diabetic patients, no antibiotics were prescribed except for infected teeth. In the unbalanced diabetic group, for the acts causing bleeding, prophylactic antibiotics were administered. In presence of dental infection, antibiotics were administered for at least 5 days.

Results

The analysis of data was carried out using Statistical Package for the Social Sciences Computer Software (SPSS 21.0, Inc., Chicago, Illinois, USA). A probability value of <0.05 was regarded as statistically significant. Around 126 acts in the balanced group and 145 in the unbalanced ones were performed. In balanced diabetic children, 125 successes and one failure were noted. In the unbalanced group, 142 successes and three failures were recorded. The comparison between variables did not show any statistical significance (p-value = 0.382).

Conclusion

This study demonstrated that working with diabetic young patients is possible and safe as long as some measures are considered. It is crucial to identify the dental acts that necessitate antibiotics administration and to differentiate between balanced and unbalanced diabetic children for the same dental procedure.

How to cite this article

Nassif N, Noueiri B. Antibiotic Prescription for Dental Procedures in Type 1 Diabetic Children. Int J Clin Pediatr Dent 2023;16(1):60-63.

Evaluating the impact of Respiratory Syncytial Virus immunisation strategies on antibiotic use and drug resistant bacterial infections in England

Background: Vaccines against viruses have been proposed as a novel means to reduce antibiotic use, which would, in turn, decrease selection for antibiotic resistant bacteria. However, the impact of this intervention is poorly quantified, and likely depends on setting-specific epidemiology. Therefore, with increasing confidence in a new vaccine against respiratory syncytial virus (RSV), it is important to quantify the impact of these vaccines on antibiotic prescribing and any downstream reduction in drug resistant bacterial infections. Methods: Here we integrate results from a dynamic transmission model of RSV and a statistical attribution framework to capture the impact of RSV vaccines on the reduction in antibiotic prescribing due to averted primary care visits in England. Results: Under base case assumptions, we find that the most impactful RSV vaccine strategy targets children aged 5–14 years, resulting in an annual reduction of 10.9 (8.0–14.2) antibiotic courses per 10,000 person years across the entire population, equivalent to reducing annual all-cause primary care prescribing by 0.23%. Our results suggest that this reduction in antibiotic use would gain 130 disability-adjusted life years and avert £51,000 associated with drug resistant bacterial infections. Seasonally administering monoclonal antibodies (mAbs) to high-risk infants under 6 months is the most efficient strategy, reducing per person year antibiotic prescribing by 2.6 (1.9–3.3) antibiotic courses per 1,000 mAb courses. Conclusions: Under optimistic conditions, the cost-effectiveness of RSV vaccine strategies in England would likely not be altered by integrating the benefits of preventing drug resistant infections in addition to RSV disease prevention.

Short-course antibiotic therapy: The next frontier in antimicrobial stewardship

Ensuring appropriate use of antibiotics is critical to preserving their effectiveness through limiting the development and spread of antimicrobial resistance. Evidence is accumulating that shorter courses of antibiotics are as effective as traditional longer regimens for many common infections and can reduce the risk of adverse events. Despite the availability of evidence and guidelines supporting short-course antibiotic therapy for these conditions, prolonged use of antibiotics remains common. This article will review the origins and evolution of our approach regarding antimicrobial prescription duration, the evidence for the use of short-course therapy for selected infections, barriers to the uptake of this practice and potential approaches that can be taken to reduce inappropriately long antibiotic use.

Antibacterial-associated acute kidney injury among older adults: A post-marketing surveillance study using the FDA adverse events reporting system

PURPOSE

Antibacterials induce a differential risk of acute kidney injury (AKI) in older adults. This study investigated the reporting risk of AKI associated with antibacterials using the individual case safety reports (ICSRs) submitted to the Food and Drug Administration Adverse Event Reporting System (FAERS) database.

METHODS

A case/non-case method was used to assess AKI risk associated with antibacterials between 1 January 2000 and 30 September 2021. Cases were ICSRs for antibacterials with AKI as preferred terms included in the Medical Dictionary of Regulatory Activities (MedDRA) system organ classes 'Renal and urinary disorders' disorders. The analyses were completed on a de-duplicated data set containing only the recent version of the ICSR. Signals were defined by a lower 95% confidence interval (CI) of reporting odds ratio (ROR) ≥ 2, proportional reporting ratio (PRR) ≥ 2, information component (IC) > 0, Empirical Bayes Geometric Mean (EBGM) > 1 and reports ≥4. Sensitivity analyses were conducted a priori to assess the robustness of signals.

RESULTS

A total of 3 680 621 reports on ADEs were retrieved from FAERS over the study period, of which 92 194 were antibacterial reports. Gentamicin, sulfamethoxazole, trimethoprim and vancomycin consistently gave strong signals of disproportionality on all four disproportionality measures and across the different sensitivity analyses: gentamicin (ROR = 2.95[2.51-3.46]), sulfamethoxazole (ROR = 2.97[2.68-3.29]), trimethoprim (ROR = 2.81[2.29-3.46]) and vancomycin (ROR = 3.35[3.08-3.64]).

CONCLUSION

Signals for gentamicin, sulfamethoxazole, trimethoprim and vancomycin were confirmed by using antibacterials as a comparator, adjusting for drug-related competition bias and event-related competition bias.

Effectiveness of antitussives, anticholinergics, and honey versus usual care in adults with uncomplicated acute bronchitis: a multiarm randomized clinical trial

BACKGROUND

Despite the frequent use of symptomatic therapies in cough, evidence of their benefits is lacking.

OBJECTIVE

We compared the effectiveness of 3 symptomatic therapies and usual care in acute bronchitis.

METHODS

Multicenter, pragmatic, multiarm parallel group, open randomized trial in primary care (ClinicalTrials.gov, Identifier: NCT03738917) was conducted in Catalonia. Patients ≥18 with uncomplicated acute bronchitis, with cough<3 weeks as the main symptom, scoring ≥4 in either daytime or nocturnal cough (7-point Likert scale), were randomized to usual care, dextromethorphan 15 mg t.i.d., ipratropium bromide inhaler 20 µg 2 puffs t.i.d, or 30 mg of honey t.i.d., all taken for up to 14 days. The main outcome measure was the number of days with moderate-to-severe cough. A symptom diary was given. A second visit was scheduled at days 2-3 for assessing evolution, with 2 more visits at days 15 and 29 for clinical assessment, evaluation of adverse effects, re-attendance, and complications.

RESULTS

We failed to achieve the sample size scheduled due to the COVID-19 pandemic. We finally recruited 194 patients. The median number of days with moderate-to-severe cough (score ≥ 3) in the usual care arm was 5 (interquartile range [IQR], 4, 8.75), 5 in the ipratropium bromide arm (IQR, 3, 8), 5 in the dextromethorphan arm (IQR, 4, 9.75), and 6 in the honey arm (IQR, 3.5, 7). The same results were obtained in the Kaplan-Meier survival analysis for the median survival time of each arm with the usual care as the reference group.

CONCLUSION

The symptomatic treatment evaluated has shown to be ineffective against cough.

Compliance to Guidelines in Prescribing Empirical Antibiotics for Individuals with Uncomplicated Urinary Tract Infection in a Primary Health Facility of Ghana, 2019-2021

Increasing trends in antimicrobial resistance among uropathogens call for rational use of empirical antibiotics for managing uncomplicated urinary tract infections (UTIs). In Ghana, standard treatment guidelines (STGs) for UTI recommend oral ciprofloxacin or cefuroxime for 5-7 days in females and 10-14 days in males. We conducted a cross-sectional audit using electronic medical records (EMR) to assess compliance to the STGs among adults (≥18 years) with uncomplicated UTIs diagnosed in a primary health facility between October 2019 and October 2021. Among 3717 patients, 71% were females and all had complete prescription details in the EMR. Of all the patients, 83% were prescribed empirical antibiotics, of whom 88% received oral ciprofloxacin or cefuroxime. Only 68% were prescribed antibiotics for the correct duration, which was significantly lower among males (10%) compared to females (90%). Among patients who received antibiotics, 60% were prescribed in line with the STGs. The results call for feedback to physicians about poor compliance to STGs with duration of antibiotic prescribed. Recommendations on 10-14 days duration of antibiotics for males needs to be reassessed and necessary amendments to STGs can be made. Leveraging the well-established EMR system, a real-time audit-feedback mechanism can be instituted to improve compliance with STGs.

Contribution of Symptomatic, Herbal Treatment Options to Antibiotic Stewardship and Microbiotic Health

Epithelial surfaces in humans are home to symbiotic microbes (i.e., microbiota) that influence the defensive function against pathogens, depending on the health of the microbiota. Healthy microbiota contribute to the well-being of their host, in general (e.g., via the gut-brain axis), and their respective anatomical site, in particular (e.g., oral, urogenital, skin, or respiratory microbiota). Despite efforts towards a more responsible use of antibiotics, they are often prescribed for uncomplicated, self-limiting infections and can have a substantial negative impact on the gut microbiota. Treatment alternatives, such as non-steroidal anti-inflammatory drugs, may also influence the microbiota; thus, they can have lasting adverse effects. Herbal drugs offer a generally safe treatment option for uncomplicated infections of the urinary or respiratory tract. Additionally, their microbiota preserving properties allow for a more appropriate therapy of uncomplicated infections, without contributing to an increase in antibiotic resistance or disturbing the gut microbiota. Here, herbal treatments may be a more appropriate therapy, with a generally favorable safety profile.

Instruments used to measure knowledge and attitudes of healthcare professionals towards antibiotic use for the treatment of urinary tract infections: A systematic review

Background

Urinary tract infections (UTIs) are the second most common condition (after upper respiratory tract infections) for which adults receive antibiotics, and this prevalence may contribute to antibiotic resistance. Knowledge and attitudes have been identified as potential determinants of antibiotic prescribing behaviour among healthcare professionals in the treatment and management of UTIs. An instrument that captures prescribers’ baseline knowledge of and attitudes towards antibiotic prescribing for UTIs could inform interventions to enhance prescribing. The current systematic review evaluates the psychometric properties of instruments already available and describes the theoretical constructs they measure.

Methods

Five electronic databases were searched for published studies and instruments. The Consensus-based Standards for the selection of health status Measurement Instruments checklist was used to assess the psychometric quality reporting of the instruments. The items included in each instrument were mapped onto the theoretical constructs underlying knowledge and attitudes using a mixed-theoretical model developed for this study.

Results

Fourteen studies met the review inclusion criteria. All instruments were available for review. None of the instruments had all the psychometric properties evaluated. Most of the instruments sought to identify knowledge and/or attitude factors influencing antibiotic prescribing for UTIs rather than to measure/assess knowledge and attitudes.

Conclusions

Few instruments for the assessment of knowledge and attitudes of healthcare professionals towards antibiotic use and UTI treatment are available. None of the instruments underwent the full development process to ensure that all psychometric properties were met. Furthermore, none of the instruments assessed all domains of knowledge and attitudes. Therefore, the ability of the instruments to provide a robust measurement of knowledge and attitudes is doubtful. There is a need for an instrument that fully and accurately measures the constructs of knowledge and attitude of healthcare professionals in the treatment of UTIs.

Unraveling the Nature of Antibiotics: Is It a Cure or a New Hurdle to the Patient Treatment?

Antimicrobial resistance is an increasing problem worldwide that has been exacerbated by antibiotic misuse worldwide. Growing antibiotic resistance can be attributed to as well as leads to severe infections, complications, prolonged hospital admissions, and higher mortality. One of the most important goals of administering antimicrobials is to avoid establishing antibiotic resistance during therapy. This can be done by drastically lowering worldwide antimicrobial usage, both in present and future. While current management methods to legislate antimicrobials and educate the healthcare community on the challenges are beneficial, they do not solve the problem of attaining an overall reduction in antimicrobial usage in humans. Application of rapid microbiological diagnostics for identification and antimicrobial susceptibility testing, use of inflammation markers to guide initiation and duration of therapies, reduction of standard antibiotic course durations, individualization of antibiotic treatments, and dosing considering pharmacokinetics are all possible strategies to optimize antibiotic use in everyday clinical practice and reduce the risk of inducing bacterial resistance. Furthermore, to remove any impediments to proper prescribing, strategies to improve antibiotic prescribing and antibiotic stewardship programs should enable clinical reasoning and enhance the prescribing environment. In addition, the well-established association between antimicrobial usage and resistance should motivate efforts to develop antimicrobial treatment regimens that facilitate the evolution of resistance. This review discusses the role of antibiotics, their current application in human medicine, and how the resistance has evolved to the existing antibiotics based on the existing literature.

Distribution and Drug Resistance of Bacterial Pathogens Associated with Lower Respiratory Tract Infection in Children and the Effect of COVID-19 on the Distribution of Pathogens

By studying the distribution and drug resistance of bacterial pathogens associated with lower respiratory tract infection (LRTI) in children in Chengdu and the effect of the COVID-19 on the distribution of pathogens and by analyzing the epidemic trend and drug resistance changes of the main pathogens of LRTI, this research is supposed to provide a useful basis for the prevention of LRTI in children and the rational use of drugs in clinical practice. Hospitalized children clinically diagnosed with LRTI in Chengdu Women and Children's Central Hospital from 2011 to 2020 were selected as the study subjects. The pathogens of LRTI in children and the distribution of pathogens in different ages, genders, seasons, years, and departments and before and after the pandemic situation of COVID-19 were counted. The drug resistance distribution of the top six pathogens with the highest infection rate in the past three years and the trend of drug resistance in the past decade were analyzed. A total of 26,469 pathogens were isolated. Among them, 6240 strains (23.6%) were Gram-positive bacteria, 20152 strains (76.1%) were Gram-negative bacteria, and 73 strains (0.3%) were fungi. Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, and Staphylococcus aureus were highly isolated in the group of infants aged 0-1 (P < 0.01), Moraxella catarrhalis and Streptococcus pneumoniae were highly isolated in children aged 1–6 (P < 0.01), and Haemophilus influenzae was highly isolated in children over 1 (P < 0.01). The isolation rates of Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Staphylococcus aureus, and Candida albicans in the lower respiratory tract of 0-1 year-old male infants were higher than those of female infants (p < 0.05). Haemophilus influenzae was highly isolated in spring and summer, and Moraxella catarrhalis was highly isolated in autumn and winter, while the infection of Streptococcus pneumoniae was mainly concentrated in winter. This difference was statistically significant (P < 0.01). Affected by the COVID-19 pandemic, the isolation rates of Haemophilus influenzae and Streptococcus pneumoniae were significantly lower than those before the pandemic, and the isolation rate of Moraxella catarrhalis was significantly higher. The difference was statistically significant (P < 0.01). The proportion of isolated negative bacteria in NICU and PICU was higher than that in positive bacteria, and the infection rates of Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, and Acinetobacter baumannii were higher than those in other departments. The differences were statistically significant (P < 0.01). The results of drug sensitivity test showed that the drug resistance of Haemophilus influenzae and Moraxella catarrhalis was mainly concentrated in Ampicillin, First- and Second-generation cephalosporins, and Cotrimoxazole, with stable sensitivity to Third-generation cephalosporins, while the drug resistance of Streptococcus pneumoniae was concentrated in Macrolides, Sulfonamides, and Tetracyclines, with stable sensitivity to Penicillin. Staphylococcus aureus is highly resistant to penicillins and macrolides and susceptible to vancomycin. Enterobacteriaceae resistance is concentrated in cephalosporins, with a low rate of carbapenem resistance. From 2018 to 2020, 1557 strains of Staphylococcus aureus were isolated, of which 416 strains were MRSA, accounting for 27% of the isolates; 1064 strains of Escherichia coli were isolated, of which 423 strains were ESBL and 23 strains were CRE, accounting for 40% and 2% of the isolates, respectively; and 1400 strains of Klebsiella pneumoniae were isolated, of which 385 strains were ESBL and 402 strains were CRE, accounting for 28% and 29% of the isolates, respectively. Since 2011, the resistance of Escherichia coli and Klebsiella pneumoniae to Third-generation cephalosporins has increased, peaking in 2017, and has decreased after 2018, years after which carbapenem resistance has increased significantly, corresponding to an increase in the detection rate of Carbapenem-resistant Enterobacteriaceae CRE. Findings from this study revealed that there are significant differences in community-associated infectious pathogens before and after the COVID-19 pandemic, and there are significant age differences, seasonal epidemic trends, and high departmental correlation of pathogens related to lower respiratory tract disease infection in children. There was a significant gender difference in the isolation rate of pathogens associated with LRTI in infants under one year. Vaccination, implementation of isolation measures and social distance, strengthening of personal protective measures, aseptic operation of invasive medical treatment, hand hygiene, and environmental disinfection are beneficial to reducing community-associated pathogen infection, opportunistic pathogen infection, and an increase in resistant bacteria. The strengthening of bacterial culture of lower respiratory tract samples by pediatricians is conducive to the diagnosis of respiratory tract infections caused by different pathogens, contributing to the selection of effective drugs for treatment according to drug susceptibility results, which is important for the rational use of antibiotics and curbing bacterial resistance.

Association between tramadol use and risk of pneumonia in the middle-aged and elderly populations: a propensity-score matched cohort study

BACKGROUND

Tramadol is a widely used weak opioid; however, the evidence for its safety profile in respiratory system needs additional information. We aimed to examine whether tramadol use is associated with an increased risk of pneumonia in the general population.

METHODS

We conducted five propensity-score (PS) matched cohort studies in The Health Improvement Network database. Participants aged ≥50-years initiated tramadol were compared with those initiated one of the following analgesics: codeine (n=144,506), naproxen (n=113,028), diclofenac (n=74,297), celecoxib (n=42,538), or etoricoxib (n=27,232). The outcome was incident pneumonia.

OUTCOMES

During six-month follow-up, 395 pneumonia (5.6/1000 person-years) occurred in the tramadol group and 414 pneumonia (5.9/1000 person-years) occurred in the PS matched codeine group. Compared with codeine group, the risk of pneumonia was lower in the tramadol group (hazard ratio [HR]=0.63, 95% confidence interval [CI]: 0.49-0.82) during the first 30-day follow-up, but comparable between groups over the entire six-month follow-up (HR=0.95, 95%CI: 0.83-1.09). In addition, the risk of pneumonia was higher in the tramadol group than that in the PS matched naproxen (HR=1.68, 95%CI: 1.37-2.06), diclofenac (HR=1.63, 95%CI: 1.31-2.03), celecoxib (HR=1.64, 95%CI: 1.20-2.24), or etoricoxib (HR=1.61, 95%CI: 1.04-2.49) group.

CONCLUSIONS

The present study indicated that tramadol initiators had a lower risk of incident pneumonia than codeine initiators during the short-time follow-up, but had a comparable pneumonia risk compared to codeine initiators and had a higher risk of pneumonia compared to NSAIDs initiators over the entire six-month follow-up duration. Confirmation of the present findings and determination of the underlying mechanism will require more studies.

Potential impact of national recommendations to use short course antibiotic therapy on antibiotic use in the emergency department of a UK hospital: retrospective observational study

BACKGROUND AND IMPORTANCE

The National Institute for Health and Care Excellence (NICE) antimicrobial prescribing guidelines for common infections recommend short course antimicrobial therapy in order to reduce antibiotic associated harm.

OBJECTIVE

To quantify the opportunity to reduce antibiotic use in an emergency department (ED) through adoption of these short antibiotic course recommendations.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective observational study in an ED in the UK with 95 000 attendances a year. Patients managed in the ED between 1 December and 31 December 2019 with the following infections were identified: acute otitis media, human and animal bites, pyelonephritis, lower urinary tract infections, cellulitis, cough, infective exacerbation of chronic obstructive pulmonary disease, pneumonia, sore throat, sinusitis, and diverticulitis.

OUTCOME MEASURE

Excess antibiotic use due to either a protracted course length, or not meeting criteria for antibiotics.

RESULTS

395 patients (260 adults and 135 children) were identified. Of the 1215 days of antibiotic therapy, 198 (16%) were excess because of protracted course lengths. In terms of antibiotic defined daily doses (DDD), there were 1201.5 antibiotic DDD prescribed, of which 232 (19%) DDD were excess because of protracted course lengths. If both protracted courses and unnecessary antibiotic use were included, then 321 (27%) DDD were excess. Excess antibiotic use and total antibiotic use by infection group were: 123/546 (23%) DDD in lower respiratory tract infection, 46/59 (79%) in upper respiratory tract infection, 44/231 (19%) in upper and lower urinary tract infection, 0/113 (0%) cellulitis, 77/180 (43%) bites, and 30/40 (75%) diverticulitis. Excess antibiotic use, as a proportion of all antibiotic use in the ED, was 321/4291 (7.5%) DDD, and of whole hospital antibiotic use, the ED's excess use was 321/33 566 (0.96%).

CONCLUSION

Adoption of NICE antibiotic prescribing guidelines for common infections has the potential to reduce total antibiotic use in the ED by 7.5% and contribute to the hospital-wide antibiotic stewardship programme.

Factors Associated With Longer Than Recommended Durations of Antibiotic Therapy for Uncomplicated Ambulatory Infections in an Integrated Healthcare System

Across the ambulatory care network of an integrated health care system, durations of antibiotic therapy prescribed for uncomplicated infections were longer than recommended in 39% of cases. By logistic regression, site of care, prescriber characteristics, and type of infection were independently associated with longer than recommended durations of therapy.

A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada

BACKGROUND

More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care.

METHODS

Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences.

RESULTS

There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37).

CONCLUSIONS

A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03517215 ).

Surviving Sepsis Campaign: Research Opportunities for Infection and Blood Purification Therapies

Patients with infection can develop sepsis, and their mortality can be high. An important aspect in the treatment of sepsis is adequate management of the infection.

Prospective trial of different antimicrobial treatment durations for presumptive canine urinary tract infections

Background

Avoidance of unnecessary antimicrobial administration is a key tenet of antimicrobial stewardship; knowing the optimal duration of therapy obviates over-treatment. However, little research has been performed to establish course lengths for common canine infections. In clinical practice, antimicrobial therapy is frequently prescribed in dogs presenting lower urinary tract signs (haematuria, pollakiuria and dysuria/stranguria). The proposed length of treatment in International Consensus guidelines has decreased with each iteration, but these recommendations remain arbitrary and largely extrapolated from experience in people.

Methods

The objective of this prospective, multi-centre study is to find the shortest course duration that is non-inferior to the standard duration of 7 days of amoxicillin/clavulanate in terms of clinical outcomes for female dogs with lower urinary tract signs consistent with a urinary tract infection. An electronic data capture platform will be used by participating veterinarians working in clinical practice in the United Kingdom. Eligible dogs must be female, aged between 6 months and 10 years and have lower urinary tract signs of up to seven days’ duration. Enrolment will be offered in cases where the case clinician intends to prescribe antimicrobial therapy. Automatic pseudo-randomisation to treatment group will be based on the day of presentation (Monday-Friday); all antimicrobial courses will be completed on the Sunday after presentation generating different treatment durations. Follow-up data will be collected 1, 8 and 22–26 days after completion of the antimicrobial course to ensure effective safety netting, and to monitor short-term outcome and recurrence rates. Informed owner consent will be obtained in all cases. The study is approved by the Ethical Review Board of the University of Nottingham and has an Animal Test Certificate from the Veterinary Medicine’s Directorate.

Discussion

This study has been designed to mirror current standards of clinical management; conclusions should therefore, be widely applicable and guide practising veterinarians in their antimicrobial decision-making process. A duration-response curve will be created allowing determination of the optimal treatment duration for the management of female dogs with lower urinary tract signs. It is hoped that these results will contribute valuable information to improve future antimicrobial stewardship as part of a wider one-health perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12917-021-02974-y.

Antibiotic treatment of common infections: more evidence to support shorter durations

PURPOSE OF REVIEW

Although there is increasing recognition of the link between antibiotic overuse and antimicrobial resistance, clinician prescribing is often unnecessarily long and motivated by fear of clinical relapse. High-quality evidence supporting shorter treatment durations is needed to give clinicians confidence to change prescribing habits. Here we summarize recent randomized controlled trials investigating antibiotic short courses for common infections in adult patients.

RECENT FINDINGS

Randomized trials in the last five years have demonstrated noninferiority of short-course therapy for a range of conditions including community acquired pneumonia, intraabdominal sepsis, gram-negative bacteraemia and vertebral osteomyelitis.

SUMMARY

Treatment durations for many common infections have been based on expert opinion rather than randomized trials. There is now evidence to support shorter courses of antibiotic therapy for many conditions.

Effect of monthly vitamin D supplementation on antibiotic prescribing in older adults: a post hoc analysis of a randomized controlled trial

BACKGROUND

Observational studies have reported that low vitamin D status is associated with increased risk of antibiotic use. However, trials on the effect of vitamin D supplementation on antibiotics are limited and inconclusive.

OBJECTIVES

The main objective of this study was to determine the effect of monthly vitamin D supplementation on the proportion of adults with ≥1 prescriptions of antibiotics. The secondary outcomes were to determine the effect of monthly vitamin D supplementation on the number of antibiotic prescriptions and the number of days on antibiotics.

METHODS

This was a post hoc analysis of a randomized, double-blinded, placebo-controlled trial with community-based older adults who were randomly assigned to receive monthly 100,000 IU of vitamin D or identical placebo. All analyses were based on the principle of "intention to treat." RR from log-binomial models and the incidence rate ratio (IRR) from negative binomial models were estimated for primary and secondary outcomes after adjusting for age, sex, and ethnicity.

RESULTS

A total of 5108 participants aged 50-84 y were randomly assigned to vitamin D supplementation (n = 2558) or placebo (n = 2550) groups. During a median follow-up of 3.3 y, 4211 (82%) participants were prescribed antibiotics. There was no difference in the proportion of participants prescribed antibiotics between vitamin D (82%) and placebo (83%) groups (adjusted RR: 0.99; 95% CI: 0.97, 1.01; P = 0.42). Similarly, the number of antibiotic prescriptions per person-year did not differ between the 2 treatment groups (adjusted IRR: 0.98; 95% CI: 0.93, 1.04; P = 0.58). However, the number of days on antibiotics per person-year was significantly lower in the vitamin D group (mean ± SEM: 15 ± 0.7) compared with the placebo group (mean ± SEM: 17 ± 0.8) (adjusted IRR: 0.90; 95% CI: 0.82, 0.98; P = 0.01), especially for the tetracyclines (IRR: 0.65; 95% CI: 0.50, 0.85; P = 0.002).

CONCLUSIONS

Long-term, monthly, high-dose vitamin D3 supplementation did not prevent antibiotic prescribing in older adults, but the vitamin D group had fewer days per person-year on antibiotics. Further research is required to replicate these findings. This trial was registered at www.anzctr.org.au as ACTRN12611000402943.

Outpatient prescribing pattern for acute bronchitis in primary healthcare settings in China

Inappropriate prescribing for acute bronchitis in primary healthcare settings (PHSs) is commonly seen worldwide. Here we describe the prescribing patterns and antibiotic use for acute bronchitis in PHSs across China. We conduct a nationwide cross-sectional survey to collect outpatient prescriptions from PHSs in 2017. Patients diagnosed with acute bronchitis without other infections are eligible for this study. Generalized estimating equations are used for analysis. Overall, 10,678 prescriptions for acute bronchitis from 214 institutions are included. The antibiotic prescription rate is 44.5% for total prescriptions, and differs significantly by region and urban/rural status (p < 0.05). Among all single-antibiotic prescriptions, 91.5% are broad-spectrum. Two-thirds of the prescriptions contain medicines for symptom management. The overall guideline compliance rate of acute bronchitis treatment for adults is 31.0%. Prescribing antibiotics, especially broad-spectrum ones, for acute bronchitis is commonly observed in Chinese PHSs. Targeted interventions are urgently needed for Chinese primary clinicians, especially in western rural areas.

Temporal trends in co-morbidities and cardiometabolic risk factors at the time of type 2 diabetes diagnosis in the UK

AIM

To evaluate temporal patterns in co-morbidities, cardiometabolic risk factors and a high atherosclerotic cardiovascular disease (ASCVD) risk population at type 2 diabetes (T2D) diagnosis by age groups and sex.

MATERIALS AND METHODS

From the UK primary care database, 248,619 people with a new diagnosis of T2D during 2005-2016 were identified. Among people without ASCVD, high ASCVD risk was defined as two or more of current smoker, grade 2+ obesity, hypertension, dyslipidaemia or microvascular disease. Cardiometabolic multimorbidity (CMM) was defined as two or more of cardiovascular disease, microvascular disease, hypertension, dyslipidaemia, grade 2+ obesity or cancer. Temporal patterns in the distribution of cardiometabolic risk factors were evaluated.

RESULTS

While the prevalence of ASCVD was stable over time (approximately 18%), 50% were identified to have a high ASCVD risk (26% and 38% in the 18-39 and 40-49 years age groups, respectively), with an increasing trend across all age groups. Overall, 51% had CMM at diagnosis, increasing during 2005-2016 for the 18-39 years age group by 14%-17%, for the 40-49 years age group by 27%-33%, for the 50-59 years age group by 41%-50%, for the 60-69 years age group by 56%-65%, and for the 70-79 years age group by 65%-80%. People with young-onset T2D had significantly higher HbA1c, body mass index and lipids at diagnosis (all p < .01). The proportions with an HbA1c of 7.5% or higher in the 18-39 and 40-49 years age groups were 58% and 54%, respectively, significantly and consistently higher over the last decade compared with those aged 50 years or older, with males having higher proportions of 15-26 and 10-18 percentage points, respectively, compared with females.

CONCLUSIONS

CMM and high ASCVD risk have been increasing consistently across all age groups and in both sex, in particular CMM in those aged younger than 50 years. Our findings indicate that the European Society of Cardiology-European Association for the Study of Diabetes recommendations need to change to consider people with young-onset T2D as a high-risk group, as recommended in the Primary Care Diabetes Europe position statement.

Overview and Evaluation of Existing Guidelines for Rational Antimicrobial Use in Small-Animal Veterinary Practice in Europe

Antimicrobial stewardship guidelines (ASGs) represent an important tool to help veterinarians optimize their antimicrobial use with the objective of decreasing antimicrobial resistance. The aim of this study was to map and qualitatively assess the ASGs for antimicrobial use in cats and dogs in Europe. Country representatives of the European Network for Optimization of Veterinary Antimicrobial Treatment (ENOVAT) were asked to identify ASGs published in their countries. All collated ASGs updated since January 2010 containing recommendations on antimicrobial therapy for at least three conditions affecting different organ systems in cats and dogs underwent detailed review including AGREE II analysis. Out of forty countries investigated, fifteen ASGs from eleven countries met the inclusion criteria. Several critical principles of antimicrobial use were identified, providing a framework that should assist development of stewardship guidance. The AGREE II analysis highlighted several methodological limitations of the currently available ASGs. This study sheds light on the lack of national ASGs for dogs and cats in multiple European countries and should encourage national bodies to prioritize guideline development in small animals. A greater awareness of the need to use a structured approach to guideline development could improve the quality of ASGs in the future.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada

BACKGROUND

Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections.

METHODS

A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects.

RESULTS

Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase.

CONCLUSIONS

PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

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.

Evaluation of the Quality of Antibiotic Prescribing in Primary Care: A Multicenter Longitudinal Study From Shenzhen, China

Background: Currently, there is no comprehensive evaluation of the quality of antibiotic prescribing in China's primary care facilities based on longitudinal data. Methods: We randomly selected 11 community health centers in Shenzhen, China, and collected all outpatient prescriptions of these centers from 2010 to 2015. To evaluate the quality of antibiotic prescribing, we used six quality indicators for analysis, including number of antibiotics per 100 consultations, ratio between broad-spectrum and narrow-spectrum antibiotics (B/N ratio), percentage of first-line antibiotics recommended by guidelines, percentage of oral antibiotics with a duration exceeding the guideline recommendation, and new pediatric-specific indicators such as percentage of antibiotics with amoxicillin (A index) and ratio between amoxicillin and broad-spectrum antibiotics (A/B ratio). Results: During the study period, 571,362 outpatient consultations resulted in antibiotic prescriptions, which contained 706,411 antibiotics. The overall number of antibiotics per 100 consultations decreased significantly from 93.50 in 2010 to 19.98 in 2015 (p = 0.004), but the B/N ratio showed an upward trend over time (p = 0.009). In different populations and different common infections, the number of antibiotics used decreased to varying degrees, while the B/N ratio increased to varying degrees, with the most obvious change in children <5 years. The percentage of first-line antibiotics for common infections was not high, ranging from 3.45 to 44.25% during 2014-2015. The percentage of oral antibiotics with an exceeded duration ranged from 0.70 to 19.39%. Moreover, the A index and A/B ratio in children remained low for a long time, which was 0.76% and 0.01 in 2015. Conclusion: A review of antibiotic prescribing in Shenzhen, China, showed a substantial reduction in antibiotic use in primary care. However, problems such as widespread use of broad-spectrum antibiotics, insufficient use of first-line antibiotics and low use of amoxicillin were prevalent. Improving and optimizing the quality of antibiotic prescribing, particularly in children prescriptions, will be the focus of future antibiotic stewardship in China.

Antibiotics' Use in Thailand: Community Pharmacists' Knowledge, Attitudes and Practices

Thailand spends $203 million on antibiotics every year, and patients can still access antimicrobials over the counter without a prescription. Community pharmacy plays a pivotal role in improving access and ensuring the appropriate use of antimicrobials. However, little is known about current practices in this setting. This study aims to assess Thai community pharmacists’ knowledge, attitudes and practices (KAP) regarding antimicrobials’ use and resistance. A cross-sectional study was conducted in Bangkok and Chonburi province in 2017 using an online self-administered questionnaire. The questionnaire was completed by 372 community pharmacists (71.4% response rate). The most commonly encountered infections in the community were upper and lower respiratory tract infections. The most commonly dispensed antimicrobials were broad-spectrum antibiotics including aminopenicillins and fluoroquinolones. Thai pharmacists have a good knowledge, attitude, and practice regarding antimicrobials’ use and resistance. They dispense anti-microbials in line with local guidelines, although international guidelines may not indicate anti-biotics for viral self-limiting infections. While community pharmacy in Thailand could be the most accessible healthcare resource for patients, inappropriate provision of antimicrobials for self-limiting viral infections by pharmacists will increase antimicrobial resistance. This highlights the need for updated guidance and improved pharmacists’ training.

Evaluation of an automated feedback intervention to improve antimicrobial prescribing among primary care physicians (OPEN Stewardship): protocol for an interrupted time-series and usability analysis in Ontario, Canada and Southern Israel

INTRODUCTION

Antimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports.

METHODS AND ANALYSIS

A non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports.

ETHICS AND DISSEMINATION

All sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.

Harnessing the wisdom of crowds can improve guideline compliance of antibiotic prescribers and support antimicrobial stewardship

Antibiotic overprescribing is a global challenge contributing to rising levels of antibiotic resistance and mortality. We test a novel approach to antibiotic stewardship. Capitalising on the concept of "wisdom of crowds", which states that a group's collective judgement often outperforms the average individual, we test whether pooling treatment durations recommended by different prescribers can improve antibiotic prescribing. Using international survey data from 787 expert antibiotic prescribers, we run computer simulations to test the performance of the wisdom of crowds by comparing three data aggregation rules across different clinical cases and group sizes. We also identify patterns of prescribing bias in recommendations about antibiotic treatment durations to quantify current levels of overprescribing. Our results suggest that pooling the treatment recommendations (using the median) could improve guideline compliance in groups of three or more prescribers. Implications for antibiotic stewardship and the general improvement of medical decision making are discussed. Clinical applicability is likely to be greatest in the context of hospital ward rounds and larger, multidisciplinary team meetings, where complex patient cases are discussed and existing guidelines provide limited guidance.

[Not Available]

Objectif

Rassembler l’information sur les effets indésirables des antibiotiques, que pourront utiliser les médecins prescripteurs comme référence et ressource d’apprentissage.

Qualité des données

Une recherche a été effectuée dans les sites web de diverses agences nationales indépendantes et dans de récentes revues de synthèse. Un tableau résume les effets indésirables de chaque groupe d’antimicrobiens et en indique les allergies, les effets nocifs à court terme et les effets nocifs graves. La fréquence de chaque effet indésirable apparaît au tableau lorsque disponible.

Message principal

Les antimicrobiens sont nécessaires pour traiter diverses maladies. Ils causent cependant des effets indésirables, tels que des réactions allergiques, en plus d’augmenter la résistance bactérienne. Nous sommes de plus en plus conscients du besoin de détecter et d’évaluer les effets indésirables associés aux médicaments. Des effets nocifs graves ont récemment été associés à des antibiotiques couramment utilisés. Ainsi, nous avons résumé, dans le présent article, les connaissances actuelles en matière d’effets nocifs liés aux antibiotiques oraux à action générale qui sont régulièrement utilisés en pratique familiale.

Conclusion

Il est difficile d’identifier et d’attribuer les probabilités exactes de la plupart des effets nocifs. Cependant, tous les antimicrobiens courants produisent des effets nocifs dont il faut tenir compte lors de la décision de prescrire. Nombreux sont les effets indésirables qui ne sont pas reconnus par les prescripteurs. Puisque les effets indésirables sont inévitables, les antimicrobiens doivent être prescrits pour la durée la plus brève possible, seulement lorsque la probabilité d’un bienfait surpasse le risque d’effets nocifs.

Update on the adverse effects of antimicrobial therapies in community practice

OBJECTIVE

To gather information about antibiotic side effects to be used as a reference and learning resource for prescribing physicians.

QUALITY OF EVIDENCE

A search of websites of various independent national agencies and recent review articles was performed. A summary table of adverse effects for each group of antimicrobials was then created, identifying allergies, short-term harms, and serious harms. The occurrence rate of each was listed when available.

MAIN MESSAGE

Antimicrobials are necessary to treat various diseases. However, they cause adverse effects, such as allergic reactions, in addition to increased bacterial resistance. There is increasing awareness of the need to detect and evaluate adverse effects associated with medicines. Recently, severe and serious harms have been described for commonly used antibiotics. Therefore, current knowledge of harms from systemic oral antibiotics that are regularly used in family medicine is summarized in this article.

CONCLUSION

It is difficult to identify and ascribe exact probabilities of most harms. However, all common antimicrobials create harms that must be considered when choosing whether to prescribe. Many adverse effects go unrecognized by prescribers. As side effects are inevitable, antimicrobials must be prescribed for as short a course as possible, only when the probability of benefit is greater than the risk of harm.

Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): A multicentre observational study

BACKGROUND

The prescription rate of antibiotics is high for febrile children visiting the emergency department (ED), contributing to antimicrobial resistance. Large studies at European EDs covering diversity in antibiotic and broad-spectrum prescriptions in all febrile children are lacking. A better understanding of variability in antibiotic prescriptions in EDs and its relation with viral or bacterial disease is essential for the development and implementation of interventions to optimise antibiotic use. As part of the PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union) project, the MOFICHE (Management and Outcome of Fever in Children in Europe) study aims to investigate variation and appropriateness of antibiotic prescription in febrile children visiting EDs in Europe.

METHODS AND FINDINGS

Between January 2017 and April 2018, data were prospectively collected on febrile children aged 0-18 years presenting to 12 EDs in 8 European countries (Austria, Germany, Greece, Latvia, the Netherlands [n = 3], Spain, Slovenia, United Kingdom [n = 3]). These EDs were based in university hospitals (n = 9) or large teaching hospitals (n = 3). Main outcomes were (1) antibiotic prescription rate; (2) the proportion of antibiotics that were broad-spectrum antibiotics; (3) the proportion of antibiotics of appropriate indication (presumed bacterial), inappropriate indication (presumed viral), or inconclusive indication (unknown bacterial/viral or other); (4) the proportion of oral antibiotics of inappropriate duration; and (5) the proportion of antibiotics that were guideline-concordant in uncomplicated urinary and upper and lower respiratory tract infections (RTIs). We determined variation of antibiotic prescription and broad-spectrum prescription by calculating standardised prescription rates using multilevel logistic regression and adjusted for general characteristics (e.g., age, sex, comorbidity, referral), disease severity (e.g., triage level, fever duration, presence of alarming signs), use and result of diagnostics, and focus and cause of infection. In this analysis of 35,650 children (median age 2.8 years, 55% male), overall antibiotic prescription rate was 31.9% (range across EDs: 22.4%-41.6%), and among those prescriptions, the broad-spectrum antibiotic prescription rate was 52.1% (range across EDs: 33.0%-90.3%). After standardisation, differences in antibiotic prescriptions ranged from 0.8 to 1.4, and the ratio between broad-spectrum and narrow-spectrum prescriptions ranged from 0.7 to 1.8 across EDs. Standardised antibiotic prescription rates varied for presumed bacterial infections (0.9 to 1.1), presumed viral infections (0.1 to 3.3), and infections of unknown cause (0.1 to 1.8). In all febrile children, antibiotic prescriptions were appropriate in 65.0% of prescriptions, inappropriate in 12.5% (range across EDs: 0.6%-29.3%), and inconclusive in 22.5% (range across EDs: 0.4%-60.8%). Prescriptions were of inappropriate duration in 20% of oral prescriptions (range across EDs: 4.4%-59.0%). Oral prescriptions were not concordant with the local guideline in 22.3% (range across EDs: 11.8%-47.3%) of prescriptions in uncomplicated RTIs and in 45.1% (range across EDs: 11.1%-100%) of prescriptions in uncomplicated urinary tract infections. A limitation of our study is that the included EDs are not representative of all febrile children attending EDs in that country.

CONCLUSIONS

In this study, we observed wide variation between European EDs in prescriptions of antibiotics and broad-spectrum antibiotics in febrile children. Overall, one-third of prescriptions were inappropriate or inconclusive, with marked variation between EDs. Until better diagnostics are available to accurately differentiate between bacterial and viral aetiologies, implementation of antimicrobial stewardship guidelines across Europe is necessary to limit antimicrobial resistance.

Application of a simple point-of-care test to reduce UK healthcare costs and adverse events in outpatient acute respiratory infections

Background: Acute respiratory infection (ARI) accounts for over two-thirds of total antibiotic prescriptions although most are caused by viruses that do not benefit from antibiotics. Most antibiotics are prescribed in the outpatients setting. Antibiotic overuse leads to antibiotic-related adverse events (AEs), inclusive of secondary infections, resistance, and increased costs. Point-of-care tests (POCT) may reduce unnecessary antibiotics. A cost analysis was performed to assess diagnostic POCT options to identify patients with an ARI that may benefit from antibiotics in a United Kingdom (UK) outpatient setting.Methods: Healthcare savings were estimated using a budget impact analysis based on UK National Institute for Health and Care Excellence (NICE) data and direct costs (antibiotics, AEs, POCTs) derived from published literature. Otitis media, sinusitis, pharyngitis and bronchitis were considered the most common ARIs. Antibiotic-related AE costs were calculated using re-consultation costs for anaphylaxis, Stevens-Johnson syndrome, allergies/diarrhea/nausea, C. difficile infection (CDI). Potential cost-savings from POCTs was assessed by evaluating NICE guideline-referenced POCTs (CRP, FebriDx, Sarasota, FL) as well as a target product profile (TPP).Results: Fifty-percent (7,718,283) of ARI consultations resulted in antibiotics while guideline-based prescribing suggest appropriate antibiotic prescriptions are warranted 9% (1,444,877) of ARI consultations. Direct antibiotic costs for actual ARI consultations associated with antibiotics was £24,003,866 vs. £4,493,568 for guideline-based, "appropriate" antibiotic prescriptions. Antibiotic-related AEs and re-consultations for actual vs. appropriate prescribing totaled £302,496,486 vs. £63,854,269. ARI prescribing plus AE costs totaled £326,729,943 annually without the use of delayed prescribing practices or POCT while the addition of delayed prescribing plus POCT totaled £60,114,564-£78,148,933 depending on the POCT.Conclusions: Adding POCT to outpatient triage of ARI can reduce unnecessary antibiotics and antibiotic-related AEs, resulting in substantial cost savings. Further, near patient diagnostic testing can benefit health systems and patients by avoiding exposure to unnecessary drugs, side effects and antibiotic resistant pathogens.Key points for decision makersMany patients are unnecessarily treated with antibiotics for respiratory infections.Antibiotic misuse leads to unnecessary adverse events, secondary infections, re-consultations, antimicrobial resistance and increased costs.Point-of-care diagnostic tests used to guide antibiotic prescriptions will avoid unnecessary adverse health effects and expenses.

Are Antimicrobial Peptide Dendrimers an Escape from ESKAPE?

Significance: The crisis of antimicrobial resistance (AMR) increases dramatically despite all efforts to use available antibiotics or last resort antimicrobial agents. The spread of the AMR, declared as one of the most important health-related issues, warrants the development of new antimicrobial strategies. Recent Advances: Antimicrobial peptides (AMPs) and AMP dendrimers (AMPDs), as well as polymer dendrimers are relatively new and promising strategies with the potential to overcome drug resistance issues arising in ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) colonizing chronic wounds. Critical Issues: AMPs-AMPDs suffer from limited efficacy, short-lasting bioactivity, and concerns of toxicity. To circumvent these drawbacks, their covalent coupling to biopolymers and/or encapsulation into different drug carrier systems is investigated, with a special focus on topical applications. Future Directions: Scientists and the pharmaceutical industry should focus on this challenging subject to either improve the activity of existing antimicrobial agents or find new drug candidates. The focus should be put on the discovery of new drugs or the combination of existing drugs for a better synergy, taking into account all kinds of wounds and existing pathogens, and more specifically on the development of next-generation antimicrobial peptides, encompassing the delivery carrier toward improved pharmacokinetics and efficacy.

Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines

OBJECTIVES

To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence (LoE), astrength of recommendations (SoR), and consideration of antibiotic stewardship.

DESIGN

Systematic review of the literature.

DATA SOURCES

Three-pronged search of (1) databases: Medline, Embase, Cochrane library, Guidelines International Network and Trip Medical Database; (2) websites of European national paediatric associations and (3) contact of European experts. Data were collected between January 2017 and February 2018.

ELIGIBILITY CRITERIA

National guidelines of European countries for the clinical management of AOM in children aged <16 years.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship.

RESULTS

AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15; 93%). The majority (15/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75-90 mg/kg/day) and five low-dose (30-60 mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data.

CONCLUSIONS

Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.