Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections

"Give Me Five": The Case for 5 Days of Antibiotics as the Default Duration for Acute Respiratory Tract Infections

Acute respiratory tract infections (ARTIs) account for most antibiotic prescriptions in pediatrics. Although US guidelines continue to recommend ≥10 days antibiotics for common ARTIs, evidence suggests that 5-day courses can be safe and effective. Academic imprinting seems to play a major role in the continued use of prolonged antibiotic durations. In this report, we discuss the evidence supporting short antibiotic courses for group A streptococcal pharyngitis, acute otitis media, and acute bacterial rhinosinusitis. We discuss the basis for prolonged antibiotic course recommendations and recent literature investigating shorter courses. Prescribers in the United States should overcome academic imprinting and follow international trends to reduce antibiotic durations for common ARTIs, where 5 days is a safe and efficacious course when antibiotics are prescribed.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology

BACKGROUND

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is a rare pediatric disorder consisting of a sudden onset of obsessive-compulsive disorder (OCD) and/or tics after a group A Streptococcus (GAS) infection.

METHODS

In the period between 2013 and 2023, 61 children presented to our Pediatric Rheumatology unit with a suspicion of PANDAS syndrome. Among these, a retrospective analysis was conducted, and 19 fulfilled the current classification criteria and were included in this study.

RESULTS

The male-to-female ratio was 14:5, the median age at onset was 7.0 (2.0-9.5) years, and the median age at diagnosis was 8.0 (3.0-10.4) years. The median follow-up period was 16.0 (6.0-72.0) months. Family and personal history were relevant in 7/19 and 6/19 patients. Tics were present in all patients. Details for motor tics were retrospectively available in 18/19 patients, with the eyes (11/18) and neck/head (10/18) being most often involved. Vocal tics were documented in 8/19, behavioral changes in 10/19, and OCD in 2/19. Regarding the therapeutic response, all patients responded to amoxicillin, 12/13 to benzathine benzylpenicillin, and 7/9 to azithromycin.

CONCLUSIONS

Our findings partially overlap with previous reports. Larger prospective studies are needed to improve treatment strategies and classification criteria.

Internet Tool to Support Self-Assessment and Self-Swabbing of Sore Throat: Development and Feasibility Study

BACKGROUND

Sore throat is a common problem and a common reason for the overuse of antibiotics. A web-based tool that helps people assess their sore throat, through the use of clinical prediction rules, taking throat swabs or saliva samples, and taking throat photographs, has the potential to improve self-management and help identify those who are the most and least likely to benefit from antibiotics.

OBJECTIVE

We aimed to develop a web-based tool to help patients and parents or carers self-assess sore throat symptoms and take throat photographs, swabs, and saliva samples for diagnostic testing. We then explored the acceptability and feasibility of using the tool in adults and children with sore throats.

METHODS

We used the Person-Based Approach to develop a web-based tool and then recruited adults and children with sore throats who participated in this study by attending general practices or through social media advertising. Participants self-assessed the presence of FeverPAIN and Centor score criteria and attempted to photograph their throat and take throat swabs and saliva tests. Study processes were observed via video call, and participants were interviewed about their views on using the web-based tool. Self-assessed throat inflammation and pus were compared to clinician evaluation of patients' throat photographs.

RESULTS

A total of 45 participants (33 adults and 12 children) were recruited. Of these, 35 (78%) and 32 (71%) participants completed all scoring elements for FeverPAIN and Centor scores, respectively, and most (30/45, 67%) of them reported finding self-assessment relatively easy. No valid response was provided for swollen lymph nodes, throat inflammation, and pus on the throat by 11 (24%), 9 (20%), and 13 (29%) participants respectively. A total of 18 (40%) participants provided a throat photograph of adequate quality for clinical assessment. Patient assessment of inflammation had a sensitivity of 100% (3/3) and specificity of 47% (7/15) compared with the clinician-assessed photographs. For pus on the throat, the sensitivity was 100% (3/3) and the specificity was 71% (10/14). A total of 89% (40/45), 93% (42/45), 89% (40/45), and 80% (30/45) of participants provided analyzable bacterial swabs, viral swabs, saliva sponges, and saliva drool samples, respectively. Participants were generally happy and confident in providing samples, with saliva samples rated as slightly more acceptable than swab samples.

CONCLUSIONS

Most adult and parent participants were able to use a web-based intervention to assess the clinical features of throat infections and generate scores using clinical prediction rules. However, some had difficulties assessing clinical signs, such as lymph nodes, throat pus, and inflammation, and scores were assessed as sensitive but not specific. Many participants had problems taking photographs of adequate quality, but most were able to take throat swabs and saliva samples.

Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study

BACKGROUND

Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A).

METHODS

We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines.

FINDINGS

We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing.

INTERPRETATION

A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours.

FUNDING

The Wellcome Trust, grant agreement number 215490/Z/19/Z.

Diagnostic Accuracy of a Real-Time Host-Protein Test for Infection

OBJECTIVE

Determining infection etiology can be difficult because viral and bacterial diseases often manifest similarly. A host protein test that computationally integrates the circulating levels of TNF-related apoptosis-induced ligand, interferon γ-induced protein-10, and C-reactive protein to differentiate between bacterial and viral infection (called MMBV) demonstrated high performance in multiple prospective clinical validation studies. Here, MMBV's diagnostic accuracy is evaluated in febrile children for whom physicians were uncertain about etiology when applied at the physician's discretion.

METHODS

Patients aged 3 months to 18 years were retrospectively recruited (NCT03075111; SPIRIT study; 2014-2017). Emergency department physician's etiological suspicion and certainty level were recorded in a questionnaire at blood-draw. MMBV results are based on predefined score thresholds: viral/non-bacterial etiology (0 ≤ score <35), equivocal (35 ≤ score ≤65), and bacterial or coinfection (65 < score ≤100). Reference standard etiology (bacterial/viral/indeterminate) was adjudicated by 3 independent experts based on all available patient data. Experts were blinded to MMBV. MMBV and physician's etiological suspicion were assessed against the reference standard.

RESULTS

Of 3003 potentially eligible patients, the physicians were uncertain about infection etiology for 736 of the cases assigned a reference standard (128 bacterial, 608 viral). MMBV performed with sensitivity 89.7% (96/107; 95% confidence interval 82.4-94.3) and specificity 92.6% (498/538; 95% confidence interval 90.0-94.5), significantly outperforming physician's etiological suspicion (sensitivity 49/74 = 66.2%, specificity 265/368 = 72.0%; P < .0001). MMBV equivocal rate was 12.4% (91/736).

CONCLUSIONS

MMBV was more accurate in determining etiology compared with physician's suspicion and had high sensitivity and specificity according to the reference standard.

Volatile profiling distinguishes Streptococcus pyogenes from other respiratory streptococcal species

Sore throat is one of the most common complaints encountered in the ambulatory clinical setting. Rapid, culture-independent diagnostic techniques that do not rely on pharyngeal swabs would be highly valuable as a point-of-care strategy to guide outpatient antibiotic treatment. Despite the promise of this approach, efforts to detect volatiles during oropharyngeal infection have yet been limited. In our research study, we sought to evaluate for specific bacterial volatile organic compounds (VOC) biomarkers in isolated cultures in vitro, in order to establish proof-of-concept prior to initial clinical studies of breath biomarkers. A particular challenge for the diagnosis of pharyngitis due to Streptococcus pyogenes is the likelihood that many metabolites may be shared by S. pyogenes and other related oropharyngeal colonizing bacterial species. Therefore, we evaluated whether sufficient metabolic differences are present, which distinguish the volatile metabolome of Group A streptococci from other streptococcal species that also colonize the respiratory mucosa, such as Streptococcus pneumoniae and Streptococcus intermedius. In this work, we identified 27 discriminatory VOCs (q-values < 0.05), composed of aldehydes, alcohols, nitrogen-containing compounds, hydrocarbons, ketones, aromatic compounds, esters, ethers, and carboxylic acid. From this group of volatiles, we identify candidate biomarkers that distinguish S. pyogenes from other species and establish highly produced VOCs that indicate the presence of S. pyogenes in vitro, supporting future breath-based diagnostic testing for streptococcal pharyngitis. IMPORTANCE Acute pharyngitis accounts for approximately 15 million ambulatory care visits in the United States. The most common and important bacterial cause of pharyngitis is Streptococcus pyogenesis, accounting for 15%-30% of pediatric pharyngitis. Distinguishing between bacterial and viral pharyngitis is key to management in US practice. The culture of a specimen obtained by a throat swab is the standard laboratory procedure for the microbiologic confirmation of pharyngitis; however, this method is time-consuming, which delays appropriate treatment. If left untreated, S. pyogenes pharyngitis may lead to local and distant complications. In this study, we characterized the volatile metabolomes of S. pyogenes and other related oropharyngeal colonizing bacterial species. We identify candidate biomarkers that distinguish S. pyogenes from other species and provide evidence to support future breath-based diagnostic testing for streptococcal pharyngitis.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BACKGROUND

Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.

METHODS

Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.

RESULTS

DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.

CONCLUSIONS

When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.

TRIAL REGISTRATION

This trial has been registered at www.

CLINICALTRIALS

gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Nurse prescriber's understanding of their antimicrobial stewardship role: a qualitative study

Introduction Antimicrobial resistance is an infectious disease threat to public health globally, and antimicrobial stewardship among healthcare professionals is one key way to address this potential problem. Registered nurse designated prescribers are the newest group of health professionals to gain prescribing authority in Aotearoa New Zealand, yet little is known about their understanding of their antimicrobial stewardship role. Aim The aim of this study was to explore registered nurse designated prescribers' understanding of their antimicrobial stewardship role through their prescribing practices and approaches to clinical reasoning. Methods This exploratory descriptive qualitative study used individual semi-structured interviews with six registered nurse designated prescribers. Thematic analysis was used to analyse the interviews. Results Four themes were identified: antibiotic prescribing practices and antimicrobial resistance; clinical indicators for prescribing antibiotics, with the sub-themes of history taking, presence of infection and bacterial versus viral infection; patient education; and safety and monitoring. These themes provide insight into registered nurse designated prescribers' understanding of their antimicrobial stewardship role and prescribing of antibiotics. Discussion This research found that the registered nurse designated prescribers had an awareness of the importance of their antimicrobial stewardship role in relation to antibiotic prescribing and reducing antimicrobial resistance. Education about antimicrobial resistance and antimicrobial stewardship for this professional group can be effective, but further research is needed to understand their ongoing educational needs.

Environmental factors related to differences in the microbiota in the upper respiratory tract in young children: Focusing on the impact of early nursery attendance

BACKGROUND

Microbial colonization of the upper respiratory tract (URT) during the first years of life differs significantly according to environmental factors. We investigated the association between early nursery attendance, URT infection (URTI) and drugs used for its treatment and the differences in the URT microbiota.

METHODS

This prospective study included 33 young children (11 and 22 with and without nursery attendance during their infancy, respectively). URT secretions were collected from the nasopharynx of these children at 2, 4, 6, 12, 18 and 24 months old. Clinical information after the latest sampling, including histories of URTI and the uses of antibiotics or cold medicines, was collected from all children. URT bacteria were identified by a clone library analysis of the 16S rRNA gene.

RESULTS

In the diversity of URT microbiota using the Shannon index, we did not detect any associations between variations in the URT microbiota and environmental factors (nursery attendance, development of URTIs, or the uses of antibiotics or cold medicines). However, in a clustering analysis, the proportion of the samples classified as Corynebacterium propinquum-dominant cluster was significantly lower in children ≥6 months old with nursery attendance than in those without nursery attendance. In addition, the URT microbiota was significantly different between samples from children ≥6 months old with and without a history of ≥3 URTI episodes after the first sampling. Furthermore, the URT microbiota was also significantly different between samples from these children with and without antibiotic use between the previous and present samplings.

CONCLUSION

Early nursery attendance and its related factors, including the frequency of URTI and antibiotic treatment, may be associated with the differences in the URT flora in young children.

Multinational consensus antimicrobial stewardship recommendations for children managed in hospital settings

Children are entitled to receive antibiotic therapy that is based on evidence and best practice, but might be overlooked in hospital programmes designed to achieve antimicrobial stewardship [AMS]. This failure to include children could be because children make up small proportion of patients in most hospitals, and are cared for by specialised paediatric staff. We reviewed the evidence and consulted experts in three global regions to develop ten recommendations for good-practice in hospital AMS programmes for children. We performed a review of scientific research, published between Jan 1, 2007, and Oct 17, 2019, concerning AMS, and formed a multinational expert group comprising members from the USA, Canada, the UK, Belgium, Switzerland, Australia, and Aotearoa New Zealand to develop the recommendations. These recommendations aim to help health-care workers who care for children in these regions to deliver best-practice care. We surveyed health-care workers with expertise in antibiotic therapy for children across these regions, and found that the recommendations were considered both very important and generally feasible. These recommendations should be implemented in hospitals to improve antibiotic therapy for children and to stimulate research into future improvements in care.

Pediatric Antibiotic Prescribing and Utilization Practices for RTIs at Private Urgent Care Centers

Data on pediatric antibiotic prescribing and utilization practices at urgent care centers (UCC) remain limited. In this study, an electronic medical record-based review of UCC encounters for respiratory tract infections (RTI) of patients belonging to one mid-sized pediatric practice was performed. Antibiotic prescribing and guideline adherence were compared between UCCs that were staffed exclusively by pediatric-trained providers to those staffed otherwise. Of a total of 457 RTI visits, 330 (72%) occurred at the pediatric UCC. Across all bacterial RTIs, 82% of encounters at the pediatric UCC were guideline-adherent versus 59% at nonpediatric UCCs (P < .001). At nonpediatric UCCs, pharyngitis was the most common RTI encounter diagnosis (40%), and full streptococcal management guideline adherence was 41%. While 93% of RTI-UCC encounters for <2 years were at pediatric UCCs, the majority of children >10 presented to nonpediatric UCCs. RTI guideline education to UCCs should be a focus of ambulatory stewardship efforts.

Impact of antibiotics on off-target infant gut microbiota and resistance genes in cohort studies

BACKGROUND

Young children are frequently exposed to antibiotics, with the potential for collateral consequences to the gut microbiome. The impact of antibiotic exposures to off-target microbes (i.e., bacteria not targeted by treatment) and antibiotic resistance genes (ARGs) is poorly understood.

METHODS

We used metagenomic sequencing data from paired stool samples collected prior to antibiotic exposure and at 1 year from over 200 infants and a difference-in-differences approach to assess the relationship between subsequent exposures and the abundance or compositional diversity of microbes and ARGs while adjusting for covariates.

RESULTS

By 1 year, the abundance of multiple species and ARGs differed by antibiotic exposure. Compared to infants never exposed to antibiotics, Bacteroides vulgatus relative abundance increased by 1.72% (95% CI: 0.19, 3.24) while Bacteroides fragilis decreased by 1.56% (95% CI: -4.32, 1.21). Bifidobacterium species also exhibited opposing trends. ARGs associated with exposure included class A beta-lactamase gene CfxA6. Among infants attending day care, Escherichia coli and ARG abundance were both positively associated with antibiotic use.

CONCLUSION

Novel findings, including the importance of day care attendance, were identified through considering microbiome data at baseline and post-intervention. Thus, our study design and approach have important implications for future studies evaluating the unintended impacts of antibiotics.

IMPACT

The impact of antibiotic exposure to off-target microbes and antibiotic resistance genes in the gut is poorly defined. We quantified these impacts in two cohort studies using a difference-in-differences approach. Novel to microbiome studies, we used pre/post-antibiotic data to emulate a randomized controlled trial. Compared to infants unexposed to antibiotics between baseline and 1 year, the relative abundance of multiple off-target species and antibiotic resistance genes was altered. Infants who attended day care and were exposed to antibiotics within the first year had a higher abundance of Escherichia coli and antibiotic resistance genes; a novel finding warranting further investigation.

International Delphi-based consensus on the appropriate use and effect of Benzydamine hydrochloride in the treatment of sore throat

BACKGROUND

Benzydamine hydrochloride is a locally-acting Non-Steroidal Anti-Inflammatory Drug (NSAID) with combined local anesthetic and analgesic properties, indicated for the symptomatic relief of pain in acute sore throat. The aim of this study was to obtain an European Consensus among pharmacists, general practitioners and pediatricians on the appropriate use of benzydamine hydrochloride in the treatment of sore throat.

METHODS

The authors developed a Delphi questionnaire organized into 15 statements focused on 4 topics: the mechanism of action of benzydamine, the benzydamine treatment in an adult patient and in a pediatric patient, and the advantages of benzydamine over other topical treatments. The survey was administered to a panel of to 320 participants including general practitioners, pediatricians, and pharmacists from 6 European countries (Italy, Germany, Portugal, Romania, Russia, and Spain), who rated their level of agreement or disagreement with each statement on a 6-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with each statement.

RESULTS

Panelists' agreement on statements was very high. Consensus was reached for all 15 statements in the Delphi survey, with more than 98% positive agreement on topic 4, suggesting a shared view among European healthcare professionals (HCPs) about the advantages of benzydamine over other topical treatments. A strong consensus (> 99%) was reached for all the statements of topic 1 regarding the mechanism of action of benzydamine, except for its anesthetic properties (79%). Strong agreement was reached for all statements in topics 2 and 3 regarding the treatment of acute sore throat symptoms in the adult and pediatric patient, except for one on the efficacy of benzydamine in preventing post-operative sore throat, for which it was 67%.

CONCLUSION

Because all relevant publications on benzydamine are dated and there are no recommendations on its use for the symptomatic treatment of sore throat in European guidelines, this Delphi-based international consensus may be important in reinforcing the appropriate use and effect of benzydamine in the treatment of sore throat among health care professionals.

Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse

BACKGROUND

Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical.

OBJECTIVES

Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing.

DESIGN

Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019.

SETTING

Academic and private practice outpatient clinics.

PARTICIPANTS

Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached).

INTERVENTIONS

All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video.

MAIN OUTCOMES AND MEASURES

Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales).

RESULTS

Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms.

CONCLUSIONS AND RELEVANCE

Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years.

TRIAL REGISTRATION NUMBER

NCT03037112.

Diagnostic Stewardship—The Impact of Rapid Diagnostic Testing for Paediatric Respiratory Presentations in the Emergency Setting: A Systematic Review

Antimicrobial resistance is a growing public health crisis, propelled by inappropriate antibiotic prescription, in particular the over-prescription of antibiotics, prolonged duration of antibiotic therapy and the overuse of broad-spectrum antibiotics. The paediatric population, in particular, those presenting to emergency settings with respiratory symptoms, have been associated with a high rate of antibiotic prescription rates. Further research has now shown that many of these antibiotic prescriptions may have been avoided, with more targeted diagnostic methods to identify underlying aetiologies. The purpose of this systematic review was to assess the impact of rapid diagnostic testing, for paediatric respiratory presentations in the emergency setting, on antibiotic prescription rates. To review the relevant history, a comprehensive search of Medline, EMBASE and Cochrane Database of Systematic Reviews was performed. Eighteen studies were included in the review, and these studies assessed a variety of rapid diagnostic testing tools and outcome measures. Overall, rapid diagnostic testing was found to be an effective method of diagnostic antibiotic stewardship with great promise in improving antibiotic prescribing behaviours. Further studies are required to evaluate the use of rapid diagnostic testing with other methods of antibiotics stewardship, including clinical decisions aids and to increase the specificity of interventions following diagnosis to further reduce rates of antibiotic prescription.

Antibiotics prior to age 2 years have limited association with preschool growth trajectory

BACKGROUND

Prior studies of early antibiotic use and growth have shown mixed results, primarily on cross-sectional outcomes. This study examined the effect of oral antibiotics before age 24 months on growth trajectory at age 2-5 years.

METHODS

We captured oral antibiotic prescriptions and anthropometrics from electronic health records through PCORnet, for children with ≥1 height and weight at 0-12 months of age, ≥1 at 12-30 months, and ≥2 between 25 and 72 months. Prescriptions were grouped into episodes by time and by antimicrobial spectrum. Longitudinal rate regression was used to assess differences in growth rate from 25 to 72 months of age. Models were adjusted for sex, race/ethnicity, steroid use, diagnosed asthma, complex chronic conditions, and infections.

RESULTS

430,376 children from 29 health U.S. systems were included, with 58% receiving antibiotics before 24 months. Exposure to any antibiotic was associated with an average 0.7% (95% CI 0.5, 0.9, p < 0.0001) greater rate of weight gain, corresponding to 0.05 kg additional weight. The estimated effect was slightly greater for narrow-spectrum (0.8% [0.6, 1.1]) than broad-spectrum (0.6% [0.3, 0.8], p < 0.0001) drugs. There was a small dose response relationship between the number of antibiotic episodes and weight gain.

CONCLUSION

Oral antibiotic use prior to 24 months of age was associated with very small changes in average growth rate at ages 2-5 years. The small effect size is unlikely to affect individual prescribing decisions, though it may reflect a biologic effect that can combine with others.

[Sore Throat - Guideline-based Diagnostics and Therapy]

Background

Sore throat is a common reason for consultation of family physicians. Acute sore throat (< 14 days) is usually triggered by infections of the pharynx. Less than 35 % of cases are caused by bacterial infections; nevertheless, antibiotics are prescribed far more often. Evidence-based guideline recommendations are available to reduce non-indicated administration of antibiotics in the treatment of sore throat.

Search Methods

Update of the clinical guideline "sore throat" of the German College of General Practitioners and Family Physicians (DEGAM) by means of a systematic search of the literature for international guidelines and systematic reviews.

Main Messages

After excluding red flags such as immunosuppression and severe systemic infections, acute sore throat is usually self-limiting with a mean duration of 7 days. Patients should be encouraged in self-management; ibuprofen and naproxen are recommended for symptomatic treatment. If antibiotics are considered, clinical scores (Centor, McIsaac, FeverPAIN) should be used to assess the risk of bacterial pharyngitis. At low risk (< 3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescription is an option; if high (> 3 points), antibiotics can be taken immediately. Even if scores suggestive a bacterial cause, the evidence suggests that antibiotic treatment only shortens the duration of symptoms modestly. Penicillin is the first choice (clarithromycin as an alternative). The antibiotic should be taken for 5-7 days.

Conclusions

In the absence of red flags, a regular use of symptomatic treatment will help to control discomfort. If administration of antibiotics is still considered a risk-adapted approach, using clinical scores is recommended.

[Risk factors and clinical features of the course of recurrent acute otitis media in children]

This article discusses the problem of recurrent acute otitis media (RAOM) in children.

OBJECTIVE

To study the risk factors and the clinical course of RAOM in children.

MATERIAL AND METHODS

148 children (81 boys and 67 girls) from 1 to 14 years old were examined with a diagnosis of recurrent otitis media. The work was carried out in the ENT departments of Pediatric Clinical Hospital No. 13 named after N.F. Filatov, Pediatric Clinical Hospital named after Z.A. Bashlyaeva. The average age of the children was 4.1±1.5 years.

All children underwent a clinical study, a laboratory study on the content of the main metabolite of vitamin D - 25(OH)D₃ (25-hydroxyvitamin D, or calcidiol) in blood serum.

RESULTS

Our clinical examination of children with RAOM allows us to identify the main risk factors for this pathology. Thus, the most significant risk factors for the development of RAOM in children included in the study were: early visits by children to preschool institutions (50.6%), allergic history (39.1%), pathology during pregnancy (28.3%), mixed (38.5%) or artificial (27.7%) feeding in the first year of life, frequent upper respiratory tract diseases (41.2%), burdened heredity in close relatives according to RAOM (33.7%), smoking in the family of one of the parents (65.5%) presence in the family of one more child (34.4%).

CONCLUSION

It was shown that the absolute number of children (96%) with RAOM is characterized by a reduced level of 25(OH) vitamin D in the blood serum, which can increase the likelihood of developing episodes of acute otitis media in children and requires therapeutic correction.

Streptococcal Pharyngitis: Compliance With National Testing Guidelines in a Pediatric Emergency Department

OBJECTIVES

The Infectious Diseases Society of America (IDSA) guidelines regarding group A streptococcal (GAS) pharyngitis advise against routine testing for patients younger than 3 years, patients without pharyngitis, and patients with symptoms suggesting a viral infection. Group A streptococcal testing may be overused in some clinical settings; thus, we conducted this study to evaluate compliance with the IDSA guidelines in a pediatric emergency department (ED) setting.

METHODS

This retrospective cohort study describes patients younger than 18 years presenting to 2 urban pediatric EDs in 2016 who underwent rapid antigen detection testing for GAS pharyngitis. Testing was classified as noncompliant with the IDSA guidelines if the chief complaint was not indicative of GAS infection and/or the patient age was younger than 3 years. Appropriate nonparametric tests compared groups by IDSA testing compliance status.

RESULTS

A total of 13,585 patient encounters met inclusion criteria; 5255 (39%) were noncompliant with the IDSA testing guidelines, the majority due to a chief complaint inconsistent with GAS pharyngitis (67%) and secondarily due to the age of younger than 3 years (48%). Among the patients with noncompliant testing, 51% were prescribed an antibiotic, and return encounters were more likely to occur (13% vs 10%, P < 0.001). Return encounters more commonly resulted in respiratory diagnoses in those with noncompliant GAS testing (60% vs 45%, P < 0.001).

CONCLUSIONS

Nearly 40% of all pediatric ED encounters with GAS testing were noncompliant with the IDSA guidelines and were associated with greater return encounter rates. Potential negative outcomes from noncompliant GAS testing include misdiagnosis, inappropriate use of antibiotics, allergic reactions, and loss of school days. Informed interventions to reduce unnecessary GAS testing are warranted.

The association between early life antibiotic exposure and the gut resistome of young children: a systematic review

Antimicrobial resistance is a growing public health burden, but little is known about the effects of antibiotic exposure on the gut resistome. As childhood (0-5 years) represents a sensitive window of microbiome development and a time of relatively high antibiotic use, the aims of this systematic review were to evaluate the effects of antibiotic exposure on the gut resistome of young children and identify knowledge gaps. We searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials. A PICO framework was developed to determine eligibility criteria. Our main outcomes were the mean or median difference in overall resistance gene load and resistome alpha diversity by antibiotic exposure groups. Bias assessment was completed using RoB 2 and ROBINS-I with quality of evidence assessed via the GRADE criteria. From 4885 records identified, 14 studies (3 randomized controlled trials and 11 observational studies) were included in the qualitative review. Eight studies that included information on antibiotic exposure and overall resistance gene load reported no or positive associations. Inconsistent associations were identified for the nine studies that assessed resistome alpha diversity. We identified three main groups of studies based on study design, location, participants, antibiotic exposures, and indication for antibiotics. Overall, the quality of evidence for our main outcomes was rated low or very low, mainly due to potential bias from the selective of reporting results and confounding. We found evidence that antibiotic exposure is associated with changes to the overall gut resistance gene load of children and may influence the diversity of antimicrobial resistance genes. Given the overall quality of the studies, more research is needed to assess how antibiotics impact the resistome of other populations. Nonetheless, this evidence indicates that the gut resistome is worthwhile to consider for antibiotic prescribing practices.

Group A Streptococcal Pharyngitis Testing Appropriateness in Pediatric Acute Care Settings

OBJECTIVE

Acute pharyngitis is one of the most common causes of ambulatory clinic visits; however, group A Streptococcus accounts for less than a third. National guidelines recommend against streptococcal testing in patients with viral features. This study aims to assess the rate of inappropriate streptococcal rapid antigen detection tests (RADT)s in children evaluated in urgent care clinics (UCC)s and emergency department (ED)s at a children's hospital.

METHODS

We retrospectively reviewed charts of 10% of children 3 years or older with RADTs ordered between April and September 2018 at EDs and UCCs. The test was determined to be inappropriate if the patient had no sore throat and/or had 2 or more viral symptoms: rhinorrhea/congestion, cough, diarrhea, hoarseness, conjunctivitis, or viral exanthem.

RESULTS

Over the study period, 7678 RADTs were performed, of which 7024 (91.2%) were in children 3 years or older. We evaluated 708 charts and found 44% of RADTs were inappropriate. The predicted probability of inappropriate RADT was highest among patients with a triaged reason for visit for respiratory complaints (70.5%), viral upper respiratory tract infection (69.7%), and rash (61.3%). Of the inappropriate RADTs, 20.1% were positive, whereas 32.2% of the appropriate RADTs were positive.

CONCLUSION

Quality improvement initiatives are needed to decrease the rate of inappropriate RADTs in pediatric UCC and ED settings.

β-Lactam Resistance in Upper Respiratory Tract Pathogens Isolated from a Tertiary Hospital in Malaysia

The rise of antimicrobial resistance (AMR) among clinically important bacteria, including respiratory pathogens, is a growing concern for public health worldwide. Common causative bacteria for upper respiratory tract infections (URTIs) include Streptococcus&nbsp;pneumoniae and Haemophilus influenzae, and sometimes Staphylococcus aureus. We assessed the β-lactam resistant trends and mechanisms of 150 URTI strains isolated in a tertiary care hospital in Kuala Lumpur Malaysia. High rates of non-susceptibility to penicillin G (38%), amoxicillin-clavulanate (48%), imipenem (60%), and meropenem (56%) were observed in S. pneumoniae. Frequent mutations at STMK and SRNVP motifs in PBP1a (41%), SSNT motif in PBP2b (32%), and STMK and LKSG motifs in PBP2x (41%) were observed in S. pneumoniae. H. influenzae remained highly susceptible to most β-lactams, except for ampicillin. Approximately half of the ampicillin non-susceptible H. influenzae harboured PBP3 mutations (56%) and only blaTEM was detected in the ampicillin-resistant strains (47%). Methicillin-susceptible S. aureus (MSSA) strains were mostly resistant to penicillin G (92%), with at least two-fold higher median minimum inhibitory concentrations (MIC) for all penicillin antibiotics (except ticarcillin) compared to S. pneumoniae and H. influenzae. Almost all URTI strains (88-100%) were susceptible to cefcapene and flomoxef. Overall, β-lactam antibiotics except penicillins remained largely effective against URTI pathogens in this region.

Antimicrobial prescription practices for outpatients with acute respiratory tract infections: A retrospective, multicenter, medical record-based study

Antimicrobial stewardship for outpatients with acute respiratory tract infections (ARTIs) should be urgently promoted in this era of antimicrobial resistance. Previous large-sample studies were based on administrative data and had limited reliability. We aimed to identify current antimicrobial prescription practices for ARTIs by directly basing on medical records. This multicenter retrospective study was performed from January to December in 2018, at five medical institutes in Japan. We targeted outpatients aged ≥18 years whose medical records revealed International Classification of Diseases (ICD-10) codes suggesting ARTIs. We divided the eligible cases into three age groups (18-64 years, 65-74 years, and ≥75 years). We defined broad-spectrum antimicrobials as third-generation cephalosporins, macrolides, fluoroquinolones, and faropenem. Primary and secondary outcomes were defined as the proportion of antimicrobial prescriptions for the common cold and other respiratory tract infections, respectively. Totally, data of 3,940 patients were collected. Of 2,914 patients with the common cold, 369 (12.7%) were prescribed antimicrobials. Overall, compared to patients aged ≥75 years (8.5%), those aged 18-64 years (16.6%) and those aged 65-74 years (12.1%) were frequently prescribed antimicrobials for the common cold (odds ratio [95% confidential interval]; 2.15 [1.64-2.82] and 1.49 [1.06-2.09], respectively). However, when limited to cases with a valid diagnosis of the common cold by incorporating clinical data, no statistical difference was observed among the age groups. Broad-spectrum antimicrobials accounted for 90.2% of the antimicrobials used for the common cold. Of 1,026 patients with other respiratory infections, 1,018 (99.2%) were bronchitis, of which antimicrobials were prescribed in 49.9% of the cases. Broad-spectrum antimicrobials were the main agents prescribed, accounting for nearly 90% of prescriptions in all age groups. Our data suggested a favorable practice of antimicrobial prescription for outpatients with ARTIs in terms of prescribing proportions, or quantitative aspect. However, the prescriptions were biased towards broad-spectrum antimicrobials, highlighting the need for further antimicrobial stewardship in the outpatient setting from a qualitative perspective.

Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis

BACKGROUND

In the past two decades, human antibiotic consumption has increased globally, contributing to the emergence and spread of antimicrobial resistance and calling for urgent effective actions.

OBJECTIVES

To systematically identify and collate studies exploring non-biomedical factors influencing healthcare consumers' antibiotic use globally, in order to inform future interventions to improve antibiotic use practices.

METHODS

Data sources: PubMed, EMBASE, PsycINFO, and Cochrane.

STUDY ELIGIBILITY CRITERIA

Original and empirical studies that identified factors for healthcare consumers' antibiotic use.

PARTICIPANTS

Healthcare consumers. Assessment of risk of bias: Adapted BMJ survey appraisal tools, the Critical Appraisal Skills Programme checklist, and the Mixed Methods Appraisal Tool were utilised for quality assessment. Methods of data synthesis: The Social Ecological Framework and Health Belief Model were employed for data synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic use.

RESULTS

We included 71 articles for systematic review and analysis: 54 quantitative, nine qualitative, and eight mixed-methods studies. Prevalent non-prescription antibiotic uses and irresponsible prescriptions were reported globally, especially in low-to-middle income countries. Barriers to healthcare - wait time, transportation, stigmatization - influenced people's antibiotic use practices. Further, lack of oversight and regulation in the drug manufacturing and weak supply chain have led to the use of substandard or falsified antibiotics. Knowledge had mixed effects on antibiotic use behaviours. Meta-analyses identified pro-attitudes towards self-medication with antibiotics, relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for self-medication with antibiotics.

CONCLUSIONS

Non-prescription antibiotic use and irresponsible prescriptions in the community are prevalent in all WHO regions and largely driven by a mixed collection of non-biomedical factors specific to the respective setting. Future AMR strategies should incorporate implementation science approach for community-based complex interventions that addresses drivers of the target behaviours tailored to local contexts.

Tertiary hospitals physician's knowledge and perceptions towards antibiotic use and antibiotic resistance in Cameroon

BACKGROUND

Infections due to resistant bacteria are associated with severe illness, increased risk for complications, hospital admissions, and higher mortality. Inappropriate use of antibiotics, which contributes to increased antibiotic resistance (ABR), is common in healthcare settings across the globe. In Cameroon, antibiotics have been reported as high as 45-70% of prescriptions. We sought to investigate the knowledge, attitudes, and perceptions regarding appropriate antibiotic use and ABR of medical doctors practicing in tertiary hospitals in Yaoundé, Cameroon.

METHODS

We conducted a cross-sectional survey using a 54-item self-administered questionnaire sent via email to medical doctors working in the four major tertiary hospitals of Yaoundé. The questionnaire recorded socio-demographics, perceptions on antibiotic use and ABR, sources and usefulness of education on ABR, and clinical scenarios to appraise knowledge.

RESULTS

A total of 98/206 (48%) doctors responded. Years of experience ranged between 1 and 17 years. Most participants agreed that ABR is a problem nationwide (93%) and antibiotics are overused (96%), but only one third (32%) thought that ABR was a problem in their wards. Most respondents (65%) were confident that they use antibiotics appropriately. We found a mean knowledge score of 56% (± 14), with prescribers not influenced by patient-exerted pressure for antibiotic prescribing scoring better compared to those influenced by patients (67% vs 53%, p = 0.01). Overall, most participants (99%) expressed interest for further education on both appropriate antibiotic use and ABR.

CONCLUSION

Confidence of prescribers in their ability to appropriately use antibiotics conflicts with the low level of knowledge on antibiotic use in this group of doctors. Moreover, the opinion of the majority, that ABR is not a problem in their own backyard is in keeping with similar studies in other countries and is of significant concern. Introduction of formal antibiotic stewardship programmes in Cameroon may be a useful intervention.

Cervical suppurative lymphadenitis in children: microbiology, primary sites of infection, and evaluation of antibiotic treatment

PURPOSE

The significant pathogens associated with paediatric cervical suppurative lymphadenitis (CSL) are unclarified, and there is a lack of clinical evaluations of antibiotic regimens in paediatric CSL. We aimed to (1) explore the bacterial findings and the associated primary sites of infection in paediatric cases of CSL and (2) evaluate the clinical outcomes in patients treated with different antibiotic regimens.

METHODS

All children (< 18 years) treated for non-mycobacterium CSL at the Department of Otorhinolaryngology, Aarhus University Hospital, from 2001 to 2018 were retrospectively evaluated.

RESULTS

Eighty-five patients were included in the study. The prevalent isolates were S. aureus (57%), S. pyogenes (17%), non-haemolytic streptococci (11%), and F. necrophorum (3%). The primary sites of infection were identified in 30 (35%) patients. The most common sites were the oropharynx (n = 15), the middle ear (n = 10), and the skin (n = 5). All patients were treated with surgical incision and antibiotics. No statistically significant differences were found between patients treated with antibiotics covering streptococci (n = 60) versus antibiotics covering streptococci and S. aureus (n = 25) in terms of duration of hospitalisation (median 4 vs 4 days, p = 0.26), altered antibiotic treatment because of insufficient clinical or biochemical progress (7% vs 12%, p = 0.41), and abscess recurrence (8% vs 12%, p = 0.69).

CONCLUSION

S. aureus was the predominant pathogen in paediatric CSL at all cervical levels, and even in cases with evidence of primary site infection not normally associated with S. aureus. We were unable to underscore the importance of antibiotic treatment covering S. aureus based on evaluation of the clinical outcomes.

The burden of Arcanobacterium haemolyticum pharyngitis: A systematic review and management algorithm

INTRODUCTION

Arcanobacterium haemolyticum causes pharyngotonsillitis in children and young adults. It is rarely isolated in pharyngeal swabs as testing for it is not routine. Data on complications, management, and antibiotic susceptibility testing is limited. We sought to review the available literature on the presentation and management of A. haemolyticum pharyngotonsillitis in this age group.

METHODS

A systematic review of eligible studies reporting pharyngotonsillitis and related complications in children and young adults caused by A. haemolyticum was conducted. Literature from case reports, case series, and available cohorts was compiled. Data were analyzed using descriptive statistics.

RESULTS

The initial database search yielded 63 articles, after applying exclusion criteria 17 studies were included. 191 patients were identified with a median age of 16.5 years. The most common presentation was throat pain reported in 93.7% of patients. Tonsillar exudates, fever at presentation and rash were present in more than half of the reviewed cases. The diagnosis was established by a positive culture on a pharyngeal swab in 98.8% of swabs collected. Complications described included peritonsillar abscesses, Lemierre's syndrome, pneumonia, and sepsis. Penicillin was the first line antibiotic in 81% of patients followed by macrolides in 19 patients (18%).

CONCLUSIONS

A. haemolyticum occurs in children and young adults and may result in complications. Our review supports its susceptibility to penicillin. We suggest a diagnostic and management algorithm to guide clinicians in targeted testing and aid with decision making regarding timely and appropriate antibiotic therapy, in an effort to reduce the burden of its complications.

Association of Early Antibiotic Exposure With Childhood Body Mass Index Trajectory Milestones

IMPORTANCE

Past studies have showed associations between antibiotic exposure and child weight outcomes. Few, however, have documented alterations to body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) trajectory milestone patterns during childhood after early-life antibiotic exposure.

OBJECTIVE

To examine the association of antibiotic use during the first 48 months of life with BMI trajectory milestones during childhood in a large cohort of children.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used electronic health record data from 26 institutions participating in the National Patient-Centered Clinical Research Network from January 1, 2009, to December 31, 2016. Participant inclusion required at least 1 valid set of same-day height and weight measurements at each of the following age periods: 0 to 5, 6 to 11, 12 to 23, 24 to 59, and 60 to 131 months (183 444 children). Data were analyzed from June 1, 2019, to June 30, 2020.

EXPOSURES

Antibiotic use at 0 to 5, 6 to 11, 12 to 23, 24 to 35, and 36 to 47 months of age.

MAIN OUTCOMES AND MEASURES

Age and magnitude of BMI peak and BMI rebound.

RESULTS

Of 183 444 children in the study (mean age, 3.3 years [range, 0-10.9 years]; 95 228 [51.9%] were boys; 80 043 [43.6%] were White individuals), 78.1% received any antibiotic, 51.0% had at least 1 episode of broad-spectrum antibiotic exposure, and 65.0% had at least 1 episode of narrow-spectrum antibiotic exposure at any time before 48 months of age. Exposure to any antibiotics at 0 to 5 months of age (vs no exposure) was associated with later age (β coefficient, 0.05 months [95% CI, 0.02-0.08 months]) and higher BMI (β coefficient, 0.09 [95% CI, 0.07-0.11]) at peak. Exposure to any antibiotics at 0 to 47 months of age (vs no exposure) was associated with an earlier age (-0.60 months [95% CI, -0.81 to -0.39 months]) and higher BMI at rebound (β coefficient, 0.02 [95% CI, 0.01-0.03]). These associations were strongest for children with at least 4 episodes of antibiotic exposure. Effect estimates for associations with age at BMI rebound were larger for those exposed to antibiotics at 24 to 35 months of age (β coefficient, -0.63 [95% CI, -0.83 to -0.43] months) or 36 to 47 (β coefficient, -0.52 [95% CI, -0.72 to -0.31] months) than for those exposed at 0 to 5 months of age (β coefficient, 0.26 [95% CI, 0.01-0.51] months) or 6 to 11 (β coefficient, 0.00 [95% CI, -0.20 to 0.20] months).

CONCLUSIONS AND RELEVANCE

In this cohort study, antibiotic exposure was associated with statistically significant, but small, differences in BMI trajectory milestones in infancy and early childhood. The small risk of an altered BMI trajectory milestone pattern associated with early-life antibiotic exposure is unlikely to be a key factor during prescription decisions for children.

Impact of guidelines on antibiotic prescribing approach in primary care-a 10-year study

BACKGROUND

Publication and implementation of clinical guidelines is an important educational measure that considerably helps physicians in choosing appropriate antimicrobial drug.

OBJECTIVES

To evaluate long-term changes in antimicrobial prescribing habits before and after publishing the guidelines and to determine the factors that influence physician's decision to prescribe an antimicrobial drug.

METHODS

The study among general practitioners in Primorsko-Goranska County was conducted in three periods (January 2009, January 2011 and April 2019) by using a structured questionnaire that included general data about the physician, questions about their habits in antibiotic prescribing, criteria that influenced decision to prescribe antibiotics and antimicrobial agent(s) preferred in treating common infections.

RESULTS

Concomitant chronic (non-pulmonary) disease was the most important factor influencing decision to prescribe an antimicrobial drug. Over 88% of physicians that completed the survey declared themselves as rational prescribers of antimicrobials but more than half of them (53.3%) sometimes prescribed an antibiotic even though it was not indicated compared to 75% of self-reported non-rational prescribers (P ˂ 0.05). Self-reported adherence to the guidelines increased from 34.6% in 2011 to 51.8% in 2019.

CONCLUSION

The research showed improvement in physicians' knowledge in choosing the right antibiotic based on the analysis of answers but indicated the necessity for improving communication skills and empowering physicians not to prescribe antibiotics 'just in case' because of diagnostic uncertainty or patient demand. Further qualitative research is needed to understand physicians' prescribing behaviour and decision-making processes in order to develop interventions that will effectively improve the use of antibiotics.

Shortness of breath in children at the emergency department: Variability in management in Europe

OBJECTIVE

Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability.

DESIGN

The TrIAGE project, a prospective observational study based on electronic health record data.

PATIENTS AND SETTING

Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014).

MAIN OUTCOME MEASURES

We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables.

RESULTS

In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings.

CONCLUSION

European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.

To prescribe or not to prescribe for paediatric sore throat: a retrospective cohort study comparing clinician-led antibiotic prescriptions to FeverPAIN and Centor scoring in a tertiary paediatric emergency department and a national review of practice

BACKGROUND

Tonsillopharyngitis is a common presentation to paediatric emergency departments (PEDs). FeverPAIN (FP) and Centor scoring systems are recommended in the UK to help delineate bacterial aetiology, despite being primarily evidenced in adult populations. We investigate how the use of FP or Centor compares to actual clinician practice in guiding antibiotic prescription rates in PED. We establish current national practice in English PEDs.

METHODS

We performed a retrospective cohort study of tonsillopharyngitis presentations to a tertiary PED in January-February 2020. Investigators retrospectively assigned each patient FP and Centor scores using documented symptoms. We compared antibiotic prescription rates guided by FP/Centor against the actual rate prescribed by clinicians, and assessed agreement between these strategies using kappa analysis. We contacted 153 English emergency departments to establish national practice.

RESULTS

We identified 632 consecutive patients aged 6 months to 15 years. Actual clinician-prescribed antibiotics numbered 116 (18.4%). Prescriptions predicted by FP score numbered 124 (19.6%) and Centor 112 (17.7%). Kappa (K) analysis indicated only moderate agreement between clinician choice versus FP (K=0.434) and clinician choice versus Centor (K=0.476). This was similar for cohorts aged under and over 3 years.National practice was reportedly heterogeneous, with 70 emergency departments (45.8%) not employing a specific system.

CONCLUSION

Current guidance is variably interpreted and inconsistently implemented in paediatric populations. FeverPAIN and Centor scoring systems may not rationalise antibiotics as much as previously reported compared with judicious clinician practice. Producing clear paediatric-specific national guidelines, especially for under-5s who are omitted from NICE sore throat guidance, may help further rationalise and standardise antibiotic use in paediatric tonsillopharyngitis.

Antibiotic prescriptions for children younger than 5 years with acute upper respiratory infections in China: a retrospective nationwide claims database study

Background

In China, there were few studies to estimate antibiotic use for children with upper respiratory infections at the national level. The aim of this study was to describe the antibiotic prescribing practice for children aged < 5 years old with upper respiratory infections (URIs) using a nationwide claims database.

Methods

This was a retrospective cross-sectional study using a sampled database from the China Health Insurance Research Association (CHIRA). Study subjects included children younger than 5 years with outpatient visits in 2015 that resulted in a diagnosis of a upper respiratory infection. We calculated the percentage of visits who received antibiotics, the proportion of injection formulations, the percentage of combined antibiotics and the proportion of each antibiotic class. The patterns of antibiotic prescription were also described by medical institution type, city level and geographical region.

Results

Among the 92,821 visits, 27.1% were prescribed antibiotics, of which 27.0% received injection formulations. The rate of antibiotic prescribing varied by age group (P < 0.001), with the lowest (16.0%) in infants and the highest in patients at age 3 to < 4 years (29.9%) and age 4 to < 5 years (32.5%). The Midwestern region, underdeveloped cities and low-level hospitals represented relatively higher rates of prescribing antibiotics (P < 0.001) and higher proportions of injection dosage forms (P < 0.001). The most 3 common antibiotic classes prescribed of all visits with antibiotic prescriptions were the third-generation cephalosporins (34.9%), macrolides (24.3%), and the second-generation cephalosporins (23.3%).

Conclusions

In mainland China, the overall rate of antibacterial prescribing and the proportion of injection formulations prescribed in children under 5 years with URIs were at a low level, but still higher in underdeveloped regions and cities. Moreover, the overuse of the second and third generation cephalosporins, macrolides, remains a serious issue. Further efforts should be focused on reducing those non-first-line antibiotic prescribing and narrowing the gaps among regions and cities.

Clinical Practice Guideline: Sore Throat

BACKGROUND

Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore throat provides evidence-based recommendations for treatment in the German healthcare system.

METHODS

Guideline revision by means of a systematic search of the literature for international guidelines and systematic reviews. All recommendations resulted from interdisciplinary cooperation and were agreed by formal consensus. The updated guideline applies to patients aged 3 years and over.

RESULTS

In the absence of red flags such as immunosuppression, severe comorbidity, or severe systemic infection, acute sore throat is predominantly self-limiting. The mean duration is 7 days. Chronic sore throat usually has noninfectious causes. Laboratory tests are not routinely necessary. Apart from non-pharmacological self-management, ibuprofen and naproxen are recommended for symptomatic treatment. Scores can be used to assess the risk of bacterial pharyngitis: one point each is assigned for tonsil lesions, palpable cervical lymph nodes, patient age, disease course, and elevated temperature. If the risk is low (<3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescribing is recommended; if high (>3 points), antibiotics can be taken immediately. Penicillin remains the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin. The antibiotic should be taken for 5-7 days.

CONCLUSION

After the exclusion of red flags, antibiotic treatment is unnecessary in many cases of acute sore throat. If administration of antibiotics is still considered in spite of consultation on the usual course of tonsillopharyngitis and the low risk of complications, a risk-adapted approach using clinical scores is recommended.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial

OBJECTIVES

To assess the effectiveness and safety of delayed antibiotic prescription (DAP) compared to immediate antibiotic prescription (IAP) and no antibiotic prescription (NAP) in children with uncomplicated respiratory infections.

METHODS

Randomized clinical trial comparing 3 antibiotic prescription strategies. The participants were children with acute uncomplicated respiratory infections attended to in 39 primary care centers. Children were randomly assigned into prescription arms as follows: (1) DAP, (2) IAP, or (3) NAP. Primary outcomes were symptom duration and severity. Secondary outcomes were antibiotic use, parental satisfaction, parental beliefs, additional primary care visits, and complications at 30 days.

RESULTS

In total, 436 children were included in the analysis. The mean (SD) duration of severe symptoms was 10.1 (6.3) for IAP, 10.9 (8.5) for NAP, and 12.4 (8.4) for DAP (P = .539), although the differences were not statistically significant. The median (interquartile range) of the greatest severity for any symptom was similar for the 3 arms (median [interquartile range] score of 3 [2-4]; P = .619). Antibiotic use was significantly higher for IAP (n = 142 [96%]) compared to DAP (n = 37 [25.3%]) and NAP (n = 17 [12.0%]) (P < .001). Complications, additional visits to primary care, and satisfaction were similar for all strategies. Gastrointestinal adverse effects were higher for IAP.

CONCLUSIONS

There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP strategies; however, DAP reduced antibiotic use and gastrointestinal adverse effects.

Nasal saline irrigation: prescribing habits and attitudes of physicians and pharmacists

OBJECTIVES

To explore the opinions, the usage and the patient education given on nasal saline irrigation by physicians and pharmaceutical personnel working in Finland.

DESIGN

An internet-based survey with predetermined, multiple-choice answers.

SETTING

Primary care centres, occupational health centres and private care centres in Eastern Finland as well as pharmacies in Finland.

MAIN OUTCOME MEASURES

Healthcare professionals views, practice and general knowledge of nasal irrigation for sinonasal symptoms and conditions.

RESULTS

We received 595 completed surveys (110 physicians, 485 pharmacists). The majority of the respondents recommended nasal saline irrigation for their patients either as a symptomatic treatment (98.0%) or to treat a specific condition (97.5%) such as acute rhinosinusitis, chronic rhinosinusitis and allergic rhinitis. Nasal saline irrigation was also often recommended as a prophylaxis for airway-infections (71.9%) and to enhance the health of the nasal mucosa (58.2%). In general, the possible adverse effects were recognised poorly by both professions. There was a clear difference between the two professions, as physicians were more conservative in recommending nasal saline irrigation and recognised possible adverse effects, such as epistaxis, pain, and dryness of the nose, better (75% vs. 59%, p = 0.002).

CONCLUSIONS

Nasal saline irrigation seems to be a popular treatment recommended by many health care professionals in Finland. Physicians and pharmaceutical personnel had variable opinions on the indications, utility and risks of nasal saline irrigation. There are also clear differences between physicians and pharmaceutical personnel's practices. There is a need to better educate professionals about nasal saline irrigation and to further study whether nasal saline irrigation is efficient and safe option for the different common sinonasal conditions.KEY POINTSLittle information is available on how physicians and pharmacists recommend nasal saline irrigation as a symptomatic treatment.Physicians and pharmacists seem to have variable opinions about the indications, utility and safety of nasal saline irrigation.The patient education given is in general very heterogenous.Both professions require more education to ensure that the usage remains as safe as possible for the patient.

Economic burden of peanut allergy in pediatric patients with evidence of reactions to peanuts in the United States

BACKGROUND: The economic burden of food allergy is large; however, costs specific to individuals with peanut allergy experiencing reactions to peanuts remain to be evaluated. As the prevalence of peanut allergy continues to increase in children, a better understanding of the cost of care is warranted. OBJECTIVE: To assess the cost of care of peanut allergy among privately insured and Medicaid-insured pediatric patients in the United States. METHODS: This retrospective matched-cohort study included patients aged 4-17 years from the Optum Health Care Solutions and Medicaid Claims databases (January 1, 2007-March 31, 2017). Patients were classified into 2 cohorts: peanut allergy (with peanut allergy diagnosis codes and reactions triggering health care resource utilization [HRU]) and peanut allergy-free (no peanut allergy diagnosis codes in claims). Peanut allergy patients were matched 1:10 to peanut allergy-free patients based on baseline covariates. Comorbidities including anxiety and depression, HRU, and direct health care costs were compared between cohorts and reported for both perspectives separately. RESULTS: Compared with peanut allergy-free patients (n = 30,840 privately insured; n = 12,450 Medicaid), peanut allergy patients (n = 3,084 privately insured; n = 1,245 Medicaid) had higher prevalence of asthma, atopic dermatitis/eczema, other food allergies, allergic rhinitis, depression, and anxiety (all P < 0.01). Peanut allergy patients had higher HRU per patient per year (PPPY), including 90% more emergency department visits among both privately insured and Medicaid patients (P < 0.01) and higher direct health care costs PPPY, with incremental costs of $2,247 total or $1,712 excluding asthma-related costs for privately insured patients and $2,845 total or $1,844 excluding asthma-related costs for Medicaid patients (all P < 0.01). CONCLUSIONS: Pediatric patients in the United States with peanut allergy and reactions triggering HRU had significantly higher comorbidity burdens, HRU, and direct health care costs, regardless of asthma-related costs, versus those without peanut allergy. DISCLOSURES: This study was funded by Aimmune Therapeutics, a Nestlé Health Science company. The study sponsor was involved in several aspects of the research including the study design, the interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication. Yu and Tilles are employees of Aimmune Therapeutics, a Nestlé Health Science company. Robison and Norrett were employees of Aimmune Therapeutics at the time this study was conducted. Blaiss, Meadows, and Hass provided paid consulting services to Aimmune Therapeutics. Guerin and Latremouille-Viau are employees of Analysis Group, a consulting company that provided paid consulting services to Aimmune Therapeutics. Parts of the results were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting held March 25-28, 2019, in San Diego, CA, and at the ISPOR Annual Meeting held May 18-22, 2019, in New Orleans, LA.

Managing Patient Pressure to Prescribe Antibiotics in the Clinic

Acute respiratory tract infections (ARTIs) are typically viral; however, in the USA, approximately one-third of adults and 52% of children with ARTIs receive an antibiotic, making antibiotic prescribing for ARTIs a major contributor to the problem of inappropriate prescribing. Relying on a synthesis of work across pediatric and adult primary care, this article shows some of the main ways that patients and parents pressure physicians for antibiotics, whether intentionally or unintentionally, and how physicians combat that pressure. All data are from video recordings of community-based clinical encounters allowing us to see what is happening "on the ground." Strategies that physicians actually use are documented; however, untutored physicians do not rely on these reliably or strategically, leaving substantial room for the deployment of a three-pronged communication strategy that can reduce patient pressure and inappropriate antibiotic prescribing.

Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective

Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.

Using evidence-based infographics to increase parents' understanding about antibiotic use and antibiotic resistance: a proof-of-concept study

Background

Communities need to see antibiotic stewardship campaigns as relevant to enhance understanding of antibiotic use and influence health-seeking behaviour. Yet, campaigns have often not sought input from the public in their development.

Objectives

To co-produce evidenced-based infographics (EBIs) about antibiotics for common childhood infections and to evaluate their effectiveness at increasing parents’ understanding of antibiotic use.

Methods

A mixed-methods study with three phases. Phase 1 identified and summarized evidence of antibiotic use for three childhood infections (sore throat, acute cough and otitis media). In phase 2, we co-designed a series of prototype EBIs with parents and a graphic design team (focus groups). Thematic analysis was used to analyse data. Phase 3 assessed the effect of EBIs on parents’ understanding of antibiotic use for the three infections using a national online survey in the UK.

Results

We iteratively co-produced 10 prototype EBIs. Parents found the evidence displayed in the EBIs novel and relevant to their families. Parents did not favour EBIs that were too medically focused. Parents preferred one health message per EBI. We included eight EBIs in a national survey of parents (n = 998). EBIs improved knowledge by more than a third across the board (34%, IQR 20%–46%, P < 0.001). Respondents confirmed that EBIs were novel and potentially useful, corroborating our focus groups findings.

Conclusions

Co-designed EBIs have the potential to succinctly change parents’ perceptions about antibiotics for acute respiratory tract infections in children. Further research should test EBIs in real-world settings to assess their reach as a potential public-facing intervention.

Impact and Sustainability of Antibiotic Stewardship in Pediatric Emergency Departments: Why Persistence Is the Key to Success

Antibiotic stewardship programs proved to be effective in improving prescribing appropriateness. This multicenter quasi-experimental study, aimed to assesses the stewardship impact on antibiotics prescribing in different semesters from 2014 to 2019 in three pediatric emergency departments (Center A, B, and C) in Italy. All consecutive patients diagnosed with acute otitis media or pharyngitis were evaluated for inclusion. Two different stewardship were adopted: for Center A and B, clinical pathways were implemented and disseminated, and yearly lectures were held, for Center C, only pathways were implemented. Broad-spectrum prescription rates decreased significantly by 80% for pharyngitis and 29.5 to 55.2% for otitis after the implementation. In Center C, rates gradually increased from the year after the implementation. Amoxicillin dosage adjusted to pharyngitis recommendations in Center C (53.7 vs. 51.6 mg/kg/die; p = 0.011) and otitis recommendations in Center A increasing from 50.0 to 75.0 mg/kg/die (p < 0.001). Days of therapy in children < 24 months with otitis increased from 8.0 to 10.0 in Center A, while in older children decreased in Center A (8.0 vs. 7.0; p < 0.001) and Center B (10.0 vs. 8.0; p < 0.001). Clinical pathways combined with educational lectures is a feasible and sustainable program in reducing broad-spectrum antibiotic prescribing with stable rates over time.

Outpatient antibiotic use associated with acute upper respiratory infections in China: a nationwide cross-sectional study

BACKGROUND

The assessment of antibiotic use for acute upper respiratory infections (AURIs) is important to promote the appropriateness of antibiotic prescribing. Evaluation of antibiotic prescriptions for AURIs at a national level is very limited in China.

OBJECTIVE

To investigate outpatient antibiotic prescriptions for AURIs in Chinese hospitals.

METHODS

This study used data from over 10 million outpatient and emergency department visits for AURIs, which contained information on drug prescription and diagnosis, from 94 cities and 28 provinces of mainland China. Antibiotic prescription rates for various subgroups and potential predictors of antibiotic use were estimated. Patterns of antibiotic prescriptions and proportions of individual antibiotics prescribed for different types of AURIs were analysed and reported.

RESULTS

In total, 10 770 219 outpatient visits for AURIs were included in this study. Of these, 40.8% (95% confidence interval 40.7-40.8%) resulted in antibiotic prescriptions. Patient characteristics, including age, gender, payment type, AURI type, department and season of visit, were significantly associated with antibiotic prescriptions for AURIs. In total, 4 984 744 antibiotic agents were prescribed, of which 87.9% were broad-spectrum antibiotics and only 36.8% were prescribed in line with the guideline recommendations. Azithromycin (13.2%), cefdinir (11.7%), cefixime (8.3%) and cefaclor (8.2%) were the most commonly prescribed antibiotics for AURIs in China.

CONCLUSIONS

Antibiotic prescribing for patients with AURIs in outpatient settings was prevalent nationwide in China. Antibiotic stewardship efforts targeting specific populations in outpatient settings are needed to reduce antibiotic use and promote appropriate antibiotic selection for AURIs in China.

Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia

Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers' antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers' CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non-guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician's selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.

Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness

BACKGROUND

One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.

METHODS

In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability.

RESULTS

Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70).

CONCLUSIONS

This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.

Antibiotic utilization in hospitalized children under 2 years of age with influenza or respiratory syncytial virus infection - a comparative, retrospective analysis

BACKGROUND

Infections due to Respiratory Syncytial Virus (RSV) and Influenza virus (FLU) are leading causes of hospitalization in young children. Yet, there is little data on factors associated with antibiotic use in these patients.

METHODS

We conducted a retrospective, single-center study of all patients below 2 years of age hospitalized between 2014 and 2018. We compared children with RSV infection to children with FLU infection analyzing clinical characteristics and factors contributing to an increased rate of antimicrobial utilization.

RESULTS

RSV infection was diagnosed in 476/573 (83.1%), FLU in 95/573 (16.6%), and RSV-FLU-co-infection in 2/573 (0.3%) patients. Median age was lower for RSV compared to FLU (4 vs. 12 months; p < 0.0001). Children with RSV had longer hospitalization (5 vs. 4 days; p = 0.0023) and needed oxygen more frequently (314/476 vs. 23/95; p < 0.0001) than FLU patients. There was no significant difference in the overall antibiotic utilization between RSV and FLU patients (136/476 vs. 21/95; p = 0.2107). Logistic regression analyses revealed that septic appearance on admission (odds ratio [OR] 8.95, 95% confidence interval [CI] 1.5-54.1), acute otitis media (OR 4.5, 95% CI 2.1-9.4), a longer oxygen therapy (OR 1.40; 95% CI 1.13-1.74) and a higher C-reactive protein (CRP) (OR 1.7, 95% CI 1.5-2.0) were significantly associated with antibiotic use in both groups, but not age or pneumonia.

CONCLUSIONS

In our cohort, the rate of antibiotic utilization was comparable between RSV and FLU patients, while for both groups distinct clinical presentation and a high CRP value were associated with higher antibiotic use.

Maternal sensitivity and mother-infant attachment are associated with antibiotic uptake in infancy

Attachment security has been associated with health status and symptom reporting. In this longitudinal study, we investigated the association between antibiotics uptake by infants at 9-months and mother-infant attachment at 12-months. Logistic regression analyses indicated that lower maternal sensitivity was associated with increased odds of antibiotic uptake. Furthermore, 89.7% of insecure-ambivalent infants consumed antibiotics, which contrasted with 32.5% of avoidant infants and 21.5% of secure infants. This study suggests that maternal behavior and mother-infant attachment impact on antibiotic consumption, which is worrying because antibiotics may lead to several health problems later in life and antibiotic-resistance.

A system dynamics model of infection risk, expectations, and perceptions on antibiotic prescribing in the United States

RATIONALE, AIMS, AND OBJECTIVES

Inappropriate antibiotic prescribing is still a major concern that can lead to devastating outcomes including antibiotic resistance. This study aimed to simulate the antibiotic prescribing behaviour by providers for acute respiratory tract infections (ARTIs) and to evaluate the impact of patient expectation, provider's perception of patient's expectation to receive a prescription, and patient's risk for bacterial infection, on the decision to prescribe.

METHODS

We developed a unique system dynamics (SD) simulation model based on the significant factors that impact the interaction between provider and patient during visits for ARTIs and the decision to prescribe antibiotics. In order to validate the model for different age groups and regions in the United States, we used the sample of 53 000 ARTI patient visits made at outpatient settings between 1993 and 2015, based on the National Ambulatory Medical Care Survey (NAMCS).

RESULTS

Simulation results reveal that physician diagnosis for prescribing antibiotics is based on physician's experience from their prior prescribing behaviour, their perception of patient's infection risk, and patient's expectation to receive antibiotics. Also, there are some variations depending on patient's age and residential region. The simulation analysis also depicts the decreasing trend in patient's expectation over the past two decades for most age groups and regions.

CONCLUSIONS

Given the high number of unnecessary prescriptions for ARTI, we found that policies are needed to influence provider's prescribing behaviour through patient's expectation and provider's perception regarding those expectations. Our simulation framework can further be used by policymakers to design and evaluate interventions that may modify the interaction between health providers and patients to optimize antibiotic prescriptions among ARTI patients for different regions and age groups.

A survey of knowledge, attitudes and practices concerning antibiotic prescription for upper respiratory tract infections among pediatricians in 2018 in Shaanxi Province, China

Objective: The objective of this study was to explore the knowledge, attitudes, and practices concerning antibiotic prescriptions to children with URTIs among pediatricians and to identify barriers to appropriate antibiotic prescription among pediatricians. Methods: An online-based survey was conducted among pediatricians in Shaanxi province, western China, with a population of 38.35 million and an area of 205,600 square kilometers. Results: A total of 472 pediatricians completed this survey, with the response rate of 26.0%. The theoretical knowledge about antibiotics was excellent, with a median score of 8(0-8). However, 30.1% of the respondents still believed that antibiotics are anti-inflammatory drugs. The pediatricians' age, education level, and monthly income and whether had ever received training had significant associations with their knowledge level. The attitude scores were 41.1 ± 3.6, with a ranged of 29-52 points (total score of 55), indicating that most respondents had positive attitudes toward antibiotics. However, 22.7% of the respondents still preferred to use antibiotics for URTIs. It was found that uncertain diagnosis, parent requirements and insufficient time were barriers to appropriate antibiotic prescription. The indiscriminate prescription of antibiotics to children with URTIs was prevalent among pediatricians. Conclusion: Effective integrated interventions should be developed to promote the prudent use of antibiotics among pediatricians.