Clinician knowledge and beliefs after statewide program to promote appropriate antimicrobial drug use

@MondayNightIBD and the expanding gastroenterology Twitterverse: A study on continuing medical education on #GITwitter

OBJECTIVES

@MondayNightIBD provides weekly continuing medical education (CME) activities focused on inflammatory bowel diseases to clinicians on Twitter. Given its novelty, we assessed whether @MondayNightIBD improves learner knowledge and leads to practice change. We also examined whether inflammatory bowel disease topics addressed in @MondayNightIBD are aligned with entrustable professional activities (EPAs) set forth by national gastroenterology societies.

METHODS

@MondayNightIBD CME sessions from February 2020 (date the handle was accredited to provide CME) to May 2021 were analyzed. Pre- and post-activity knowledge was assessed for average score improvement using student's T-tests and Cohen's D effect size. Post-activity surveys examined for learners' perceptions of whether activities met educational goals and affected willingness to change clinical practice using descriptive percentages. In addition, activities from April 2019 (date of @MondayNightIBD inception) to May 2021 were assessed for whether they address EPAs set forth by national gastroenterology societies.

RESULTS

Learners' knowledge improved after @MondayNightIBD activities with average pre-activity correct answers of 58% to a post-activity average of 79% (p < 0.001). Greater than 95% of learners found that activities met learning objectives and enhanced knowledge. A total of 92% of learners were committed to practice change because of their @MondayNightIBD participation. Finally, 78% of EPAs set forth by a national gastroenterology society have been covered by @MondayNightIBD since its inception.

CONCLUSIONS

@MondayNightIBD is a Twitter-based CME activities platform for gastroenterologists and other clinicians that is embraced by learners, improves knowledge, and encourages practice change. Topics covered during @MondayNightIBD are aligned with EPAs set forth by national gastroenterology societies. @MondayNightIBD is a successful model of social media medical education, and a novel approach to effectively provide evidence-based CME.

Knowledge, attitudes and behaviors on antibiotic use and resistance among healthcare workers in Italy, 2019: investigation by a clustering method

BACKGROUND

Identifying healthcare workers (HCW) who have less awareness and knowledge on antibiotic use and resistance represents a challenge for public health, since it might help the development of novel educational and training initiatives tailored on specific subgroups of professionals. This work aims to compare knowledge, attitudes and behaviors on antibiotic use and resistance across different groups of Italian HCW.

METHODS

We used data from the multi-country and multi-professional survey launched by the European Centre for Disease Prevention and Control between 28 January to 4 March 2019 to assess knowledge, attitude and behaviors of HCW on antibiotics, antibiotic use and resistance. We distinguished three clusters of HCW using the Two-Step Cluster analysis, based on their personal and professional characteristics (i.e. profession, role, activity as prescriber, setting, and activity as antibiotic use advisor).

RESULTS

In general, cluster 1 consisted mostly of allied healthcare workers, while clusters 2 and 3 were made up almost completely of pharmacists and medical doctors, respectively. Interestingly, healthcare workers in cluster 3 had the highest knowledge on antibiotic use and resistance. Workers in cluster 1, instead, were those reporting the highest awareness of the importance and role of hand hygiene as an infection prevention and control measure. However, HCW in cluster 2 were those who recognized more their role of advisors on prudent antibiotic use.

CONCLUSIONS

Italian HCW exhibited different knowledge, attitudes, and behaviors on antibiotic use and resistance. These findings raised the need for educational and training interventions targeting specific professional groups.

Indiscriminate Use of Antibiotics in Neurotrauma Patients Referred for Expert Neurosurgical Care in a Developing Country

Background In Nigeria, pre-neurosurgical care of most neurotrauma patients usually involves administration of many empirical agents including antibiotics with no apparent indications. This practice is fraught with two particular dangers: increase in health care costs and development of drug resistance. This study aimed to interrogate antibiotic stewardship in the pre-neurosurgical care of neurotrauma patients referred to our practice. Materials and Methods This 7-month prospective descriptive study was performed in one University Teaching Hospital of a developing country. Clinical data on all admitted neurotrauma patients with information on the pre-neurosurgical treatment received were captured and analyzed. Results There were 113 patients, 87(77.0%) males; 103(91.2%) had head injury, and 10(8.8%) spinal cord injury. Associated systemic injuries occurred in 47(41.6%): 40 involved skeletal and soft tissue systems, and 12(10.6%) presented with aspiration pneumonitis. These patients were referrals from public health facilities including primary health facilities (PHF), secondary (SHF), and tertiary (THF), as well as private clinics (PC). Antibiotics were given to 74 (65.5%) patients, with a probabilistic indication in only 17.6% (13/74) of these. The proportional distribution of this antibiotic administration according to the referral base was not statistically significant (χ 2 =6.87, p = 0.3): 70% (14/20) from PHF, 56% (14/25) from SHF, 71% (23/32) from THF, and 63% (23/36) from PC. The antimicrobial agent administered was specified in 40 cases: Ceftriaxone was the commonest antibiotic agent implicated. Conclusion There is apparent unnecessary exposure of patients to antibiotics in the pre-neurosurgical care of neurotrauma in this study. There is, therefore, need for education on antibiotic stewardship to the group of health workers involved.

Communication interventions to promote the public's awareness of antibiotics: a systematic review

Background

Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public.

Methods

We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes.

Results

Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful.

Conclusions

Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7258-3) contains supplementary material, which is available to authorized users.

An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study

Background

Antibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs).

Methods

The entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use.

Results

Post-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample.

Conclusions

Overall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt.

Knowledge, attitude and practice (KAP) survey regarding antibiotic use among pilgrims attending the 2015 Hajj mass gathering

BACKGROUND

Overuse and misuse of antibiotics have been reported in Hajj. However, little is known about Knowledge, Attitude and Practice (KAP) of pilgrims themselves in relation to these agents.

METHODS

Adult pilgrims from seven countries attending the 2015 Hajj were interviewed using a structured KAP questionnaire.

RESULTS

KAP information was collected from 1476 pilgrims. Misconceptions regarding antibiotics included that they: cure all diseases (24.6%); cure common cold and flu (63.0%); are used to stop fever (47.3%); have no side effects (43.2%). Negative attitudes included prophylactic use (50%), self-medication (43.2%), non-compliance with therapy (63.5%) and storage of left-overs for future use (54.1%). In practice, 87.3% of pilgrims admitted to using non-prescribed antibiotics, only 19.3% use antibiotic as directed by their doctor and 54% do not usually check the expiry date of antibiotics before use. Over 60% brought antibiotics from their home country to KSA and 39.2% acquired non-prescribed antibiotics in Saudi Arabia. KAP scores were higher among the younger age group (≤43 years old) and among those with healthcare-related work or education and increased with increasing levels of education.

CONCLUSIONS

Multifaceted and multidisciplinary approaches, both in KSA and in pilgrims' countries of origin, are needed to address antibiotic misuse during Hajj.

Physicians' knowledge, expectations, and practice regarding antibiotic use in primary health care

OBJECTIVE

Physicians' knowledge of antibiotics, their attitudes, expectations, and practices regarding antibiotic prescription is fundamental for controlling the irrational antibiotic use. This study evaluates primary health care (PHC) physicians' knowledge, expectation, and practices regarding antibiotics use in upper respiratory tract infections.

METHODS

A cross-sectional study conducted in the Qassim region where 32 PHC centers were selected randomly. A total of 294 PHC physicians were surveyed. A pre-tested questionnaire was used after an orientation of participating physicians.

RESULTS

Response rate was 80.3%. There is a significant belief among participants that the use of antibiotics leads to relief of symptoms in the case of viral disease and that taking antibiotics without rational indication increases the side effects. Participants identified that inadequate prescription, use without prescription, and non-compliance of patients are the most important factors contributing to the development of bacterial resistance. Participants often blamed the pharmacist for contributing mostly to the development of the problem of antibiotic resistance. Most physicians identified that they feel under pressure if patients expect an antibiotic prescription. In the absence of laboratory confirmation, most physicians selected high fever as the symptom that makes them prescribe antibiotics. Although having practice guidelines, participants demonstrated that these guidelines do not consider individual variations of patients' need. They do not support a regulation to prohibit antibiotic prescription without laboratory confirmation.

CONCLUSIONS

The distribution of PHC physicians' knowledge, attitudes, and practices did not significantly vary between urban and rural centers. Therefore, whichever measures will be taken to improve the antibiotics practices can be applied to any PHC setting.

Factors associated with doctors' knowledge on antibiotic use in China

Misuse of antibiotics by the medical profession is a global concern. Examining doctors’ knowledge about antimicrobials will be important in developing strategies to improve antibiotic use. The aim of the study was to survey Chinese doctors’ knowledge on antibiotics and reveal the factors associated with their level of knowledge. A cross-sectional survey was conducted in Shanxi in central China. A total of 761 physicians were surveyed using a structured self-administered questionnaire. A generalized linear regression model was used to identify the factors associated with doctors’ knowledge on antibiotic. Based on a full score of 10, the average score for doctors’ knowledge on antibiotics was 6.29 (SD = 1.79). Generalized linear regression analysis indicated that doctors who either worked in the internal medicine department, who were chief doctors or who received continuing education on antibiotic, had better knowledge of antibiotics. Compared with doctors working in tertiary hospitals, doctors working in secondary hospitals or primary healthcare facilities had poorer knowledge about antibiotics. Chinese doctors have suboptimal knowledge about antimicrobials. Ongoing education is effective to enhance doctors’ knowledge, but the effect remains to be further improved. More targeted interventions and education programs should improve knowledge about antimicrobials, especially for doctors working in primary healthcare institutions.

Roles of Clinician, Patient, and Community Characteristics in the Management of Pediatric Upper Respiratory Tract Infections

PURPOSE

Prior studies have evaluated factors predictive of inappropriate antibiotic prescription for upper respiratory tract infections (URIs). Community factors, however, have not been examined. The aim of this study was to evaluate the roles of patient, clinician, and community factors in predicting appropriate management of URIs in children.

METHODS

We used a novel database exchange, linking electronic health record data with community statistics, to identify all patients aged 3 months to 18 years in whom URI was diagnosed in the period from 2007 to 2012. We followed the Healthcare Effectiveness Data and Information Set (HEDIS) quality measurement titled "Appropriate treatment for children with upper respiratory infection" to determine the rate of appropriate management of URIs. We then stratified data across individual and community characteristics and used multiple logistic regression modeling to identify variables that independently predicted antibiotic prescription.

RESULTS

Of 20,581 patients, the overall rate for appropriate management for URI was 93.5%. Family medicine clinicians (AOR = 1.5; 95% CI 1.31, 1.71; reference = pediatric clinicians), urgent care clinicians (AOR = 2.23; 95% CI 1.93, 2.57; reference = pediatric clinicians), patients aged 12 to 18 years (AOR = 1.44; 95% CI 1.25, 1.67; reference = age 3 months to 4 years), and patients of white race/ ethnicity (AOR = 1.83; 95% CI 1.41, 2.37; reference = black non-Hispanic) were independently predictive of antibiotic prescription. No community factors were independently predictive of antibiotic prescription.

CONCLUSIONS

Results correlate with prior studies in which non-pediatric clinicians and white race/ethnicity were predictive of antibiotic prescription, while association with older patient age has not been previously reported. Findings illustrate the promise of linking electronic health records with community data to evaluate health care disparities.

Predictors of rational management of diarrhea in an endemic setting: observation from India

Background

Decades after the establishment of clear guidelines for management, mostly due to irrational approach, diarrhea is still a major concern in the developing world, including India. The scenario is even worse in urban slums owing to poor health-seeking and socio-environmental vulnerability. Determining the distribution of rational diarrhea management by practitioners and identification of its important predictors seemed urgent to minimize the potential for antibiotic resistance, diarrhea-related mortality and morbidity in these areas.

Methods

Between May 2011 and January 2012, 264 consenting, randomly selected qualified and non-qualified practitioners (including pharmacists) were interviewed in the slums of Kolkata, a populous city in eastern India, regarding their characteristics, diarrhea-related knowledge (overall and in six separate domains: signs/symptoms, occurrence/spread, management, prevention/control, cholera and ORS), prescribed antibiotics, intravenous fluid (IVF) and laboratory investigations. Rationality was established based on standard textbooks.

Results

Among participants, 53.03% had no medical qualifications, 6.06% were attached to Governmental hospitals, 19.32% had best knowledge regarding diarrhea. While treating diarrhea, 7.20%, 17.80% and 20.08% respectively advised antibiotics, IVF and laboratory tests rationally. Logistic regression revealed that qualified and Governmental-sector practitioners managed diarrhea more rationally. Having best diarrhea-related knowledge regarding signs/symptoms (OR=5.49, p value=0.020), occurrence/spread (OR=3.26, p value=0.035) and overall (OR=6.82, p value=0.006) were associated with rational antibiotic prescription. Rational IVF administration was associated with best knowledge regarding diarrheal signs/symptoms (OR=3.00, p value=0.017), occurrence/spread (OR=3.57, p value=0.004), prevention/control (OR=4.89, p value=0.037), ORS (OR=2.55, p value=0.029) and overall (OR=4.57, p value<0.001). Best overall (OR=2.68, p value=0.020) and cholera-related knowledge (OR=2.34, p value=0.019) were associated with rational laboratory testing strategy.

Conclusion

Diarrheal management practices were unsatisfactory in urban slums where practitioners’ knowledge was a strong predictor for rational management. Interventions targeting non-qualified, independent practitioners to improve their diarrhea-related knowledge seemed to be required urgently to ensure efficient management of diarrhea in these endemic settings.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

Long-term effects of an educational seminar on antibiotic prescribing by GPs: a randomised controlled trial

BACKGROUND

High levels of outpatient antibiotic use remain observed in many European countries. Several studies have shown a strong relationship between antibiotic use and bacterial resistance.

AIM

To assess the long-term effect of a standardised educational seminar on antibiotic prescriptions by GPs.

DESIGN AND SETTING

Randomised controlled trial of 171 GPs (of 203 initially randomised) in France.

METHOD

GPs in the control group (n = 99) received no antibiotic prescription recommendation. Intervention group GPs (n = 72) attended an interactive seminar presenting evidence-based guidelines on antibiotic prescription for respiratory infections. The proportion of prescriptions containing an antibiotic in each group and related costs were compared to the baseline up to 30 months following the intervention. Data were obtained from the National Health Insurance System database.

RESULTS

In the intervention group, 4-6 months after the intervention, there was a significant decrease in the proportion of prescriptions containing an antibiotic from 15.2 ± 5.4% to 12.3 ± 5.8% (-2.8% [95% CI = -3.8 to -1.9], P<0.001). By contrast, an increase was observed in controls from 15.3 ± 6.0 to 16.4 ± 6.7% (+1.1% [95% CI = +0.4 to +1.8], P<0.01), resulting in a between-group difference of 3.93% ([95% CI = 2.75 to 5.11], P<0.001). The between-group difference was maintained 30 months after intervention (1.99% [95% CI = 0.56 to 3.42], P<0.01). Persistence of the intervention effect over the entire study period was confirmed in a hierarchical multivariate analysis.

CONCLUSION

This randomised trial shows that a standardised and interactive educational seminar results in a long-term reduction in antibiotic prescribing and could justify a large-scale implementation of this intervention.

Childhood infections, antibiotics, and resistance: what are parents saying now?

Parental misconceptions and even "demand" for unnecessary antibiotics were previously viewed as contributors to overuse of these agents. We conducted focus groups to explore the knowledge and attitudes surrounding common infections and antibiotic use in the current era of more judicious prescribing. Among diverse groups of parents, we found widespread use of home remedies and considerable concern regarding antibiotic resistance. Parents generally expressed the desire to use antibiotics only when necessary. There was appreciation of inherent error in the diagnosis of common infections, with most trust placed in providers with whom parents had long-standing relationships. While some parents had experience with "watchful waiting" for otitis media, there was little enthusiasm for this approach. While there may still be room for further education, it appears that parents have become more informed and sophisticated regarding appropriate uses of antibiotics. This has likely contributed to the declines seen in their use nationally.

Assessing the impact of a school intervention to promote students' knowledge and practices on correct antibiotic use

The clinical efficacy of antibiotics depends on their correct use. Widespread ignorance and inappropriate attitudes to antibiotic use have been identified among consumers. In order to improve the knowledge of middle-school students on antibiotics and their correct use, 82 ninth-grade students were enrolled in a teaching activity. The teaching activity consisted of a slide show presentation followed by discussion in a regular class. To evaluate the impact of the teaching activity the students were asked to answer a questionnaire before and after the activity. This study aimed: (1) to evaluate knowledge on the use of antibiotics in students of two schools in the north of Portugal and (2) to evaluate the efficacy of the school intervention in improving students' knowledge on correct antibiotic use. We found lack of knowledge among students regarding antibiotic spectra and indications and incorrect attitudes in the pre-test. Significant increases in knowledge were observed after implementation of the teaching activity. Knowledge of the correct use of antibiotics for bacterial diseases rather than viral diseases rose from 43% to 76% in the post-test (p < 0.01). Knowledge of the risk of bacterial resistance to antibiotics from their incorrect use rose from 48% to 74% in the post-test (p < 0.05). We believe that it is important to reinforce the teaching activities on microbiology and antibiotic use at the middle school level.

Public knowledge and attitudes regarding antibiotic use in South Korea

PURPOSE

This study was conducted to examine public level of knowledge and attitudes regarding antibiotic use and potential drug resistance.

METHODS

A cross-sectional face-to-face survey of 1,177 residents aged 18 or over was conducted in Korea. A quota sampling method was used.

RESULTS

Most respondents (70%) did not know that antibiotics are ineffective in treating coughs and colds. Two-thirds of the respondents were unaware of the conditions under which antibiotic resistance occurs, despite understanding the concept of resistance. Lower education level and older age were independently associated with inadequate knowledge. Lower education level, older age, inadequate knowledge and no exposure to the education campaign were independently associated with poor attitude.

CONCLUSION

The results of this study demonstrate that the general public has misunderstandings and a lack of knowledge with regard to antibiotic use, despite a national educational campaign. However, the campaign may have had an effect on the public's attitudes towards antibiotics.

A survey of medical staff attitudes to an antibiotic approval and stewardship programme

BACKGROUND

Antibiotic stewardship programmes (ASPs) are advocated to ensure appropriate antimicrobial use; with short-term evidence they may improve outcomes, limit adverse effects, encourage cost-effectiveness and reduce antibiotic resistance. At Concord Hospital, a 450-bed acute care hospital, we have used a telephone-based ASP for 15 years. There may be differences in attitudes to the ASP by prescribers, which may influence its long-term efficacy.

METHOD

A 40-item self-administered questionnaire was sent to 190 junior and 250 specialist medical staff. We aimed to elicit medical staff attitudes to the ASP's utility, educational value, effect on patient care and ease of use.

RESULTS

One hundred and sixty-four completed questionnaires were returned. Most (82%, 95% confidence interval (95%CI) 75-87%) clinicians had used the ASP, 98% of whom believed it to be a reasonable system. Most staff (85%, 95%CI 79-90%) believed that seeking approval made teams think carefully about antibiotic choice, agreed it provided helpful advice (91%, 95%CI 85-95%) and that the approval system provided useful advice and was educational (88%, 95%CI 81-92%). The ASP was felt time-consuming and detracting from clinical duties by 33% (95%CI 26-41%), while 10% (95%CI 5.8-15.7%) believed it undervalued intuition and experience. Few (19%, 95%CI 13-25%, P < 0.0001) clinicians believed it infringed their autonomy. The advice given through the ASP was believed by most (89%, 95%CI 81-92%) to improve patient outcomes.

CONCLUSION

The ASP was surprisingly well supported by all levels of staff, and reinforced the benefits of maintaining an ASP policy.

Sustainability for behaviour change in the fight against antibiotic resistance: a social marketing framework

Antibiotic resistance is one of today's most urgent public health problems, threatening to undermine the effectiveness of infectious disease treatment in every country of the world. Specific individual behaviours such as not taking the entire antibiotic regimen and skipping doses contribute to resistance development as does the taking of antibiotics for colds and other illnesses that antibiotics cannot treat. Antibiotic resistance is as much a societal problem as it is an individual one; if mass behaviour change across the population does not occur, the problem of resistance cannot be mitigated at community levels. The problem is one that potentially can be solved if both providers and patients become sufficiently aware of the issue and if they engage in appropriate behaviours. Although a number of initiatives have been implemented in various parts of the world to elicit behaviour change, results have been mixed, and there is little evidence that trial programmes with positive outcomes serve as models of sustainability. In recent years, several scholars have suggested social marketing as the framework for behaviour change that has the greatest chance of sustained success, but the antibiotic resistance literature provides no specifics for how the principles of social marketing should be applied. This paper provides an overview of previous communication-based initiatives and offers a detailed approach to social marketing to guide future efforts.

Sustained reduction of antibiotic use and low bacterial resistance: 10-year follow-up of the Swedish Strama programme

Increasing use of antibiotics and the spread of resistant pneumococcal clones in the early 1990s alarmed the medical profession and medical authorities in Sweden. Strama (Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance) was therefore started in 1994 to provide surveillance of antibiotic use and resistance, and to implement the rational use of antibiotics and development of new knowledge. Between 1995 and 2004, antibiotic use for outpatients decreased from 15.7 to 12.6 defined daily doses per 1000 inhabitants per day and from 536 to 410 prescriptions per 1000 inhabitants per year. The reduction was most prominent in children aged 5-14 years (52%) and for macrolides (65%). During this period, the number of hospital admissions for acute mastoiditis, rhinosinusitis, and quinsy (peritonsillar abscess) was stable or declining. Although the epidemic spread in southern Sweden of penicillin-resistant Streptococcus pneumoniae was curbed, the national frequency increased from 4% to 6%. Resistance remained low in most other bacterial species during this period. This multidisciplinary, coordinated programme has contributed to the reduction of antibiotic use without measurable negative consequences. However, antibiotic resistance in several bacterial species is slowly increasing, which has led to calls for continued sustained efforts to preserve the effectiveness of available antibiotics.

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts

OBJECTIVES

Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.

METHODS

We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.

RESULTS

The data include 223,135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.

CONCLUSIONS

A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

Characteristics of nurse practitioner curricula in the United States related to antimicrobial prescribing and resistance

PURPOSE

The purpose of this study was to examine current nurse practitioner (NP) curricula in the United States with regard to antibiotics and antimicrobial resistance and assess the need for a web-based module for instruction on antimicrobial resistance and appropriate prescribing of antibiotics.

DATA SOURCES

A 22-item, anonymous, self-administered, web-based survey was sent to 312 NP programs; 149 (48%) responded. Survey items included questions related to NP specialties offered, program accreditation, format of pharmacology course(s), lecture hours related to antimicrobial therapy, and whether the participant would use a Web-based module to teach NP students about antimicrobial resistance, if one were available.

CONCLUSIONS

Most NP programs (99.3%) required a pharmacology course, and 95% had lectures dedicated to antimicrobial therapy. Half of the programs (53.5%) devoted >or=4 lecture hours to antimicrobial therapy in the pharmacology course, and most (84.8%) reported covering antimicrobial therapy in nonpharmacology courses as well. Approximately half of the programs (45.3%) reported <4 h of lecture on antimicrobial therapy in nonpharmacology courses. Many programs (51.9%) did not offer a microbiology course; 39.2% required microbiology as a prerequisite. Most respondents (86.7%) were familiar with the Centers for Disease Control and Prevention antimicrobial resistance program, and 92.6% reported that they would use an electronic module regarding resistance.

IMPLICATIONS FOR PRACTICE

NP curricula generally include <10 h of content on antimicrobial therapy. An electronic module regarding antimicrobial resistance is likely to be a useful and relevant adjunct to current curricula.

Antimicrobial stewardship and the role of pharmacokinetics-pharmacodynamics in the modern antibiotic era

Antimicrobial stewardship, a term coined by Dale Gerding, is defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance development. Methods to promote and ensure good antimicrobial stewardship have been implemented and studied, and have typically provided tangible benefits in terms of a reduction in overall or targeted antimicrobial usage and resistance emergence. Although most of the programmatic antimicrobial stewardship efforts have been conducted in acute care inpatient settings, some strategies usually involving education have been evaluated in the outpatient venue. In this review, we shall discuss issues related to why antimicrobial stewardship is of particular importance in the modern antibiotic era. In addition, general pharmacokinetic-pharmacodynamic (PK-PD) concepts will be reviewed and specific PK-PD analyses that support the optimal selection, dosing, and duration of therapy for beta-lactam antimicrobials will be provided.

Assessment and promotion of judicious antibiotic use on dairy farms in Washington State

The aims of this study were to describe antibiotic use and biosecurity practices among Washington State dairy producers and to evaluate the effectiveness of a collaborative approach to promoting judicious antibiotic use on dairy farms. In collaboration with a statewide industry group, Washington State dairy producers participated in a written, self-administered survey in 2003. They were then provided several educational interventions followed by a second written survey in 2005. Sixty-five percent (381) of dairy producers completed the 2003 survey. The most commonly cited drugs used for disease treatment were penicillin, ceftiofur, and oxytetracycline. Participants also indicated significant preventive uses with 28% using medicated milk replacer. Most producers appeared to consider intramammary infusion at dry-off to be a treatment rather than a preventative practice. Twenty-three percent of initial respondents indicated at least one extra-label use of antibiotics, yet only half routinely consulted with a veterinarian when doing so. Most agreed that using written protocols for disease treatment could reduce errors, but less than one-third had protocols. After the educational intervention there was a tendency toward reduced use of antibiotic medicated milk replacer: 51% of producers who originally reported using medicated milk replacer discontinued this practice, whereas 12% of producers began using medicated milk replacer between the 2003 and 2005 surveys. Most reported that the resources and educational materials were useful. Areas where additional work is needed include reducing the use of medicated milk replacer, increasing veterinary involvement in antibiotic use decisions, implementing treatment protocols, enhancing biosecurity, and ensuring optimal cow and calf immunity.

Knowledge, attitudes, and practices regarding antibiotic use among Latinos in the United States: review and recommendations

Inappropriate use of antibiotics contributes to antimicrobial resistance worldwide. In Latin America, antibiotics are easily obtained over the counter. In the United States, the Latino population is the largest and fastest growing immigrant group. Hence, it is necessary to understand Latino cultural practices in regards to antibiotic use to develop effective interventions that reduce inappropriate antibiotic use among this population. We conducted a systematic review of descriptive and intervention studies measuring knowledge, attitudes, and practices of antibiotic use among Latinos in the United States. The search yielded only 11 descriptive studies and no interventions. The literature suggests that many Latinos in the United States self-prescribe antibiotics because of financial and sociocultural barriers and inaccurately believe that antibiotics help treat viral infections. Increased access to health care and appropriate culturally tailored interventions specific to Latinos are needed to promote judicious antibiotic use among Latinos.

Impact of statewide program to promote appropriate antimicrobial drug use

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.