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

Physicians', pharmacists', and nurses' education of patients about antibiotic use and antimicrobial resistance in primary care settings: a qualitative systematic literature review

Background

Patients' adherence to antibiotic treatment and related prevention of AMR is significant. Understanding healthcare professionals' strategies for advising and educating patients in primary care settings is crucial.

Aim

From the perspectives of professionals and patients, to explore how physicians, pharmacists, and nurses educate patients about antibiotic use and antimicrobial resistance in primary care settings.

Methods

A qualitative systematic literature review was conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, SocINDEX, PsycInfo, Web of Science and Scopus. The study included 102 publications, followed PRISMA recommendations and was registered in PROSPERO (reg.no. CRD4202455761). The studies were screened and selected based on specific inclusion and exclusion criteria using Covidence. Quality appraisal followed the Critical Appraisal Skills Program (CASP) qualitative study checklist. Data were extracted, and the analysis consisted of a descriptive numerical summary analysis and a qualitative thematic analysis.

Results

The analyzed studies spanned multiple countries and settings and included perspectives of primary care physicians, pharmacists, nurses and patients. Two main themes emerged: (1) Relationships between professionals and patients influenced educational strategies, showing that trust and rapport between healthcare professionals and patients played a crucial role in shaping educational strategies around antibiotic use; (2) The organizational structures challenged professionals in guiding and educating patients, highlighting how limited resources, time constraints, and system-level pressures hindered healthcare professionals' ability to provide consistent and effective education. Often, structural challenges led to not educating the patients on the risks of antibiotic misuse and antimicrobial resistance. The use of delayed prescriptions emerged as a strategy for improved AMR stewardship and to meet patients' expectations for antibiotic treatment, though it raised concerns about undermining professional responsibility and authority in ensuring appropriate antibiotic use.

Conclusion

Healthcare professionals' role in educating patients about antibiotic use and AMR in primary care settings was complex, with different challenges faced by nurses, pharmacists and primary care physicians. These challenges extended beyond the clinical level, including relational, social and structural factors. Power dynamics, trust issues, and time pressures often hindered effective education on antibiotic use. Addressing gaps in education on antibiotic use and AMR requires acknowledging these multifaceted challenges, with future efforts focusing on better supporting healthcare professionals in this context.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD4202455761.

Gut dysbiosis mediates the association between antibiotic exposure and chronic disease

Antibiotics are safe, effective drugs and continue to save millions of lives and prevent long-term illness worldwide. A large body of epidemiological, interventional and experimental evidence shows that exposure to antibiotics has long-term negative effects on human health. We reviewed the literature data on the links between antibiotic exposure, gut dysbiosis, and chronic disease (notably with regard to the "developmental origins of health and disease" ("DOHaD") approach). Molecular biology studies show that the systemic administration of antibiotic to infants has a rapid onset but also often a long-lasting impact on the microbial composition of the gut. Along with other environmental factors (e.g., an unhealthy "Western" diet and sedentary behavior), antibiotics induce gut dysbiosis, which can be defined as the disruption of a previously stable, functionally complete microbiota. Gut dysbiosis many harmful long-term effects on health. Associations between early-life exposure to antibiotics have been reported for chronic diseases, including inflammatory bowel disease, celiac disease, some cancers, metabolic diseases (obesity and type 2 diabetes), allergic diseases, autoimmune disorders, atherosclerosis, arthritis, and neurodevelopmental, neurodegenerative and other neurological diseases. In mechanistic terms, gut dysbiosis influences chronic disease through direct effects on mucosal immune and inflammatory pathways, plus a wide array of direct or indirect effects of short-chain fatty acids, the enteric nervous system, peristaltic motility, the production of hormones and neurotransmitters, and the loss of intestinal barrier integrity (notably with leakage of the pro-inflammatory endotoxin lipopolysaccharide into the circulation). To mitigate dysbiosis, the administration of probiotics in patients with chronic disease is often (but not always) associated with positive effects on clinical markers (e.g., disease scores) and biomarkers of inflammation and immune activation. Meta-analyses are complicated by differences in probiotic composition, dose level, and treatment duration, and large, randomized, controlled clinical trials are lacking in many disease areas. In view of the critical importance of deciding whether or not to prescribe antibiotics (especially to children), we suggest that the DOHaD concept can be logically extended to "gastrointestinal origins of health and disease" ("GOHaD") or even "microbiotic origins of health and disease" ("MOHaD").

The effectiveness of homeopathy in relieving symptoms and reducing antibiotic use in patients with otitis media: A systematic review and meta-analysis

Aim

This systematic review of clinical trial evidence aims to determine whether homeopathy can effectively relieve symptoms and reduce antibiotic use in patients diagnosed with otitis media (OM).

Methods

Seven databases and four trial registries were searched. Eligible studies included randomised- and non-randomised-controlled-trials in patients diagnosed with OM. Studies on Individualised- and non-Individualised-Homeopathy (IH, non-IH) were included, and controls were inactive and/or active treatment. Primary outcomes were clinical-improvement and antibiotic-use. Data extraction, Risk of Bias and certainty of evidence (GRADE) were performed using established methodology.

Results

Nine studies (IH = 4, non-IH = 5) comprising seven Randomised Clinical Trials (RCTs) and two non-RCTs (nRCTS) compared homeopathy with placebo (n = 2) or standard care (n = 7). 4/7 included RCTs reported statistically significant individual outcomes at relevant time points (symptom score, MEE, and antibiotic use) favouring homeopathy. However, heterogeneity of study designs, homeopathic interventions and outcome measures hindered the pooling of data for most outcomes, except for antibiotic use (non-IH). Add-on non-IH reduced filled antibiotic prescriptions by 46 % (RR = 0.54 [95%CI: 0.28, 1.06], P = 0.07, I2 = 12 %), but this did not reach statistical significance. Most studies demonstrated that the homeopathy group had less adverse events than the control group.

Conclusions

The evidence base for the effectiveness of homeopathy and OM treatment is modest in study number, size, and risk of bias assessment. Individual RCTs report positive effects on clinical improvement and/or antibiotic use at relevant time points with homeopathy with no safety issues. Due to heterogeneity, the current evidence is insufficient to satisfactorily answer whether homeopathy is effective for clinical improvement and reducing antibiotic use in patients with OM. A Core Outcome Set for OM for future research is warranted to improve the potential for meta-analyses and strengthen the evidence base.

GPs' experience with diagnosis and treatment guidelines for lower UTI in men: a qualitative interview

BACKGROUND

The incidence of lower urinary tract infection (LUTI) in men visiting primary health care (PHC) is low. Hence, GPs do not diagnose and treat men with LUTI very often. Previous studies have shown that adherence to treatment guidelines regarding LUTI in men is low. There is limited knowledge concerning why guidelines are not adhered to.

AIM

To gain knowledge on GPs' experiences and concerns when treating men with LUTI, including their use of clinical guidelines. Furthermore, this study aimed to explore GPs' knowledge and concern regarding antibiotic resistance.

DESIGN & SETTING

A qualitative study based on semi-structured interviews with GPs was performed.

METHOD

15 GPs from seven PHC centres (PHCC) in southern Sweden were interviewed. The interviews were conducted from September 2022 to March 2023. All interviews were audio recorded and transcribed verbatim. A thematic analysis was performed.

RESULTS

GPs had limited experience with and felt less certainty when diagnosing male LUTI. Extended examinations could partially relieve this feeling. GPs were well informed about the Swedish treatment guidelines for LUTI in men and felt safe to treat their patients according to the guidelines. However, GPs also acknowledged that guidelines do not cover all situations and need to be individualised.

CONCLUSION

Many GPs feel insecure when diagnosing male LUTI. The relatively low prevalence of this condition in PHC could contribute to this feeling. Clear and instructive guidelines regarding both the diagnostic process and adequate antibiotic choices are important to maintain good quality in the management of LUTI in men.

Practices, strategies, and challenges in antibiotic treatment and prevention of antimicrobial resistance from the perspectives of Romanian community pharmacists and general practitioners: a Goffman-inspired qualitative interview study

Introduction

Antimicrobial resistance (AMR) represents a persistent and ascensive global threat influenced by antibiotic misuse and overuse. In the Romanian context, patterns of antibiotic consumption and resistance within the healthcare system are marked in the red scenario on the European map. General practitioners and pharmacists, among others, play a major role in stewardship towards AMR.

Aim

To explore the practices, strategies, and challenges in antibiotic treatment and prevention of antimicrobial resistance from the perspectives of Romanian community pharmacists and general practitioners.

Method and Materials

Semi-structured interviews were conducted with six general practitioners and five community pharmacists in Romania from January to March 2024. An inductive, Goffman theory-inspired thematic analysis was conducted, inspired by Braun and Clarke's thematic analysis method, consisting of familiarization with the data, iterative coding guided by theoretically inspired questions, and identification and refinement of (sub)themes. Goffman's theory of social interaction, focusing on the concepts of front stage, backstage, and roles, guided the analytical questions.

Results

The results were presented in three overarching themes: 'Knowledge acquired backstage to support challenges and performance on front stage', 'Adapting roles and performances on the front stage: A mix of structured and twisted acts', and 'Interprofessional Collaboration: A latent part in the play's roles and performances'. Professionals prepared their understandings of AMR and antibiotics backstage, with an awareness of the challenges rooted in the Romanian context. The front stage scenario evolved from structured antibiotic performances led by AMR strategies with compliant actors to challenging performances influenced by actors which changed the course of performances and intended AMR strategies. The revealed competition between general practitioners and pharmacists further complicated antibiotic use and AMR-related performances.

Conclusion

The Romanian socio-political system influenced the course of antibiotic treatment and the professionals' intended antibiotic related practices and AMR strategies. The study showed a theory-practice gap in health professionals' practices, leading to limited strategy integration towards AMR and increased antibiotic use. The study underscores the need for context-specific policies and interventions to minimize identified gaps.

Factors behind Antibiotic Therapy: A Survey of Primary Care Pediatricians in Lombardy

BACKGROUND

Antimicrobial resistance represents one of the most significant future health challenges in terms of both clinical and economic impacts on healthcare systems. The reason behind this issue is the misuse of antibiotics for the treatment of non-bacterial pathologies. The objective of this study is to investigate the factors underlying antibiotic prescription in pediatricians in the Lombardy region.

METHODS

The study was conducted by means of a 32-item questionnaire that investigated both pediatricians' knowledge of antimicrobial resistance and the factors determining the choice to prescribe antibiotic therapy.

RESULTS

A total of 253 pediatricians participated in the survey. Most participants (71.6%) reported as highly relevant the need for a national plan against AMR. However, approximately half of the respondents declared the phenomenon of AMR as uncommon in pediatric settings. Among the identified associated factors, diagnostic uncertainty was associated with a stronger fear of legal repercussions and the influence of parental pressure when prescribing antibiotics.

CONCLUSIONS

The inability to diagnose the bacterial origin of an infection might be the primary driver of prescribing choices, rather than other non-clinical factors, such as parental demands or a fear of lawsuits.

Optimising antibiotic exposure by customising the duration of treatment for respiratory tract infections based on patient needs in primary care

Primary care antimicrobial stewardship programs have limited success in reducing antibiotic use, prompting the search for new strategies. Convincing general practitioners to resist antibiotic prescription amid uncertainty or patient demands usually poses a significant challenge. Despite common practice, standard durations for common infections lack support from clinical studies. Contrary to common belief, extending antibiotic treatment beyond the resolution of symptoms does not seem to prevent or reduce antimicrobial resistance. Shortening the duration of antibiotic therapy has shown to be effective in mitigating the spread of resistance, particularly in cases of pneumonia. Recent hospital randomised trials suggest that ending antibiotic courses by day three for most lower respiratory tract infections is effective and safe. While community studies are scarce, it is likely that these shorter, tailored courses to meet patients' needs would also be effective and safe in primary care. Therefore, primary care studies should investigate the outcomes of advising patients to discontinue antibiotic treatment upon symptom resolution. Implementing patient-centred, customised treatment durations, rather than fixed courses, is crucial for meeting individual patient needs.

Bacteriuria and phenotypic antimicrobial susceptibility testing in 45 min by point-of-care Sysmex PA-100 System: first clinical evaluation

PURPOSE

This study compared the results of the new Sysmex PA-100 AST System, a point-of-care analyser, with routine microbiology for the detection of urinary tract infections (UTI) and performance of antimicrobial susceptibility tests (AST) directly from urine.

METHODS

Native urine samples from 278 female patients with suspected uncomplicated UTI were tested in the Sysmex PA-100 and with reference methods of routine microbiology: urine culture for bacteriuria and disc diffusion for AST.

RESULTS

The analyser delivered bacteriuria results in 15 min and AST results within 45 min. Sensitivity and specificity for detection of microbiologically confirmed bacteriuria were 84.0% (89/106; 95% CI: 75.6-90.4%) and 99.4% (155/156; 95% CI: 96.5-100%), respectively, for bacterial species within the analyser specifications. These are Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis and Staphylococcus saprophyticus, which are common species causing uncomplicated UTI. Overall categorical agreement (OCA) for AST results for the five antimicrobials tested in the Sysmex PA-100 (amoxicillin/clavulanic acid, ciprofloxacin, fosfomycin, nitrofurantoin and trimethoprim) ranged from 85.4% (70/82; 95%CI: 75.9-92.2%) for ciprofloxacin to 96.4% (81/84; 95% CI: 89.9-99.3%) for trimethoprim. The Sysmex PA-100 provided an optimal treatment recommendation in 218/278 cases (78.4%), against 162/278 (58.3%) of clinical decisions.

CONCLUSION

This first clinical evaluation of the Sysmex PA-100 in a near-patient setting demonstrated that the analyser delivers phenotypic AST results within 45 min, which could enable rapid initiation of the correct targeted treatment with no further adjustment needed. The Sysmex PA-100 has the potential to significantly reduce ineffective or unnecessary antibiotic prescription in patients with UTI symptoms.

Why Do Physicians Prescribe Antibiotics? A Systematic Review of the Psycho-Socio-Organisational Factors Related to Potentially Inappropriate Prescribing of Antimicrobials in Europe

Purpose: Effective antimicrobial use enhances care quality and combats antibiotic resistance. Yet, non-guideline factors influence potentially inappropriate prescribing. This study explores psycho-socio-organisational factors in antimicrobial prescribing as perceived by physicians across primary, secondary, and tertiary care. Methods: Adhering to PRISMA guidelines, a systematic review was conducted using PubMed and Scopus databases from 1 January 2000, to 8 March 2023, with an update search until 30 January 2024. Inclusion criteria focused on studies in Europe exploring psycho-socio-organisational factors for antibiotic prescribing from physicians' perspectives in hospital, inpatient, or primary care settings. Exclusion criteria targeted out-of-office prescriptions or low-quality studies. To evaluate the latter, several quality and risk-of-bias checklists were used. Data were extracted on study characteristics, study design, and methods and identified determinants of antibiotic prescribing. Data was analysed using a narrative synthesis method. Results: Among 8370 articles, 58 met inclusion criteria, yielding 35 articles from 23 countries. Three main themes emerged: personal, psychological, and organisational factors, encompassing seven determinants including work experience, knowledge, guideline adherence, uncertainty management, perceived pressure, time constraints, and diagnostic resource availability. Uncertainty management was key, with work experience and knowledge mitigating it. No additional factors emerged in the updated search. Conclusion: Enhanced uncertainty management decreases perceived patient and/or parental pressure to prescribe antibiotics, contributing to reducing potentially inappropriate prescribing (PIP). Therefore, it is imperative to educate physicians on effectively managing uncertainty. Interventions to improve antibiotic prescribing should be tailored to the specific needs and preferences of the different prescribing physicians.

Pharmacotherapies for multidrug-resistant gram-positive infections: current options and beyond

INTRODUCTION

Infections due to multidrug-resistant organisms (MDRO) are a serious concern for public health with high morbidity and mortality. Though many antibiotics have been introduced to manage these infections, there are remaining concerns regarding the optimal management of Gram-positive MDROs.

AREAS COVERED

A literature search on the PubMed/Medline database was conducted. We applied no language and time limits for the search strategy. In this narrative review, we discuss the current options for managing Gram-positive MDROs as well as non-traditional antibacterial agents in development.

EXPERT OPINION

Despite their introduction more than 70 years ago, glycopeptides are still the cornerstone in treating Gram-positive infections: all registrative studies of new antibiotics have glycopeptides as control; these studies are designed as not inferior studies, therefore it is almost impossible to give recommendations other than the use of glycopeptides in the treatment of Gram-positive infections. The best evidence on treatments different from glycopeptides comes from post-hoc analysis and meta-analysis. Non-traditional antibacterial agents are being studied to aid in short and effective antibiotic therapies. The use of non-traditional antibacterial agents is not restricted to replacing traditional antibacterial agents with alternative therapies; instead, they should be used in combination with antibiotic therapies.

Appropriate use of antibiotics for oral/dental conditions in older adults: a narrative review

OBJECTIVES

Considering the high rates in the use of antibiotics for oral/dental conditions in older patients and the rise in antimicrobial resistance, appropriate antibiotic prescription is important. This narrative review aimed to discuss the challenges and special considerations when prescribing antibiotics to older patients for oral/dental conditions.

METHODS

PubMed/MEDLINE, Scopus, Web of Science, and articles' reference lists were searched for antibiotics use for oral conditions by older patients. Moreover, scientific and professional organisations' official websites were searched for guidelines on antibiotic use in dentistry.

RESULTS

Despite several guidelines about the use of antibiotics in dentistry, specific information on their administration to older patients is missing. Relevant challenges include age-related changes in pharmacokinetics and pharmacodynamics, comorbidities and polypharmacy associated with low adherence, contraindications, adverse reactions, and drug-drug interactions. In unfit and frail older patients some antibiotics should be avoided, or doses should be adjusted, according to medical conditions or medications received. Amoxicillin, with doses adapted to renal function, is one of the safest options, while other antibiotics should be chosen with caution upon indications and individual patient characteristics.

CONCLUSIONS

Healthcare providers should prescribe antibiotics to unfit and frail older adults with caution, given the multitude of comorbidities and potential interactions with medications received. Further research is needed on the safe and effective use of antibiotics in older patients.

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers

BACKGROUND

Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners.

METHODS

Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30-61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation.

RESULTS

Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour.

CONCLUSIONS

Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

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

Background

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

Methods

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

Results

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

Conclusions

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

Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis

BACKGROUND

Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship.

OBJECTIVES

To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries.

METHODS

On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed.

RESULTS

We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible.

CONCLUSIONS

Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.

Antimicrobial stewardship: knowledge, attitudes and practices regarding antimicrobial use and resistance among non-healthcare students at the University of Zambia

Background

Antimicrobial resistance (AMR) poses a significant threat to the world and could become humanity's next major challenge. This study assessed non-healthcare students' knowledge, attitude and practices (KAP) towards antimicrobial use (AMU) and AMR at the University of Zambia.

Methods

This cross-sectional study was conducted among 443 non-healthcare students from August to October 2022 using a structured questionnaire. Data analysis was done using IBM SPSS version 24.0.

Results

Of the 433 participants, 55.2%, 63.5% and 45% had moderate KAP scores regarding AMU and AMR. The prevalence of self-medication with antibiotics was 76.7%. Male participants were less likely to have good knowledge (OR = 0.524, 95% CI: 0.347-0.792) and positive attitudes (OR = 0.585, 95% CI: 0.364-0.940) towards AMU and AMR compared with females. Students who were studying Engineering and Mining were more likely to have good knowledge of AMR (OR = 1.891, 95% CI: 1.197-2.987) compared with those in Social Sciences. Those who were in their fourth and fifth years were more likely to have positive attitudes towards AMU and AMR (OR = 1.851, 95% CI: 1.147-2.986) compared with those who were in the first, second and third years. Finally, students who practised self-medication were less likely to have good self-reported practice towards AMR (OR = 0.442, 95% CI: 0.278-0.702) compared with those who did not.

Conclusions

This study demonstrated that non-healthcare students had moderate KAP regarding AMU and AMR. All university students should be provided with education about AMU and AMR through free short courses, seminars, workshops, and AMR and antimicrobial stewardship awareness campaigns.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA.

METHODS

The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript.

RESULTS

Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials.

CONCLUSIONS

Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.