Detection of carbapenem resistance genes and cephalosporin, and quinolone resistance genes along with oqxAB gene in Escherichia coli in hospital wastewater: a matter of concern.

AIMS: This study was performed to detect the presence of Escherichia coli resistant to cephalosporins, carbapenems and quinolones in hospital wastewater. METHODS AND RESULTS: Wastewaters from a rural (H1) and an urban (H2) hospital were tested for E. coli resistant to cephalosporins, carbapenem and quinolones. Genes coding for chromosomal and plasmid-mediated resistance and phylogenetic grouping was detected by multiplex polymerase chain reaction (PCR) and for genetic relatedness by rep-PCR. Of 190 (H1 = 94; H2 = 96) E. coli examined, 44% were resistant to both cephalosporins and quinolones and 3% to imipenem. ESBLs were detected phenotypically in 96% of the isolates, the gene blaCTX-M coding for 87% and blaTEM for 63%. Quinolone resistance was due to mutations in gyrA and parC genes in 97% and plasmid-coded aac-(6')-Ib-cr in 89% of isolates. Only in one carbapenem-resistant E. coli, NDM-1 was detected. Nearly 67% of the isolates belonged to phylogenetic group B2. There was no genetic relatedness among the isolates. CONCLUSIONS: Hospital wastewater contains genetically diverse multidrug-resistant E. coli. SIGNIFICANCE AND IMPACT OF THE STUDY: This study stresses the need for efficient water treatment plants in healthcare settings as a public health measure to minimize spread of multidrug-resistant bacteria into the environment.

Use of a pilot drug information centre.

INTRODUCTION: Provision of access to drug information by prescribers and other health care professionals is important in pharmacotherapy. At the time of this study there was very scanty literature in this area from Africa. OBJECTIVE: To assess use of a pilot drug information centre (DIC) which was set up in a department of Pharmacology and Therapeutics in a university teaching hospital in Uganda. METHODS: This was a situational analysis with a prospective study design. The pilot DIC was established and its use over an eleven-month period was assessed. The received queries were evaluated for source of the query, reason for the query and type of query. RESULTS: During the 11 months 297 queries were received, 72.3% of which were from public hospitals. Most were from prescribing doctors (54.2%). Majority were on drug-drug interaction (41.2%), followed by therapy (23.2%). Out of 197 specific drug requests, 65.5% were on antiretroviral. CONCLUSION: We found that healthcare professionals were enthusiastically using the drug information centre. It is, therefore, necessary and feasible to establish a DIC in Uganda that will enable these professionals to readily access drug information.

Health education improves both arthritis-related illness and self-rated health: an intervention study among older people in rural Bangladesh.

OBJECTIVES: To examine changes in self-reported arthritis-related illness and self-rated health as a result of a health education intervention, and the association between self-reported arthritis-related illness and self-rated health. STUDY DESIGN: A quasi-experimental study was conducted in eight randomly selected villages in rural Bangladesh (intervention = 4; control = 4). METHODS: The intervention consisted of home-based physical activities, health advice and aspects of healthcare management over 15 months followed by a 3-month latent period. Data were collected before the intervention and after the latent period. Analyses included 839 participants (≥60 years of age) who participated in both surveys. Participants in the intervention area were further categorized into two groups who self-reported compliance or non-compliance with recommended health advice. Self-rated health was assessed using a single global question. Self-reported arthritis-related illness was indicated by the presence of arthritis, back and joint pain, biting sensation, swelling and inflammation in the joints. RESULTS: Hierarchical logistic regression analyses revealed that positive effects on episodes of arthritis-related illness [odds ratio (OR) 1.9, 95% confidence interval (CI) 1.3-2.8] and self-rated health (OR 1.4, 95% CI 1.0-1.9) were more likely among the compliant group compared with the control group. Furthermore, positive self-rated health was more likely among participants reporting a positive change in their arthritis-related illness (OR 2.2, 95% CI 1.5-3.2). The results also showed that literate and non-poor participants were more likely to report positive health, and participants with advancing age were less likely to report positive health. CONCLUSION: Community-based health education is effective in reducing the burden of arthritis-related illness and in enhancing general health in old age.

Perceptions among Swedish hospital physicians on prescribing of antibiotics and antibiotic resistance.

OBJECTIVE: To explore and describe perceptions of antibiotic prescribing among Swedish hospital physicians, with special reference to whether the perceptions included awareness of antibiotic resistance (AR). DESIGN: A phenomenographic approach was used and data were collected in face-to-face interviews. SETTING: Hospitals in seven different counties in central Sweden. PARTICIPANTS: A strategic sample of 20 hospital physicians specialising in internal medicine, surgery or urology. MAIN OUTCOME: The variation of perceptions of antibiotic prescribing. RESULTS: Five qualitative different perceptions were found. AR was considered in two of the perceptions. Reasons for not considering AR included a dominating focus on the care of the patient combined with lack of focus on restrictive antibiotic use, or uncertainty about how to manage infectious diseases or the pressure from the healthcare organisation. Parallels between the five perceptions and the stages in the transtheoretical model of health behaviour change were seen. CONCLUSIONS: In three of the perceptions, AR was not considered when antibiotics were prescribed. Physicians who primarily express these three perceptions do not seem to be prepared to change to restrictive prescribing. Our findings can be useful in designing activities that encourage AR prevention. Organisational changes are also needed.

The impact of health education in managing self-reported arthritis-related illness among elderly persons in rural Bangladesh.

This study examines the impact of health education on prevalence of and expenditure on treatment of self-reported arthritis-related illness among elderly persons in rural Bangladesh. An intervention study was conducted, including 1135 elderly persons (>or=60 years) from eight randomly selected villages, four each of an intervention and a control area. The analyses include 839 elderly persons who participated in both pre- and post-intervention surveys (intervention area: n = 425, control area: n = 414). Participants of the intervention area were further categorized as compliant (n = 315) and non-compliant (n = 110) based on adherence to the intervention instructions. The intervention that lasted for 15 months comprised home-based physical exercise, dietary instructions and other aspects of management. Results show that although there was no significant difference in self-reported arthritis-related illness between the compliant and non-compliant groups at baseline, it was significantly lower in the compliant group (71%) at post-intervention compared with the non-compliant (81%). Related monthly expenditure on treatment was significantly reduced in the compliant group (from Taka 104 to Taka 52) but not in the other two groups. Logistic regressions further showed that the control group had a higher probability of increased treatment-related expenditure compared with the compliant group (OR 2.0, 95% CI 1.4-2.8).

Antimicrobial self medication for reproductive tract infections in two provinces in Lao People's Democratic Republic.

OBJECTIVES: To describe antimicrobial self medication for reproductive tract infections (RTI) including sexually transmitted infections (STI), and to explore the understanding and use of health information among the adult population self medicating with antimicrobials for RTI/STI in two provinces of Laos. This could contribute to quality improvement of RTI/STI management. METHODS: Cross sectional community based study. Structured interviews (household survey) were conducted among 500 subjects aged 18 or more, who had used antimicrobials as self medication for RTI/STI during the past year. They were recruited among 3056 family members in Vientiane capital and Champasak province, divided equally between the two study sites, and between urban and rural areas. RESULTS: Among the 500 respondents reporting self medication for RTI/STI, 91% had bought the antimicrobials from local private pharmacies without a physician's prescription. 58% of those were advised to buy the drugs from drug sellers. Ampicillin (not recommended as syndromic treatment for RTI/STI) was used in 83% of all cases, in 28% combined with tetracycline. 79% of respondents used antimicrobials for a non-recommended duration of time. Most respondents had access to health messages for RTI/STI, largely from radio/television and drug sellers. However, only 17% of all respondents reported that they had ever used a condom. CONCLUSIONS: More than three quarters of respondents, self medicating for RTI/STI with antimicrobials, used inappropriate drugs bought from private pharmacies. There is a need to improve RTI/STI management, including health promotion, through interventions at community level, and to health providers, including private drug sellers.

Variations in general practitioners' views of asthma management in four European countries.

The aim was to identify differences and similarities in views regarding asthma management among general practitioners in four European countries (Germany, Netherlands, Norway and Sweden), and to explore reasons for suboptimal performance. The results are to be used for the development and tailoring of educational interventions. Semistructured interviews with 20 GPs in each country were conducted and analysed using a phenomenographic approach. The domains of (i) general view of asthma, (ii) the doctor-patient relationship in managing asthma, and (iii) overall management of asthma (treatment goals and evaluation of results) were approached during the interviews. There were different ways of experiencing phenomena related to asthma management both within and between the four countries. Three general views on asthma were found where different perspectives were emphasised: a medical, a 'global' (including community health, social and environmental aspects) and a patient's perspective. Within the medical perspective, only a few German doctors emphasised a psychological aetiology of asthma. The views on the doctor-patient relationship described as 'authoritarian', 'teaching' or 'empowering' occurred similarly in all countries. The majority of the doctors showed confidence in the effectiveness of the pharmaceutical treatment of asthma, some doctors were concerned about limitations, but only in Germany a few doctors were explicitly critical of the values of conventional pharmaceutical treatment. The main treatment goals were either conceived as getting the patient symptom-free (Netherlands, Norway, and Germany) or to control the inflammatory process (Sweden). Several German and some Norwegian doctors expressed the view that patients had to accept the disease and learn how to manage it, while a few German doctors aimed at alternative treatments of asthma. The existence of qualitatively different ways of experiencing asthma management, both in and between countries, calls for consideration when trying to implement general evidence-based treatment guidelines. A variation of approaches in continuing medical education for GPs is needed to address such existing beliefs and conceptions that could sometimes be opposed to the content of educational messages.

Private pharmacy practice and regulation. A randomized trial in Lao P.D.R.

OBJECTIVES: The objective of this study was to assess the effectiveness of government regulation of private pharmacy practice in a low-income country. METHODS: The intervention comprised inspections of the pharmacies, information, and distribution of documents to drug sellers and sanctions. It was implemented at two different intensity levels, active and regular intervention. The methods used to assess the effect of the interventions were interviews with the district drug inspectors, drug sellers and customers, inspection of drug purchases, and indicator surveys of pharmacies. Indicators for pharmacy-specific quality as well as for dispensing quality were developed. RESULTS: The main finding was one of strong overall improvements from initially low levels. The improvements were particularly marked by increases in the availability of essential materials for dispensing by 34% and in order in the pharmacy by 19%. Information given to customers increased from 35% to 51% and the mixing of different drugs in the same package went down from 17% to 9%. The pharmacies in the active intervention districts showed greater improvements for four of the six indicators, although statistically significant compared with the regular intervention districts only for the essential materials indicator. CONCLUSIONS: It was concluded that the regulatory activities have probably been an important factor behind the service quality improvements. It appeared feasible as well as effective to regulate private pharmacy practice in this particular low-income setting.

Treatment of uncomplicated urinary tract infections: exploring differences in adherence to guidelines between three European countries. Drug Education Project Group.

OBJECTIVE: To evaluate adherence of general practitioners to treatment guidelines regarding urinary tract infections in three European countries and to investigate whether differences in adherence at the prescribing level within and between countries could be explained by general practitioners' knowledge and attitudes, characteristics, or national setting. DESIGN: Prescribing data collected in 1994-1995 were analyzed regarding use of first-choice drugs and duration of treatment, knowledge and attitudes were assessed with a questionnaire, and multiple regression analysis was used to explain differences in prescribing behavior within and between countries. RESULTS: Our study is based on data from 85.6% of the 584 general practitioners who were scheduled to participate in a continuing education program. The mean proportion of responses in agreement with the guidelines regarding first-choice drugs was 0.69 in Sweden, 0.78 in the Netherlands, and 0.79 in Norway; regarding duration of treatment, the mean proportion was 0.56 in Sweden, 0.67 in the Netherlands, and 0.59 in Norway. The proportion of first-choice drugs prescribed for women (18-75 y) was 0.55 in Sweden, 0.83 in the Netherlands, and 1.00 in Norway (patients >16 y). The duration of treatment was 7.6 defined daily doses per prescription in Sweden, 5.9 in the Netherlands, and 6.6 in Norway. Knowledge and attitudes explained 0-17% of the variation in prescribing. Years in practice explained 0-11%, and the general practitioners' gender had no explanatory value. The national setting explained most of the variation between countries. CONCLUSIONS: Differences in prescribing behavior can be explained only to a small extent by deviations from the guidelines in terms of knowledge and attitudes. Between countries, differences in regulation, marketing, and distribution of drugs seem to be of much greater importance.

Influencing prescribing for urinary tract infection and asthma in primary care in Sweden: a randomized controlled trial of an interactive educational intervention.

Our aim was to evaluate effects on prescribing for urinary tract infection (UTI) and asthma, of an education with messages based on national guidelines, aimed at improving prescribing in primary care in Sweden. The study is part of the European Drug Education Project. A randomized controlled trial, with groups of general practitioners (GPs) allocated to education on UTI (18 groups, 104 GPs) or asthma (18 groups, 100 GPs), the two parallel intervention arms being controls for each other. Feedback was provided on the GP's judgments of simulated cases and prescribing. Prescribing indicators were developed and measured before and after the intervention. Analysis was performed by multi-level technique. Prescribing of first choice UTI drugs increased in the intervention arm from 52% to 70% and remained constant in the control arm (P < 0.001). The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms. The educational model can be used to improve prescribing. Further studies are needed to define when the model is effective.

Combining feedback from simulated cases and prescribing. Design and implementation of an educational intervention in primary care in Sweden.

OBJECTIVES: To develop and evaluate a new model of continuing medical education (CME) for general practitioners (GPs). The study is part of the joint European Drug Education Project (DEP). This paper presents the Swedish part regarding the design of the evaluation study, the educational methodology, and the participants' evaluation. METHODS: An educational model was developed. Two peer group discussions (facilitated by a GP/pharmacist team), including individual feedback on the GPs' judgments of written simulated cases and prescribing, were main components. The model was tested in a parallel randomized controlled study including 36 GP groups, allocated to education on asthma or urinary tract infections. Background and outcome data were knowledge and attitudes (K/A) assessed by a questionnaire and prescribing practices for actual and written simulated cases. The GPs' evaluation of the model was captured through a questionnaire. RESULTS: All 36 groups completed the program. The mean participation rate in the group discussions was 75%. The response rates were 82-98% regarding outcome data K/A questionnaire and written cases), and 80% regarding the evaluation questionnaire. Prescribing data were captured for 99% of the GPs. Both group discussions were considered important by 84-89%. Eighty-seven percent wished to take part in similar CME activities for other conditions. About 80% reported that their purpose in participating had been fulfilled. CONCLUSIONS: It was feasible to evaluate the developed educational model by using a two-armed parallel study design. The model was well received by the participants.

Ways of experiencing asthma management. Variations among general practitioners in Sweden.

OBJECTIVE: To identify and describe variations in ways of experiencing asthma management among general practitioners (GPs) in Sweden. DESIGN: Descriptive and explorative study using a phenomenographic approach. Semi-structured tape-recorded face-to-face interviews, focusing on the GP's own experiences regarding asthma management. SETTING: Primary health care. SUBJECTS: Twenty GPs (12 men, eight women) from 16 health centres in seven counties in central Sweden, 15 from rural areas and small cities and five from medium sized cities or Stockholm suburbs. MAIN OUTCOME MEASURES: Descriptions of ways of experiencing asthma management. RESULTS: Four categories were identified, which described qualitatively different ways of experiencing asthma management: A. The GP focuses on transferring factual knowledge to the patient; B. The GP primarily addresses the patients' application of knowledge in management of the disease; C. The GP aims at improving the patients' understanding of the disease and its management as a prerequisite for self-management; D. The GP concentrates on how to maintain/improve the patient's quality of life despite the asthma disease. CONCLUSION: The GPs describe their ways of experiencing asthma management in qualitatively different ways, likely to have implications for patient care and educational programmes on asthma for GPs.

"Academic drug-detailing": from project to practice in a Swedish urban area.

OBJECTIVES: To develop and test the long-term feasibility of an interdisciplinary independent drug information service providing both written and oral drug information to physicians in an urban area of Sweden (> 400,000 inhabitants). METHODS: A drug information service was developed encouraging a cooperative approach between a department of clinical pharmacology, general practitioners (GPs), pharmacists, and Drug and Therapeutic Committees. Scientifically-based drug information was condensed and interpreted by a team and presented in both written and oral form. In one part of the area, both oral and written information was provided, while in another part of the area, only written information was distributed. Questionnaires and one prescription survey were performed to elucidate the knowledge and attitudes of the GPs regarding drug treatment of one condition (urinary tract infection, UTI, and norfloxacin were used as examples), as well as their opinion of our services. RESULTS: Over a period of 10 years, 75 issues of a drug bulletin (2000 copies) were distributed. Oral producer-independent drug information, provided jointly by a GP and a pharmacist, was given on 16 occasions in each of 30 health centres (150 GPs). Around 80% of the GPs participated in the meetings. Of these GPs, 75% found the service important for their daily work. A majority of the GPs had prescribed the test drug, norfloxacin, not a first-line drug according to local recommendations, 1 year after approval. A significantly lower proportion of prescribers were observed in the area where the GPs had been provided with both written and oral information regarding recommended treatment (including first-line drugs) for uncomplicated cystitis. The approximate cost for this service in 1995 was SEK 0.685 million (USD 0.1 million); the prescribing costs of the 150 GPs were estimated at SEK 255 million per year. This means that the cost of the service per GP is only around 0.3% of normal prescribing costs. CONCLUSION: Over a period of 10 years the information/education method described here has proven sustainable and feasible in terms of providing the information, regarding participation of the target group GPs in the oral sessions, and regarding integration of the service into the existing health care system.

Advertisements for medicines in leading medical journals in 18 countries: a 12-month survey of information content and standards.

The information content of 6,710 advertisements for medicines in medical journals was surveyed to provide a baseline for monitoring the effect of WHO's Ethical Criteria for Medicinal Drug Promotion. The advertisements (ads) appeared during 12 months (1987-1988) in 23 leading national medical journals in 18 countries. Local participants, mostly doctors or pharmacists, examined them. The presence or absence in each ad of important information was noted. In most ads the generic name appeared in smaller type than the brand name. Indications were mentioned more often than the negative effects of medicines. The ads gave less pharmacological than medical information. However, important warnings and precautions were missing in half, and side effects and contraindications in about 40 percent. Prices tended to be given only in countries where a social security system pays for the medicines. The information content of ads in the developing countries differed surprisingly little from that in the industrialized countries. Almost all the ads (96 percent) included one or more pictures; 58 percent of these were considered irrelevant. The authors believe it is a mistake to regard ads as trivial. If they are not considered seriously they will influence the use of medicines as they are intended to do, but read critically they can provide useful information.