The role of real-world data in the development of treatment guidelines: a case study on guideline developers' opinions about using observational data on antibiotic prescribing in primary care

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.

Accuracy of thermal microsensors embedded in orthodontic retainers of different material composition and thickness: An in vitro study

Objectives: The present research aimed to assess the accuracy and precision of the TheraMon® microsensor embedded in different thicknesses of Hawley retainers (HR) for comparison with vacuum formed retainers (VFR).

Methods: Thirty microsensors contained within different thicknesses and composition of retainers were divided into three equal groups: Group A thick coverage HR (3 mm), Group B thin coverage HR (1 mm), and Group C VFR (1 mm). The microsensors were immersed in thermostatic water at a controlled temperature of 35°C, which corresponds to the average intra-oral temperature. After 1 week, data were gathered using the TheraMon® client software and analysed using ANOVA and Turkey’s HSD tests.

Results: All TheraMon® microsensors were functional and produced uninterrupted recordings during the 1-week test period. Thermal detection differed between the three removable retainer groups. A near accurate thermostatic water detection was noticed with the thin HR with a mean temperature of 34.81 ± 0.04°C, followed by VFR 34.77 ± 0.09°C, and finally the thick HR 34.73 ± 0.05°C (ANOVA p-value = 0.025). A between-group comparison showed a significant mean difference (MD) between the thin and thick HR groups (MD: 0.08, p-value = 0.01). However, there were no significant differences between VFR and neither the thick Hawley (MD: 0.04, p-value = 0.27) nor the thin Hawley group (MD: -0.03, p-value = 0.39).

Conclusion: A removable retainer’s variation in material thickness and composition could induce small but detectable changes in the precision of thermal detection by TheraMon® microsensors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evidence of Antibiotic Resistance from Population-Based Studies: A Narrative Review

The 20th century witnessed the dawn of the antibiotic revolution and is now facing the rising phenomenon of antibiotic resistance. In this narrative review, we aim to describe antibiotic resistance in clinical practice settings through population-based studies from different countries reporting the role of misuse of antibiotics in the development of resistance and the clinical and economic burden associated. The misuse of antibiotics was documented in the wide population as well as in hospitals and care facilities. It was mainly reported as over-use and inappropriate prescribing. Improper dosage regimens and longer treatment duration were regarded as pivotal factors related to antibiotic resistance; the emerging strategy of "antibiotic-de-escalation" could be the key to overcome these issues. The investigation of the self-medication attitude revealed widespread antibiotic use without following medical instructions or medical consultation. Moreover, several studies established the association of antibiotic resistance with increased risk of longer hospitalizations and mortality, highlighting the heavy clinical and economic burden of this phenomenon. In this narrative review, the widespread inappropriate use of antibiotics emerged as one of the main causes of antibiotic resistance, which negative outcomes call for the development of antibiotic stewardship programs and global surveillance networks.