Use of Rapid Influenza Testing to Reduce Antibiotic Prescriptions Among Outpatients with Influenza-Like Illness in Southern Sri Lanka

Prevalence of pharmaceuticals and personal care products, microplastics and co-infecting microbes in the post-COVID-19 era and its implications on antimicrobial resistance and potential endocrine disruptive effects

The COVID-19 (coronavirus disease 2019) pandemic's steady condition coupled with predominance of emerging contaminants in the environment and its synergistic implications in recent times has stoked interest in combating medical emergencies in this dynamic environment. In this context, high concentrations of pharmaceutical and personal care products (PPCPs), microplastics (MPs), antimicrobial resistance (AMR), and soaring coinfecting microbes, tied with potential endocrine disruptive (ED) are critical environmental concerns that requires a detailed documentation and analysis. During the pandemic, the identification, enumeration, and assessment of potential hazards of PPCPs and MPs and (used as anti-COVID-19 agents/applications) in aquatic habitats have been attempted globally. Albeit receding threats in the magnitude of COVID-19 infections, both these pollutants have still posed serious consequences to aquatic ecosystems and the very health and hygiene of the population in the vicinity. The surge in the contaminants post-COVID also renders them to be potent vectors to harbor and amplify AMR. Pertinently, the present work attempts to critically review such instances to understand the underlying mechanism, interactions swaying the current health of our environment during this post-COVID-19 era. During this juncture, although prevention of diseases, patient care, and self-hygiene have taken precedence, nevertheless antimicrobial stewardship (AMS) efforts have been overlooked. Unnecessary usage of PPCPs and plastics during the pandemic has resulted in increased emerging contaminants (i.e., active pharmaceutical ingredients and MPs) in various environmental matrices. It was also noticed that among COVID-19 patients, while the bacterial co-infection prevalence was 0.2-51%, the fungi, viral, protozoan and helminth were 0.3-49, 1-22, 2-15, 0.4-15% respectively, rendering them resistant to residual PPCPs. There are inevitable chances of ED effects from PPCPs and MPs applied previously, that could pose far-reaching health concerns. Furthermore, clinical and other experimental evidence for many newer compounds is very scarce and demands further research. Pro-active measures targeting effective waste management, evolved environmental policies aiding strict regulatory measures, and scientific research would be crucial in minimizing the impact and creating better preparedness towards such events among the masses fostering sustainability.

Influenza Vaccination Implementation in Sri Lanka: A Cost-Effectiveness Analysis

Influenza causes an estimated 3 to 5 million cases of severe illness annually, along with substantial morbidity and mortality, particularly in low- and middle-income countries (LMICs). Currently, Sri Lanka has no influenza vaccination policies and does not offer vaccination within the public healthcare sector. Therefore, we performed a cost-effectiveness analysis of influenza vaccine implementation for the Sri Lankan population. We designed a static Markov model that followed a population cohort of Sri Lankans in three age groups, 0-4, 5-64, and 65+ years, through two potential scenarios: trivalent inactivated vaccination (TIV) and no TIV across twelve-monthly cycles using a governmental perspective at the national level. We also performed probabilistic and one-way sensitivity analyses to identify influential variables and account for uncertainty. The vaccination model arm reduced influenza outcomes by 20,710 cases, 438 hospitalizations, and 20 deaths compared to no vaccination in one year. Universal vaccination became cost-effective at approximately 98.01% of Sri Lanka's 2022 GDP per capita (incremental cost-effectiveness ratio = 874,890.55 Rs/DALY averted; 3624.84 USD/DALY averted). Results were most sensitive to the vaccine coverage in the 5-64-year-old age group, the cost of the influenza vaccine dose in the 5-64-years-old age group, vaccine effectiveness in the under-5-years-old age group, and the vaccine coverage in the under-5-years-old age group. No value for a variable within our estimated ranges resulted in ICERs above Rs. 1,300,000 (USD 5386.15) per DALY adverted. Providing influenza vaccines was considered highly cost-effective compared to no vaccines. However, large-scale national studies with improved data are needed to better inform estimates and determine the impact of vaccination implementation.

Cost-of-illness comparison between clinical judgment and molecular point-of-care testing for influenza-like illness patients in Germany

A high economic burden stems from seasonal influenza as a well-known but serious public health problem. Rapid diagnostic tests have not yet been integrated into routine use in German primary care, even though they are likely to reduce overall costs in cases of suspected infection. This study aims to demonstrate that the use of point-of-care testing (POCT) produces lower costs of illness compared to the costs incurred by relying on clinical judgment alone. With the help of a decision tree model, two different diagnostic approaches for influenza-like illness (ILI) in primary care were compared: (1) clinical judgment with no technical support and (2) POCT. The costs of illness, as well as their differences, vary widely among the three age groups considered (elderly people, adults, and children). For the pathway of using clinical judgment alone, the costs of illness sum up to 155.99 € for elderly people compared to 76.31 € for adults and 74.15 € for children. With POCT, the costs of illness for the elderly amount to 115,09 €, which is 26% lower than the costs without diagnostic support. The costs for adults and children are 74.42 € and 75.66 €, respectively, which means 2.5% lower costs of illness for adults and 2% higher costs for children. The results demonstrate that the use of POCT to support detecting influenza in ILI patients may reduce the overall cost of illness. The provided data can help governments make informed decisions about potential cost savings by integrating POCT into the reimbursement scheme.

Clinical Features of COVID-19, Dengue, and Influenza among Adults Presenting to Emergency Departments and Urgent Care Clinics-Puerto Rico, 2012-2021

Dengue and influenza are pathogens of global concern and cause febrile illness similar to COVID-19. We analyzed data from an enhanced surveillance system operating from three emergency departments and an urgent care clinic in Puerto Rico to identify clinical features predictive of influenza or dengue compared with COVID-19. Participants with fever or respiratory symptoms and aged ≥18 years enrolled May 2012-January 2021 with dengue, influenza, or SARS-CoV-2 confirmed by reverse transcriptase polymerase chain reaction were included. We calculated adjusted odds ratios (aORs) and 95% CIs using logistic regression to assess clinical characteristics of participants with COVID-19 compared to those with dengue or influenza, adjusting for age, subregion, and days from illness onset to presentation for clinical care. Among 13,431 participants, we identified 2,643 with dengue (N = 303), influenza (N = 2,064), or COVID-19 (N = 276). We found differences in days from onset to presentation among influenza (2 days [interquartile range: 1-3]), dengue (3 days [2-4]), and COVID-19 cases (4 days [2-7]; P < 0.001). Cough (aOR: 0.12 [95% CI: 0.07-0.19]) and shortness of breath (0.18 [0.08-0.44]) were less common in dengue compared with COVID-19. Facial flushing (20.6 [9.8-43.5]) and thrombocytopenia (24.4 [13.3-45.0]) were more common in dengue. Runny nose was more common in influenza compared with COVID-19 (8.3 [5.8-12.1]). In summary, cough, shortness of breath, facial flushing, and thrombocytopenia helped distinguish between dengue and COVID-19. Although few features distinguished influenza from COVID-19, presentation > 4 days after symptom onset suggests COVID-19. These findings may assist clinicians making time-sensitive decisions regarding triage, isolation, and management while awaiting pathogen-specific testing.

The Use of PCR for Respiratory Virus Detection on the Diagnosis and Treatment Decision of Respiratory Tract Infections in Iraq

Diseases of the respiratory system are a common cause of antibiotic prescription in Iraq and worldwide. Technology has been recently used for its diagnosis, such as the Film Array Respiratory Panel. This study aims to identify the correlation between the diagnosis and treatment of respiratory tract infections with the result of polymerase chain reaction (PCR) for respiratory viruses. A descriptive, cross-sectional, retrospective study included 134 patients treated at Alkharama Hospital and the Private Hospital in Baghdad, Iraq, in the period from January 2020 to March 2020 For all cases, the results of the panel and the treatment received by the patients were analysed. 58% received antibiotic treatment upon admission, 13% combined treatment (antibiotic + antiviral), 27% received symptomatic treatment, and 2% were treated with the first-instance antiviral. After the result, 38% continued with antibiotics, 30% with antibiotics and antivirals, 13.8% with antivirals and 18.2% with symptomatic treatment. Despite the worldwide alarm over antimicrobial resistance, patients continue to be treated with antibiotics due to a situation that is influenced by several factors.

Rapid Diagnostic Tests to Guide Case Management of and Improve Antibiotic Stewardship for Pediatric Acute Respiratory Illnesses in Resource-Constrained Settings: a Prospective Cohort Study in Southwestern Uganda

Pediatric acute respiratory illness (ARI) is one of the most common reasons for evaluation at peripheral health centers in sub-Saharan Africa and is frequently managed based on clinical syndrome alone. Although most ARI episodes are likely caused by self-limited viral infections, the majority are treated with antibiotics. This overuse contributes to the development of antimicrobial resistance. To evaluate the preliminary feasibility and potential impact of adding pathogen-specific and clinical biomarker diagnostic testing to existing clinical management algorithms, we conducted a prospective, observational cohort study of 225 children presenting with malaria-negative, febrile ARI to the outpatient department of a semi-urban peripheral health facility in southwestern Uganda from October 2019 to January 2020. In addition to routine clinical evaluation, we performed influenza and Streptococcus pneumoniae antigen testing and measured levels of C-reactive protein, procalcitonin, and lactate in the clinic's laboratory, and conducted a follow-up assessment by phone 7 days later. Almost one-fifth of participants (40/225) tested positive for influenza. Clinical biomarker measurements were low with C-reactive protein of >40 mg/L in only 11% (13/222) of participants and procalcitonin >0.25 ng/mL in only 13% (16/125). All but two children received antibiotic treatment; only 3% (7/225) were admitted. At follow-up, 59% (118/201) of caregivers reported at least one persistent symptom, but fever had resolved for all children. Positive influenza testing was associated with persistent symptoms. In summary, we demonstrate that simple, rapid pathogen-specific testing and biomarker measurement are possible in resource-limited settings and could improve syndromic management and, in turn, antibiotic stewardship. IMPORTANCE Globally, respiratory illness is one of the most common reasons that children seek care. It is often treated inappropriately with antibiotics, which can drive the development of antibiotic resistance. In resource-rich settings, testing for specific pathogens or measurement of clinical biomarkers, such as procalcitonin and C-reactive protein, is often employed to help determine which children should receive antibiotics. However, there are limited data on the use of these tests in resource-constrained, outpatient contexts in sub-Saharan Africa. We enrolled children with respiratory illness presenting to a clinic in southwestern Uganda and performed testing for influenza, Streptococcus pneumoniae, C-reactive protein, and procalcitonin on-site. Almost all children received antibiotics. We demonstrate that employing clinical algorithms that include influenza and clinical biomarker testing could significantly decrease antibiotic prescriptions. Our study therefore provides preliminary data to support the feasibility and potential utility of diagnostics to improve management of respiratory illness in resource-constrained settings.

Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review

Containing antimicrobial resistance and reducing high levels of antibiotic consumption in low- and lower middle-income countries are a major challenge. Clinical guidelines targeting antibiotic prescribing can reduce consumption, however, the degrees to which clinical guidelines are adopted and adhered to are challenging for developers, policy makers and users. The aim of this study was to review the strategies used for implementing and promoting antibiotic guideline adherence in low- and lower middle-income countries. A review of published literature was conducted using PubMed, Cochrane Library, SCOPUS and the information systems of the World Health Organization and the Australian National University according to PRISMA guidelines and our PROSPERO protocol. The strategies were grouped into five broad categories based on the Cochrane Effective Practice and Organization of Care taxonomy. The 33 selected studies, representing 16 countries varied widely in design, setting, disease focus, methods, intervention components, outcomes and effects. The majority of interventions were multifaceted and resulted in a positive direction of effect. The nature of the interventions and study variability made it impossible to tease out which strategies had the greatest impact on improving CG compliance. Audit and feedback coupled with either workshops and/or focus group discussions were the most frequently used intervention components. All the reported strategies are established practices used in antimicrobial stewardship programs in high-income countries. We recommend interrupted time series studies be used as an alternative design to pre- and post-intervention studies, information about the clinical guidelines be made more transparent, and prescriber confidence be investigated.

Pediatricians' Compliance to the Clinical Management Guidelines for Community-Acquired Pneumonia in Infants and Young Children in Pakistan

Community-acquired pneumonia (CAP) is among the most commonly prevailing acute infections in children that may require hospitalization. Inconsistencies among suggested care and actual management practices are usually observed, which raises the need to assess local clinical practices. The current study was conducted to evaluate pediatricians’ compliance with the standard clinical practice guidelines and their antibiotic-prescribing behavior for the management of CAP in children. Methods: A descriptive cross-sectional study was conducted using a self-administered questionnaire; which was provided to pediatricians by the researchers. Statistical analysis was performed with SPSS 25 Statistics; χ² tests (or Fisher-exact tests) with the p-value set at < 0.05 as the threshold for statistical significance. Results: The overall response rate was 59.2%. Male respondents were (n = 101; 42.6%), and the respondents (n = 163; 68.7%) were under 30 years of age. Amoxicillin (n = 122; 51.5%) was considered as the most commonly used first-line treatment for non-severe pneumonia, whereas a smaller proportion (n = 81; 34.2%) of respondents selected amoxicillin–clavulanate. Likewise, amoxicillin (n = 100; 42.2%) was the most popular choice for non-severe pneumonia in hospitalized children; however, if children had used antibiotics earlier to admission, respondents showed an inclination to prescribe a macrolide (n = 95; 40.0%) or second-generation cephalosporin (n = 90; 37.9%). More than 90% responded that children <6 months old with suspected bacterial CAP will probably receive better therapeutic care by hospitalization. Restricting exposure to the antibiotic as much as possible (n = 71; 29.9%), improving antibiotic prescribing (n = 59; 24.8%), and using the appropriate dose of antimicrobials (n = 29; 12.2%) were considered the major factors by the respondents to reduce antimicrobials resistance. Conclusions: The selection of antibiotics and diagnostic approach was as per the recommendations, but indication, duration of treatment, and hospitalization still can be further improved.

Colonization with multidrug-resistant Enterobacteriaceae among infants: an observational study in southern Sri Lanka

BACKGROUND

The timing of and risk factors for intestinal colonization with multidrug-resistant Enterobacteriaceae (MDRE) are still poorly understood in areas with high MDRE carriage. We determined the prevalence, timing, and risk factors associated with MDRE intestinal colonization among infants in southern Sri Lanka.

METHODS

Women and their newborn children were enrolled within 48 h after delivery in southern Sri Lanka. Rectal swabs were collected from women and infants at enrollment and 4-6 weeks later. Enterobacteriaceae were isolated and identified as MDRE (positive for extended-spectrum β-lactamases or carbapenem resistant) using standard microbiologic procedures. We used exact methods (Fisher's exact and Kruskal-Wallis tests) and multivariable logistic regression to identify sociodemographic and clinical features associated with MDRE intestinal colonization. Whole-genome sequencing was performed on selected MDRE isolates to identify phylogroups and antibiotic resistance-encoding genes were identified with NCBI's AMRfinder tool.

RESULTS

Overall, 199 post-partum women and 199 infants were enrolled; 148/199 (74.4%) women and 151/199 (75.9%) infants were reassessed later in the community. Twenty-four/199 (12.1%) women and 3/199 (1.5%) infants displayed intestinal colonization with MDRE at enrollment, while 26/148 (17.6%) women and 24/151 (15.9%) infants displayed intestinal colonization with MDRE at the reassessment. While there were no risk factors associated with infant colonization at enrollment, multivariable analysis indicated that risk factors for infant colonization at reassessment included mother colonized at enrollment (aOR = 3.62) or reassessment (aOR = 4.44), delivery by Cesarean section (aOR = 2.91), and low birth weight (aOR = 5.39). Of the 20 MDRE isolates from infants that were sequenced, multilocus sequence typing revealed that 6/20 (30%) were clustered on the same branch as MDRE isolates found in the respective mothers. All sequenced isolates for mothers (47) and infants (20) had at least one ESBL-producing gene. Genes encoding fosfomycin resistance were found in 33/47 (70%) of mothers' isolates and 16/20 (80%) of infants' isolates and genes encoding resistance to colistin were found in one (2%) mother's isolate.

CONCLUSIONS

Our results suggest that a substantial proportion of infants undergo MDRE intestinal colonization within 6 weeks of birth, potentially due to postnatal rather than intranatal transmission.

Reducing Antibiotic Use in Ambulatory Care Through Influenza Vaccination

BACKGROUND

Improving appropriate antibiotic use is crucial for combating antibiotic resistance and unnecessary adverse drug reactions. Acute respiratory illness (ARI) commonly causes outpatient visits and accounts for ~41% of antibiotics used in the United States. We examined the influence of influenza vaccination on reducing antibiotic prescriptions among outpatients with ARI.

METHODS

We enrolled outpatients aged ≥6 months with ARI from 50-60 US clinics during 5 winters (2013-2018) and tested for influenza with RT-PCR; results were unavailable for clinical decision making and clinical influenza testing was infrequent. We collected antibiotic prescriptions and diagnosis codes for ARI syndromes. We calculated vaccine effectiveness (VE) by comparing vaccination odds among influenza-positive cases with test-negative controls. We estimated ARI visits and antibiotic prescriptions averted by influenza vaccination using estimates of VE, coverage, and prevalence of antibiotic prescriptions and influenza.

RESULTS

Among 37 487 ARI outpatients, 9659 (26%) were influenza positive. Overall, 36% of ARI and 26% of influenza-positive patients were prescribed antibiotics. The top 3 prevalent ARI syndromes included: viral upper respiratory tract infection (47%), pharyngitis (18%), and allergy or asthma (11%). Among patients testing positive for influenza, 77% did not receive an ICD-CM diagnostic code for influenza. Overall, VE against influenza-associated ARI was 35% (95% CI, 32-39%). Vaccination prevented 5.6% of all ARI syndromes, ranging from 2.8% (sinusitis) to 11% (clinical influenza). Influenza vaccination averted 1 in 25 (3.8%; 95% CI, 3.6-4.1%) antibiotic prescriptions among ARI outpatients during influenza seasons.

CONCLUSIONS

Vaccination and accurate influenza diagnosis may curb unnecessary antibiotic use and reduce the global threat of antibiotic resistance.

Differences in antibiotic and antiviral use in people with confirmed influenza: a retrospective comparison of rapid influenza PCR and multiplex respiratory virus PCR tests

Background

Influenza is a highly contagious respiratory virus with clinical impacts on patient morbidity, mortality and hospital bed management. The effect of rapid nucleic acid testing (RPCR) in comparison to standard multiplex PCR (MPCR) diagnosis in treatment decisions is unclear. This study aimed to determine whether RPCR influenza testing in comparison to standard MPCR testing was associated with differences in antibiotic and antiviral (oseltamivir) utilisation and hospital length of stay in emergency department and inpatient hospital settings.

Methods

A retrospective cohort study of positive influenza RPCR and MPCR patients was performed utilising data from the 2017 influenza season. Medical records of correlating patient presentations were reviewed for data collection. An analysis of RPCR versus MPCR patient outcomes was performed examining test turnaround time, antibiotic initiation, oseltamivir initiation and hospital length of stay for both emergency department and inpatient hospital stay. Subgroup analysis was performed to assess oseltamivir use in high risk populations for influenza complications. Statistical significance was assessed using Mann-Whitney test for numerical data and Chi-squared test for categorical data. Odds ratio with 95% confidence intervals were calculated where appropriate.

Results

Overall, 122 RPCR and 362 MPCR positive influenza patients were included in this study. Commencement of antibiotics was less frequent in the RPCR than MPCR cohorts (51% vs 67%; p < 0.01, OR 0.52; 95% CI 0.34–0.79). People at high risk of complications from influenza who were tested with the RPCR were more likely to be treated with oseltamivir compared to those tested with the MPCR (76% vs 63%; p = 0.03, OR 1.81; 95% CI 1.07–3.08). Hospital length of stay was not impacted when either test was used in the emergency department and inpatient settings.

Conclusions

These findings suggest utilisation of RPCR testing in influenza management can improve antibiotic stewardship through reduction in antibiotic use and improvement in oseltamivir initiation in those at higher risk of complications. Further research is required to determine other factors that may have influenced hospital length of stay and a cost-benefit analysis should be undertaken to determine the financial impact of the RPCR test.

Point-prevalence survey of outpatient antibiotic prescription at a tertiary medical center in Sri Lanka: opportunities to improve prescribing practices for respiratory illnesses

Background

Inappropriate antibiotic use is linked to the spread of antimicrobial resistance worldwide, but there are limited systemic data on antibiotic utilization in low- and middle-income countries. The purpose of this study was to evaluate the prevalence and patterns of antibiotic prescription in an ambulatory care setting in Sri Lanka.

Methods

This cross-sectional survey was conducted at the Outpatient Department of a public tertiary medical center in Southern Province, Sri Lanka from February to April 2019. Among consecutive outpatients presenting for care, questionnaires were verbally administered to a systematic random sample to capture information about patient demographics, illness characteristics, and visit outcomes. Prescription data were obtained from the outpatient pharmacy’s electronic prescribing system.

Results

Of 409 surveyed patients, 146 (35.7%) were prescribed an antibiotic. The most frequently prescribed agents were amoxicillin (41 patients, 28.1% of antibiotic recipients) and first-generation cephalosporins (38, 26.0%). Respiratory indications were the most common reason for antibiotic use, comprising 69 (47.3%) of all antibiotic prescriptions. Antibiotics were prescribed for 66.1% of patients presenting with cough and 78.8% of those presenting with rhinorrhea or nasal congestion. Among all antibiotic recipients, 6 (4.1%) underwent diagnostic studies.

Conclusions

A high prevalence of antibiotic prescription was observed, in particular for treatment of respiratory conditions. These data support the need for improved antimicrobial stewardship in the Sri Lankan outpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05804-6.

Antibiotics and antimicrobial resistance in the COVID-19 era: Perspective from resource-limited settings

The dissemination of COVID-19 around the globe has been followed by an increased consumption of antibiotics. This is related to the concern for bacterial superinfection in COVID-19 patients. The identification of bacterial pathogens is challenging in low and middle income countries (LMIC), as there are no readily-available and cost-effective clinical or biological markers that can effectively discriminate between bacterial and viral infections. Fortunately, faced with the threat of COVID-19 spread, there has been a growing awareness of the importance of antimicrobial stewardship programs, as well as infection prevention and control measures that could help reduce the microbial load and hence circulation of pathogens, with a reduction in dissemination of antimicrobial resistance. These measures should be improved particularly in developing countries. Studies need to be conducted to evaluate the worldwide evolution of antimicrobial resistance during the COVID-19 pandemic, because pathogens do not respect borders. This issue takes on even greater importance in developing countries, where data on resistance patterns are scarce, conditions for infectious pathogen transmission are optimal, and treatment resources are suboptimal.

Viral Etiology, Clinical Features and Antibiotic Use in Children <5 Years of Age in the Gambia Presenting With Influenza-like Illness

BACKGROUND

Knowledge regarding the prevalence, clinical features and etiology of pediatric influenza-like illness (ILI) remains limited in African settings. Furthermore, it is likely that many children presenting with ILI receive antibiotics unnecessarily. More data are required to develop antimicrobial stewardship practice and guide effective vaccine strategies. We undertook a 1-year prospective study of ILI in the Gambia.

METHODS

Children <5 years of age presenting with ILI from March 2018 to March 2019 were recruited. Clinical and antibiotic prescribing data were collected. Nasopharyngeal swabs were collected and analyzed for 12 respiratory viruses using a multiplex polymerase chain reaction.

RESULTS

From a total of 735 ILI episodes, 530 (72.1%) nasopharyngeal swabs were positive for ≥1 virus. Of these, 36.7% were positive for rhinovirus, 14.7% for respiratory syncytial virus, 8.4% for influenza and 7.2% for human metapneumovirus. Compared with children <6 months of age, influenza was more common in 6- to 23-month-old children [odd ratio (OR): 5.68; 95% confidence interval (CI): 1.72-18.76; P = 0.004]. Respiratory syncytial virus and human metapneumovirus were associated with low peripheral oxygen saturations (OR: 2.13; 95% CI: 1.23-3.69; P = 0.007; and OR: 2.44; 95% CI: 1.13-5.27; P = 0.023, respectively). Antibiotics were prescribed in 78.3% of all ILI cases.

CONCLUSIONS

A broad range of viruses are responsible for pediatric ILI in the Gambia. Refined treatment guidelines, improved diagnostic capacity and vaccines to prevent respiratory viruses will all play a role in reducing antimicrobial use for these cases.

Comparative Severity of Influenza A and B Infections in Hospitalized Children

BACKGROUND

Influenza A viruses are conventionally thought to cause more severe illnesses than B viruses, but few studies with long observation periods have compared the clinical severity of A and B infections in hospitalized children.

METHODS

We analyzed the clinical presentation, outcomes and management of all children <16 years of age admitted to Turku University Hospital, Finland, with virologically confirmed influenza A or B infection during the 14-year period of 1 July 2004 to 30 June 2018. All comparisons between influenza A and B were performed both within predefined age groups (0-2, 3-9 and 10-15 years) and in all age groups combined.

RESULTS

Among 391 children hospitalized with influenza A or B infection, influenza A was diagnosed in 279 (71.4%) and influenza B in 112 (28.6%) children. Overall, there were no significant differences in any clinical features or outcomes, management, treatment at intensive care unit or length of stay between children with influenza A and B, whether analyzed by age group or among all children. As indicators of the most severe clinical presentations, blood cultures were obtained from 101 (36.2%) children with influenza A and 39 (34.8%) with influenza B (P = 0.80), and lumbar puncture was performed to 16 (5.7%) children with influenza A and 11 (9.8%) children with influenza B (P = 0.15).

CONCLUSIONS

The clinical severity of influenza A and B infections is similar in children. For optimal protection against severe influenza illnesses, the use of quadrivalent vaccines containing both lineages of B viruses seems warranted in children.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Antimicrobial resistance in the Pacific Island countries and territories

Antimicrobial resistance (AMR) is a critical global health threat with a disproportionate impact on low-income and middle-income countries (LMICs) due to their higher burden of infections, reduced laboratory surveillance infrastructure and fewer regulations governing antimicrobial use among humans or animals. While there have been increasing descriptions of AMR within many LMICs in WHO's Western Pacific and South East Asian regions, there remains a paucity of data from Pacific Island countries and territories (PICTs). The PICTs represent 22 predominantly middle-income countries and territories with a combined population of 12 million people and 20 official languages, spread over hundreds of separate islands spanning an area corresponding to more than 15% of the earth's surface. Our paper outlines the present state of the evidence regarding AMR in PICTs-discussing the present estimates of AMR and their accompanying limitations, important drivers of AMR, as well as outlining key priorities and potential solutions for tackling AMR in this region. Significant areas for action include developing National Action Plans, strengthening laboratory surveillance systems and educational activities targeted at both healthcare workers and the wider community. Ensuring adequate funding for AMR activities in PICTs is challenging given competing health and environmental priorities, in this context global or regional funding initiatives such as the Fleming Fund can play a key role.

Utility of Rapid Influenza Molecular Testing in an Outpatient Hemodialysis Unit: A Prospective Cohort Study

Background:

Early initiation of antiviral therapy for individuals at risk for severe influenza infection is important for improving patient outcomes. Current guidelines recommend empiric antiviral therapy for patients with end-stage kidney disease presenting with suspected influenza infection. Rapid molecular influenza assays may reduce diagnostic uncertainty and improve patient outcomes by providing faster diagnostics compared to traditional batched polymerase chain reaction (PCR) testing.

Objective:

To determine the utility of implementing a rapid influenza PCR assay compared to the standard of care in a hemodialysis unit.

Design:

This is a prospective cohort study.

Setting:

A hospital-based dialysis unit in a tertiary care hospital.

Patients:

Adult patients with end-stage kidney disease on intermittent hemodialysis.

Measurements:

Patient characteristics, influenza PCR swab results, antibiotic prescriptions, antiviral prescriptions, emergency room visits and hospitalizations.

Methods:

From November 1, 2017 to March 31, 2018, we assigned samples collected from a single center, hemodialysis unit to be processed using a rapid influenza PCR (cobas® Influenza A/B & respiratory syncytial virus assay) or the standard of care (in-house developed multiplex PCR). Samples were assigned to the rapid PCR if the patient received dialysis treatment in the morning dialysis shift, while the remainder were processed as per standard of care. Study outcomes included the time from collection to result of nasopharyngeal swab, prescription of influenza antiviral therapy, time to receiving prescription, and the need for emergency department visit or hospitalization within 2 weeks of presentation.

Results:

During the study period, 44 patients were assessed (14 with the rapid PCR and 30 with the standard of care assay). Compared to conventional testing, the time to result was shorter using rapid PCR compared to conventional testing (2.3 vs 22.6 hours, P < .0001). Individuals who were tested using the rapid PCR had a tendency to shorter time to receiving antiviral prescriptions (0.7 days vs 2.1 days, P = .11), and fewer emergency department visits (7.1% vs 30%, P = .13) but no difference in hospitalizations (14.3% vs 30%, P = .46) within 2 weeks of testing.

Limitations:

This is a single center non-randomized study with a relatively small sample size. Patients who were tested using the standard of care assay experienced a delay in the prescription of antiviral therapy which deviates from recommended clinical practice.

Conclusions:

Rapid influenza molecular testing in the hemodialysis unit was associated with a shorter time to a reportable result and with a tendency to reduced time to prescription of antiviral therapy. Rapid molecular testing should be compared with standard of care (empiric therapy) in terms of economic costs, adverse events, and influenza-related outcomes.

The Importance of Rapid Influenza Testing in Pediatric Primary Care: Experience During Three Consecutive Influenza Seasons (2016-2019) in Barcelona (Catalonia, Spain)

Clinical diagnosis of influenza has low sensitivity in infants and children. Signs and symptoms are non-specific and similar to those of other respiratory viruses. Rapid influenza diagnostic tests (RIDTs) with adequate sensitivity and specificity used at the point of care can be useful for an etiologic diagnosis of influenza in primary care. This should have an impact on better management of these patients. We conducted a study during three consecutive influenza seasons (2016-2017, 2017-2018, and 2018-2019) in pediatric primary care settings collecting data from influenza point-of-care tests (POCTs)-confirmed ≤ 6-year-old patients. During the first two influenza seasons, antibiotic prescriptions and additional visits from influenza POCT-confirmed patients (Group_1) were compared to patients with influenza-like illness (ILI) (Group_2), or fever (2016 ICD-10 code R50) with no other signs of influenza (Group_3). Group_1 had 0.19 (2016-2017) and 0.23 (2017-2018) additional visits compared to 0.48 (2016-2017) and 0.49 (2017-2018) Group_2 p < 0.001 and 1.01 (2016-2017) and 0.80 (2017-2018) Group_3 p < 0.001. Antibiotic prescription was lower in Group_1 (10.2%) vs. Group_3 (17.2%) p < 0.002, difference statistically significant only for the 2017-2018 season. During the third season (2018-2019), RIDTs results were transmitted in real time to the reference laboratory ia the cloud, which strengthens the monitoring of circulating influenza viruses in the community. In our experience, the use of POCTs has a great potential in primary care specially in infants and young children in which the diagnosis maybe missed due to non-specific signs and symptoms.

Paediatric use of antibiotics in children with community acquired pneumonia: A survey from Da Nang, Vietnam

AIM

To characterise paediatricians' antibiotic-prescribing behaviour when managing community acquired pneumonia.

METHODS

We conducted a knowledge and attitudes survey of paediatric doctors practicing at a regional provincial hospital in central Vietnam over a 2-week period (from 12 December 2017 to 29 December 2017).

RESULTS

Of 79 eligible paediatric doctors, 69 (87.3%) completed the questionnaire, of whom 65 (94.2%) thought that antibiotics were overused in Vietnam. Thirty-eight doctors (55.1%) indicated that they routinely hospitalised children with pneumonia to provide intravenous antibiotics. Most doctors reported discharging children with non-severe pneumonia after 5 days (76.9%) and those with severe pneumonia after 7-10 days (88.4%); older doctors generally continued intravenous antibiotics for longer. The two most important factors driving discharge decisions were clinical assessment (95.6%) and completion of the full course of intravenous antibiotics (80.0%). Antibiotic prescription was influenced by local guidelines (62.3%), drugs used before admission (50.0%) and the opinion of senior clinicians (37.7%). Most doctors believed antibiotic stewardship was necessary (98.6%) and that over-the-counter use of antibiotics should be restricted (97.1%).

CONCLUSIONS

Paediatricians recognised an urgent need for more effective regulation and antibiotic stewardship in Vietnam. Routinely completing a full course of intravenous antibiotics leads to unnecessary and prolonged hospitalisation.

Rapid Influenza Testing in Infants and Children Younger than 6 Years in Primary Care: Impact on Antibiotic Treatment and Use of Health Services

Influenza is often misdiagnosed in children because of the low sensitivity of clinical diagnosis because of nonspecific signs and symptoms. This can be overcome by using digital immunoassays or rapid molecular diagnostic tests with adequate sensitivity and specificity. When using these tests at the patient care site, antibiotic consumption and number of healthcare consultations were reduced.

Megatrends in Infectious Diseases: The Next 10 to 15 Years

It has been about 100 years since the Spanish influenza pandemic of 1918-19 that killed an estimated 50 million individuals globally. While we have made remarkable progress in reducing infection-related mortality, infections still account for 13 to 15 million deaths annually. This estimate is projected to remain unchanged until 2050. We have identified 4 megatrends in infectious diseases and these are “emerging and re-emerging infections”, “antimicrobial resistance”, “demographic changes” and “technological advances”. Understanding these trends and challenges should lead to opportunities for the medical community to reshape the future. Further inroads will also require broad approaches involving surveillance, public health and translating scientific discoveries into disease control efforts. Key words: Antimicrobial resistance, Demographic changes, Emerging infections, Technological advances

Use of clinical algorithms and rapid influenza testing to manage influenza-like illness: a cost-effectiveness analysis in Sri Lanka

Background

Acute respiratory infections are a common reason for antibiotic overuse. We previously showed that providing Sri Lankan clinicians with positive rapid influenza test results was associated with a reduction in antibiotic prescriptions. The economic impact of influenza diagnostic strategies is unknown.

Methods

We estimated the incremental cost per antibiotic prescription avoided with three diagnostic strategies versus standard care when managing Sri Lankan outpatients with influenza-like illness (ILI): (1) influenza clinical prediction tool, (2) targeted rapid influenza testing and (3) universal rapid influenza testing. We compared findings with literature-based estimates of the cost of antimicrobial resistance attributable to each antibiotic prescription.

Results

Standard care was less expensive than other strategies across all parameter values in one-way sensitivity analyses. The incremental cost per antibiotic prescription avoided with clinical prediction versus standard care was US$3.0, which was lower than the base-case estimate of the cost of antimicrobial resistance per ILI antibiotic prescription (US$12.5). The incremental cost per antibiotic prescription avoided with targeted testing and universal testing versus standard care were both higher than the base-case cost of antimicrobial resistance per ILI antibiotic prescription: US$49.1 and US$138.3, respectively. To obtain a cost-effectiveness ratio lower than US$12.5 with targeted testing versus standard care, the test price must be <US$2.6. At a higher threshold of US$28.7, the test price must be <US$7.7.

Conclusion

Clinical prediction tools and targeted rapid influenza testing may be cost-saving strategies in Sri Lanka when accounting for the societal cost of antimicrobial resistance.

Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa

These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.

Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

Systematic review of the impact of point-of-care testing for influenza on the outcomes of patients with acute respiratory tract infection

Acute respiratory tract infections are a major cause of morbidity and mortality and represent a significant burden on the health care system. Laboratory testing is required to definitively distinguish infecting influenza virus from other pathogens, resulting in prolonged emergency department (ED) visits and unnecessary antibiotic use. Recently available rapid point-of-care tests (POCT) may allow for appropriate use of antiviral and antibiotic treatments and decrease patient lengths of stay. We undertook a systematic review to assess the effect of POCT for influenza on three outcomes: (1) antiviral prescription, (2) antibiotic prescription, and (3) patient length of stay in the ED. The databases Medline and Embase were searched using MeSH terms and keywords for influenza, POCT, antivirals, antibiotics, and length of stay. Amongst 245 studies screened, 30 were included. The majority of papers reporting on antiviral prescription found that a positive POCT result significantly increased use of antivirals for influenza compared with negative POCT results and standard supportive care. A positive POCT result also led to decreased antibiotic use. The results of studies assessing the effect of POCT on ED length of stay were not definitive. The studies assessed in this systematic review support the use of POCT for diagnosis of influenza in patients suffering an acute respiratory infection. Diagnosis using POCT may lead to more appropriate prescription of treatments for infectious agents. Further studies are needed to assess the effect of POCT on the length of stay in ED.

Epidemiology and molecular characterization of influenza viruses in Burkina Faso, sub-Saharan Africa

Background

The importance of influenza viruses in respiratory infections in sub‐Saharan Africa has been historically overlooked, including in Burkina Faso.

Objectives

This study therefore aimed at evaluating the prevalence and seasonal occurrence of influenza viruses in children under 5 years old, at risk of influenza‐related complications, presenting with influenza‐like illness (ILI) or severe acute respiratory infection (SARI). The study also aimed at identifying the periods with increased influenza transmission for vaccination recommendations in Burkina Faso.

Methods

From January 2014 to December 2015, ILI and SARI (2015 only) patients were recruited in six healthcare centers in Burkina Faso. Influenza A and B molecular detection and subtyping were performed. Clade clustering of a subset of A(H1N1)pdm09 and A(H3N2) strains was deduced by performing phylogenetic analyses on hemagglutinin gene sequences. Weekly surveillance data from FluNet (2011‐2013; 2016) and this study (2014‐2015) were used to identify periods of increased influenza activity.

Results

Influenza A and B viruses were detected in 15.1% (112 of 743) of ILI and 6.6% (12 of 181) of SARI patients. Overall, influenza A viruses were largely predominant (81 of 124, 65.3%), with 69.1% of A(H3N2) and 30.9% of A(H1N1)pdm09 strains. Four waves of increased transmission were identified in 2014‐2015, each dominated by different influenza subtypes and clades. Between 2011 and 2016, periods of increased influenza activity varied in their frequency, duration, and timing.

Conclusion

Influenza A and B viruses were detected in a substantial number of ILI and SARI cases in Burkina Faso. Vaccination in September‐October would likely protect the highest number of patients.

Evaluation of the molecular Xpert Xpress Flu/RSV assay vs. Alere i Influenza A & B assay for rapid detection of influenza viruses

A new FDA-approved Xpert Xpress Flu/RSV assay has been released for rapid influenza virus detection. We collected 134 nasopharyngeal specimens to compare the diagnostic performance of the Xpert assay and the Alere i Influenza A & B assay for influenza A and B virus detection. The Xpert assay demonstrated 100% and 96.3% sensitivity to influenza A and influenza B virus respectively. Its specificity was 100% for both viruses. The Alere i assay demonstrated slightly lower sensitivity but similar specificity to the Xpert Xpress assay. Although the Xpert assay (30 min) required longer processing time than the Alere assay (15 min), the handling procedure of the Alere assay was more complicated than the Xpert assay. As the GenXpert system has higher throughput than the Alere system, it is more suitable for hospital clinical laboratories. Overall, the new Xpert Xpress Flu/RSV assay is a reliable and useful tool for rapid influenza detection.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED

STUDY OBJECTIVE

This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic.

METHODS

Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED.

RESULTS

A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively).

CONCLUSIONS

The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.

Burden and Seasonality of Viral Acute Respiratory Tract Infections among Outpatients in Southern Sri Lanka

In tropical and subtropical settings, the epidemiology of viral acute respiratory tract infections varies widely between countries. We determined the etiology, seasonality, and clinical presentation of viral acute respiratory tract infections among outpatients in southern Sri Lanka. From March 2013 to January 2015, we enrolled outpatients presenting with influenza-like illness (ILI). Nasal/nasopharyngeal samples were tested in duplicate using antigen-based rapid influenza testing and multiplex polymerase chain reaction (PCR) for respiratory viruses. Monthly proportion positive was calculated for each virus. Bivariable and multivariable logistic regression were used to identify associations between sociodemographic/clinical information and viral detection. Of 571 subjects, most (470, 82.3%) were ≥ 5 years of age and 53.1% were male. A respiratory virus was detected by PCR in 63.6% (N = 363). Common viral etiologies included influenza (223, 39%), human enterovirus/rhinovirus (HEV/HRV, 14.5%), respiratory syncytial virus (RSV, 4.2%), and human metapneumovirus (hMPV, 3.9%). Both ILI and influenza showed clear seasonal variation, with peaks from March to June each year. RSV and hMPV activity peaked from May to July, whereas HEV/HRV was seen year-round. Patients with respiratory viruses detected were more likely to report pain with breathing (odds ratio [OR] = 2.60, P = 0.003), anorexia (OR = 2.29, P < 0.001), and fatigue (OR = 2.00, P = 0.002) compared with patients with no respiratory viruses detected. ILI showed clear seasonal variation in southern Sri Lanka, with most activity during March to June; peak activity was largely due to influenza. Targeted infection prevention activities such as influenza vaccination in January-February may have a large public health impact in this region.

Impact of introduction of xpert flu assay for influenza PCR testing on obstetric patients: a quality improvement project

OBJECTIVE

The aim of this project was to assess the implementation of a quality improvement project regarding the introduction of on-site influenza PCR testing in a stand-alone obstetric hospital.

METHODS

As part of a quality improvement project on the management of influenza in obstetric patients, the Xpert Flu assay (Cepheid Inc., Sunnyvale, CA) was introduced on-site and it replaced the previous method of PCR testing which was off-site. The main outcome measures were duration of antimicrobials, rate of admission and administration of oseltamavir in the emergency department.

RESULTS

Twenty-eight patients were included in the pre-intervention period and 45 patients were included in the post-intervention period. Following the introduction of the test, there was a statistically significant reduction seen in commencement of antimicrobials (76% pre- and 33% post-intervention), and also rate of admission (88% pre- and 45% post-intervention) while there was a statistically significant improvement in the commencement of oseltamavir in the emergency department (72% pre-and 95% post-intervention) (p < .01 for all outcomes).

CONCLUSION

Introduction of on-site rapid influenza PCR testing can lead to a significant improvement in patient management and should be considered for introduction to other sites.

Antibiotic overuse for acute respiratory tract infections in Sri Lanka: a qualitative study of outpatients and their physicians

Background

Acute respiratory tract infections (ARTIs) are a common reason for antibiotic overuse worldwide. We previously showed that over 80% of outpatients presenting to a tertiary care hospital in Sri Lanka with influenza-like illness received antibiotic prescriptions, although almost half were later confirmed to have influenza. The purpose of this qualitative study was to assess Sri Lankan patients’ and physicians’ attitudes towards ARTI diagnosis and treatment.

Methods

Semi-structured interviews were conducted with 50 outpatients with ARTIs and five physicians in the Outpatient Department (OPD) at a large, public tertiary care hospital in southern Sri Lanka. Interviews were audio-recorded, transcribed, and analyzed for themes related to ARTI diagnosis and treatment.

Results

Patients frequently sought ARTI care in the public sector due to the receipt of free care and the perception that government hospitals carried a sense of responsibility for patients’ health. Patients reported multiple medical visits for their illnesses of short duration and many indicated that they were seeking care in the OPD while at the hospital for another reason. While patients generally expected to receive medication prescriptions at their visit, most patients were not specifically seeking an antibiotic prescription. However, more than 70% of patients received antibiotic prescriptions at their OPD visit. Physicians incorrectly perceived that patients desired antibiotics or “capsules,” a common formulation of antibiotics dispensed in this outpatient setting, and cited patient demand as an important cause of antibiotic overuse. Physicians also indicated that high patient volume and fear of bacterial superinfection drove antibiotic overuse.

Conclusions

Patients in this study were seeking medication prescriptions for their ARTIs, but physicians incorrectly perceived that antibiotic prescriptions were desired. High patient volume and fear of bacterial superinfection were also important factors in antibiotic overuse. Training of physicians regarding guideline-concordant management and dealing with diagnostic uncertainty, education of patients regarding ARTI etiology and management, and systematic changes in the public outpatient care structure may help decrease unnecessary antibiotic prescriptions for ARTIs in this setting.