Reducing unnecessary antibiotic prescription through implementation of a clinical guideline on self-limiting respiratory tract infections

Evaluation of physicians' current practices and awareness regarding the treatment of acute uncomplicated diverticulitis: results of a provincial survey

OBJECTIVE

International guidelines now recommend nonantibiotic treatment of uncomplicated diverticulitis. We assessed physicians' current management strategies for uncomplicated diverticulitis, their awareness of the updated recommendations, and barriers to practice change.

METHODS

A 21-question web-based survey conducted between 09/2022 and 11/2022 was sent to participants through their respective Quebec provincial associations or working groups. Participants included general surgeons, emergency physicians, gastroenterologists and general practitioners. Physicians who did not treat diverticulitis were excluded. The main outcomes were awareness of guideline recommendations on uncomplicated diverticulitis treatment, the use of nonantibiotic management for uncomplicated diverticulitis and identification of perceived barriers to practice change.

RESULTS

The participation rate was 15.9%. The 465 participants consisted primarily of general practitioners (41.7%), general surgeons (29.2%) and emergency physicians (17.8%). Eighty-two percent had heard of the nonantibiotic treatment strategy for uncomplicated diverticulitis; 7.5% were "uncomfortable" and 44.6% "somewhat uncomfortable" with this practice. A third (31.8%) of all physicians had no knowledge of the updated guidelines on uncomplicated diverticulitis treatment. Most reported "never" (41.6%) or "rarely" (25.1%) omitting antibiotics for uncomplicated diverticulitis. When informed about nonantibiotic treatment, 28.7% and 51.4% of all physicians, respectively, indicated that this "will" change or "may" change their practice. Common perceived barriers to nonantibiotic treatment were concerns about treatment failure (69.6%), unawareness of updated recommendations (67.0%), difficulty in ensuring proper follow-up (59.0%) and workplace culture (54.9%).

CONCLUSION

Physicians' awareness of practice guidelines recommending nonantibiotic treatment for uncomplicated diverticulitis and their application are suboptimal. Knowledge transfer activities, educational interventions and optimization of local protocols are needed to ensure the rational use of antibiotics.

The treatment of mild upper respiratory tract infections - a position paper with recommendations for best practice

Following the waning severity of COVID-19 due to vaccination and the development of immunity, the current variants of SARS-CoV-2 often lead to mild upper respiratory tract infections (MURTIs), suggesting it is an appropriate time to review the pathogenesis and treatment of such illnesses. The present article reviews the diverse causes of MURTIs and the mechanisms leading to symptomatic illness. Different symptoms of MURTIs develop in a staggered manner and require targeted symptomatic treatment. A wide variety of remedies for home treatment is available, including over-the-counter drugs and plant-derived substances. Recent pharmacological research has increased the understanding of molecular effects, and clinical studies have shown the efficacy of certain herbal remedies. However, the use of subjective endpoints in these clinical studies may suggest limited validity of the results. In this position paper, the importance of patient-centric outcomes, including a subjective perception of improved well-being, is emphasized. A best practice approach for the management of MURTIs, in which pharmacists and physicians create an improved multi-professional healthcare setting and provide healthcare education to patients, is proposed. Pharmacists act as first-line consultants and provide patients with remedies, considering the individual patient's preferences towards chemical or plant-derived drugs and providing advice for self-monitoring. Physicians act as second-line consultants if symptoms worsen and subsequently initiate appropriate therapies. In conclusion, general awareness of MURTIs should be increased amongst medical professionals and patients, thus improving their management.

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Pathogen Profile of Children Hospitalised with Severe Acute Respiratory Infections during COVID-19 Pandemic in the Free State Province, South Africa

Severe acute respiratory infections (SARI) contribute to mortality in children ≤5 years. Their microbiological aetiologies are often unknown and may be exacerbated in light of coronavirus disease 19 (COVID-19). This study reports on respiratory pathogens in children ≤5 years (n = 84) admitted with SARI during and between the second and third waves of COVID-19 infection in South Africa. Nasopharyngeal/oropharyngeal swabs collected were subjected to viral detection using QIAstat-Dx^® Respiratory SARS-CoV-2 Panel. The results revealed viral positivity and negativity detection rates of 88% (74/84) and 12% (10/84), respectively. Of the 21 targeted pathogens, human rhinovirus/enterovirus (30%), respiratory syncytial virus (RSV; 26%), and severe acute respiratory syndrome coronavirus 2 (24%) were mostly detected, with other viruses being 20% and a co-infection rate of 64.2% (54/84). Generally, RSV-positive samples had lower Ct values, and fewer viruses were detected during the third wave. Changes in the circulation patterns of respiratory viruses with total absence of influenza virus could be attributed to measures against COVID-19 transmission, which may result in waned immunity, thereby increasing susceptibility to severe infections in the following season. High viral co-infection rate, as detected, may complicate diagnosis. Nonetheless, accurate identification of the pathogens may guide treatment decisions and infection control.

eHealthResp, a Digital Intervention to Improve Antibiotic Prescribing in Respiratory Infections: A Pilot Study

The emergence of antibiotic resistance (ABR) is one of the most serious public health threats worldwide. The inappropriate use of antibiotics is considered the main determinant for the increase and development of ABR, contributing to a greater risk of therapeutic ineffectiveness, particularly within primary care context. Therefore, this pilot study aims to raise awareness and promote an adequate antibiotic use among physicians, through the evaluation of the eHealthResp platform, a digital intervention composed by an online course and a mobile application, to aid in the management of respiratory tract infections. The global validation of the eHealthResp platform was carried out by 12 physicians who explored and performed a quantitative and qualitative evaluation of the contents of the online course and mobile app. The global evaluation of the analyzed parameters was very positive, with the highest median scores being attributed to adequacy, correction, format, and trust of the eHealthResp platform. The qualitative feedback enhanced the contents’ relevance, clarity, and consolidation, as well as the effectiveness of the educational intervention against ABR. Overall, this study revealed that the eHealthResp may be regarded as an important e-health tool for the management of respiratory tract infections and improvement of antibiotic prescription practices among physicians.

Māori Experiences and Beliefs about Antibiotics and Antimicrobial Resistance for Acute Upper Respiratory Tract Symptoms: A Qualitative Study

Antimicrobial resistance (AMR) is a threat to public health. Addressing unnecessary antibiotic use provides an opportunity to reduce antibiotic consumption and to slow AMR. Understanding people’s beliefs is important for informing antimicrobial stewardship (AMS) initiatives. Within New Zealand, health inequities exist between Māori and non-Māori; however, no research has examined Māori beliefs about antibiotics and AMR. The aim of this study was to explore the experiences related to antibiotic use of Māori in New Zealand. In-depth, semi-structured interviews were conducted with 30 Māori adults recruited from primary care to explore the experiences, perceptions and beliefs that Māori have about antibiotics, and about AMR. Overall, 30 Māori adults (23% male; age range from 20 to 77 years) participated. Three themes emerged: systemic-, social-, and individual-related factors. From these themes, seven subthemes explained the factors that influenced antibiotic use and their perceptions of AMR in Māori: general practitioner (GP) times and ratios, effect of colonisation, lack of knowledge and information, access and poverty barriers, relationship with health professionals, illness perceptions, treatment beliefs and Whaakaro (thoughts), and beliefs pertaining to natural (rongoā) and Western medicine. Participants identified potential solutions to improve antibiotic use such as cultural support and involving Te Ao Māori; recognising these can inform future AMS initiatives.

Antibiotic stewardship programmes had a low impact on prescribing for acute respiratory tract infections in children

Aim

This mini review summarises the available data on antibiotic stewardship programmes (ASP) for acute respiratory tract infections (ARTI) in paediatric outpatients, particularly the implementation and impact of programmes.

Methods

PubMed was searched from 1 January 2012 to 31 December 2021 for papers with abstracts that used the terms respiratory tract infection, antibiotic, child and guideline. We then saw how many of these included the individual terms impact, implementation or stewardship. After exclusions, we included 10 papers that were published in English on children treated as outpatients for ARTIs. All of these included data on implementing and assessing the impact of ASPs.

Results

The primary care data were mainly from the United States. The ASP programmes did not influence antibiotic prescription rates, but broad‐spectrum antibiotics decreased by 43–48%. The emergency department data were mainly from France and the antibiotic prescription rate decreased by 31–35% and the rate for broad‐spectrum antibiotics by 63–71%. A nationwide register‐based study from France confirmed these results.

Conclusion

ASPs had a low impact on overall antibiotic prescription rates and a modest impact on prescribing broad‐spectrum antibiotics. The implementation of ASP protocols needs further development, and more research is necessary on barriers to complying with ASPs.

Audits of Antimicrobial Usage in a Tertiary Care Center in Hyderabad

Background

Irrational prescriptions have an ill effect on health as well as on healthcare expenditure. Prescription auditing is an important tool to improve the quality of prescriptions, which in turn improves the quality of health care provided. Regular and timely audits of antibiotic prescriptions can prevent irrational antibiotic usage.

Introduction

The inappropriate use of drugs is a global health problem, especially in developing countries like India. In 2015, during the 68th World Health Organization (WHO) Regional Committee for Southeast Asia, all Member States of the region, including India, endorsed the “Regional Strategy for Patient Safety in the WHO Southeast Asia Region (2016-2025)” aiming to support the development of national quality of care and patient safety strategies, policies, and plans and commit to translating those objectives of the Regional Strategy into actionable strategies at country level.

Methodology

A retrospective observational study was conducted in a 330-bedded, National Accreditation Board for Hospitals & Healthcare Providers (NABH)-accredited tertiary healthcare center. The study period was six months, from January 2019 to June 2019.

Results

Ninety-five point four-five percent (95.45%) of the doctors attended the sensitization program and all accepted following the standard prescribing protocols. Sixty-nine point seven percent (69.7%) of the doctors were aware of the availability of drugs in the hospital pharmacy stores. Seventy-four point two-four percent (74.24%) of the doctors were aware of the ongoing prescription audits. Seventy-two point two-seven percent (72.27%) of the treating doctors were of the opinion of selecting the appropriate antibiotics based on hospital antibiogram. The importance of antibiograms from cultures and environmental surveillance was followed well only after sensitizing all the treating doctors. Ninety-five point four-five percent (95.45%) of the doctors were of the opinion of taking the permission of a higher authority to start high-end antibiotics. Seventy-seven point one-zero percent (77.10%) doctors recommended sample collection prior to antibiotic administration. Sixty-three percent (63%) of the patient’s clinical condition improved with the antibiotics prescribed prior to the culture report.

Conclusion

By judicious use of antibiotics, we can reduce the evolution of antibiotic resistance in bacteria and extend the useful life of antibiotics that are still effective. Antibiotic use patterns must be studied to address complications resulting from a large number of antibiotics.

Impact of Selected Behavioral and Environmental Factors on the Antibiotic Therapy in Polish Children With Upper Respiratory Tract Infections

Antibiotic therapy must be carried out consistently and according to the guidelines. Viruses are the dominant cause of upper respiratory tract infections (URTIs) in children, as has been shown in many previous studies. Unnecessary antibiotic therapy should be avoided so that it does not affect patients' health and lead to the development of resistant bacterial strains. Here we report a national survey conducted in a group of 4,389 children to assess the impact of selected behavioral and environmental factors on antibiotic therapy in patients with URTIs. We found that selected environmental factors influenced the type of treatment. The place of residence, having siblings, an absence of vaccinations, the presence of allergies, and attendance at educational institutions were conducive to antibiotic therapy. These factors also influenced the frequency of hospitalization of children and their absence from nurseries, kindergartens, and schools, as well as the absence of their guardians from work.