Rainbows over the world's public health: determinants of health models in the past, present, and future.

The need to visualise the complexity of the determinants of population health and their interactions inspired the development of the rainbow model. In this commentary we chronicle how variations of this model have emerged, including the initial models of Haglund and Svanström (1982), Dahlgren and Whitehead (1991), and the Östgöta model (2014), and we illustrate how these models have been influential in both public health and beyond. All these models have strong Nordic connections and are thus an important Nordic contribution to public health. Further, these models have underpinned and facilitated other examples of Nordic leadership in public health, including practical efforts to address health inequalities and design new health policy approaches.Apart from documenting the emergence of rainbow models and their wide range of contemporary uses, we examine a range of criticisms levelled at these models - including limitations in methodological development and in scope. We propose the time is ripe for an updated generic determinants of health model, one that elucidates and preserves the core value in older models, while recognising the developments that have occurred over the past decades in our understanding of the determinants of health. We conclude with an example of a generic model that fulfills the general purposes of a determinants of health model while maintaining the necessary scope for further adjustments to be made in the future, as well as adjustments to location or context-specific purposes, in education, research, health promotion and beyond.

An international inventory of antimicrobial stewardship (AMS) training programmes for AMS teams.

BACKGROUND: Healthcare professionals are increasingly expected to lead antimicrobial stewardship (AMS) initiatives. This role in complex healthcare environments requires specialized training. OBJECTIVES: Little is known about the types of AMS training programmes available to clinicians seeking to play a lead role in AMS. We aimed to identify clinicians' awareness of AMS training programmes, characteristics of AMS training programmes available and potential barriers to participation. METHODS: AMS training programmes available were identified by members of the ESCMID Study Group for Antimicrobial Stewardship (ESGAP) via an online survey and through an online search in 2018. Individual training programme course coordinators were then contacted (September-October 2018) for data on the target audience(s), methods of delivery, intended outcomes and potential barriers to accessing the training programme. RESULTS: A total of 166/250 ESGAP members (66%) responded to the survey, nominating 48 unique AMS training programmes. An additional 32 training programmes were identified through an online search. AMS training programmes were from around the world. Less than half (44.4%) of respondents were aware of one or more AMS training programmes available, with pharmacists more aware compared with medical doctors and other professionals (73% versus 46% and 25%, respectively). AMS training programmes were most commonly delivered online (59%) and aimed at medical doctors (46%). Training costs and a lack of recognition by health professional societies were the most frequently cited barriers to participation in AMS training programmes. CONCLUSIONS: The development of a systematic inventory of AMS training programmes around the globe identifies opportunities and limitations to current training available. Improving access and increasing awareness amongst target participants will support improved education in AMS.

Preparedness to prescribe antibiotics responsibly: a comparison between final year medical students in France and Sweden.

Students should graduate from medical school feeling prepared to prescribe antibiotics responsibly. We assessed self-reported preparedness among students at medical schools in Europe, and we focus here on the results from students in Sweden and France, countries with wide differences in the intensity of antibiotic consumption and burden of antibiotic resistance. We conducted a cross-sectional web-based survey in 2015, based on a comprehensive set of topics related to prudent antibiotic use. All final year students at a medical school in France or Sweden were eligible to participate. Preparedness scores were calculated for each student, and mean scores were compared at medical school and country levels. Comparisons were also made on availability of teaching methods. We received responses from 2085/7653 (response rate 27.2%) students from 31/34 eligible medical schools in France and 302/1124 (26.9%) students from 7/7 schools in Sweden. The relative ranking order of curriculum topics by preparedness level was consistent between countries, but students in Sweden had higher self-reported levels of preparedness in 21/27 topics. There was higher availability for eight of nine teaching methods at Swedish medical schools. Students in France were more likely to report a need for further education on antibiotic use (63.5% vs. 20.3%, p < 0.001). Final year students in France report lower levels of preparedness, less availability of teaching methods and higher needs for more education on antibiotic use. Furthermore, we have identified specific areas for improvement in education on prudent antibiotic use in both Sweden and France.

Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey.

PURPOSE: Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising. METHODS: We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks. RESULTS: Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices. CONCLUSION: Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.

Defensive medicine among antibiotic stewards: the international ESCMID AntibioLegalMap survey.

Objectives: To investigate fear of legal claims and defensive behaviours among specialists in infectious diseases (ID) and clinical microbiology (CM) and to identify associated demographic and professional characteristics. Methods: AntibioLegalMap was an international cross-sectional internet-based survey targeting specialists in ID and CM. Three variables were explored: fear of legal liability in antibiotic prescribing/advising on antibiotic prescription; defensive behaviours in antibiotic prescribing; and defensive behaviours in advising. A multivariable logistic regression analysis was performed to identify factors significantly associated with each of the three variables. Results: Eight hundred and thirty individuals from 74 countries participated. Only 0.4% (3/779) had any kind of condemnation for malpractice related to antibiotic prescription. Concerning the fear of liability, 21.2% (164/774) of respondents said they never worried, 45.1% (349/774) sometimes worried and 28.6% (221/774) frequently worried when prescribing/advising on antibiotic prescription. Being female, younger than or equal to 35 years and aware of previous cases of litigation were independently associated with fear. Most respondents (85.0%, 525/618) reported some defensive behaviour in antibiotic prescribing. These behaviours were independently associated with being younger than or equal to 35 years and sometimes or often worried about liability. Similarly, 76.4% (505/661) reported defensive behaviours in advising. These behaviours were associated with being sometimes or often worried about liability. The preferred measures to reduce fear and defensive behaviours were having local guidelines and sharing decisions through teamwork. Conclusions: A significant proportion of specialists in ID and CM reported some form of defensive behaviour in prescribing or advising to prescribe antibiotics. Defensive medicine should be considered when implementing antibiotic stewardship programmes.

Do medical students feel prepared to prescribe antibiotics responsibly? Results from a cross-sectional survey in 29 European countries.

Background: In an era of antibiotic resistance, medical students must be prepared to prescribe antibiotics responsibly. Objectives: To assess self-reported preparedness among final-year medical students at European universities, using a comprehensive set of topics related to prudent antibiotic use. Methods: We conducted a cross-sectional, multicentre, web-based survey. All medical-degree students in their final year of studies at European universities were eligible to participate. A preparedness score was calculated for each student and mean scores were compared at medical school and country levels. Comparisons were made with national-level data on resistance among four common bacterial pathogens. Results: In total, 7328 responses were included from 179/296 eligible medical schools in 29/29 countries. Students felt at least sufficiently prepared on a mean of 71.2% of topics assessed, ranging from 54.8% (Portugal) to 84.8% (Latvia). The proportion of students wanting more education on prudent antibiotic use or general antibiotic use ranged from 20.3% (Sweden) to 94.3% (Slovakia), with a mean of 66.1%, and was strongly inversely correlated with preparedness scores (Spearman's ρ = -0.72, n = 29, P < 0.001). Higher prevalence rates of antibiotic-non-susceptible bacteria were associated with lower preparedness scores and higher self-reported needs for further education (P < 0.01). Conclusions: Most final-year European medical students feel they still need more education on antibiotic use for their future practice as junior doctors. Patterns of preparedness on specific topics were identified, were highly consistent across countries, and correlated with both perceived need for further education and levels of antibiotic resistance among common bacteria.

Antibiotic use in people and pigs: a One Health survey of rural residents' knowledge, attitudes and practices in Shandong province, China.

Objectives: To evaluate rural residents' knowledge, attitudes and practices (KAP) towards antibiotic use in humans and pigs, among individuals with and without backyard pig farms living in Shandong province, China. Methods: We conducted a cross-sectional questionnaire study among residents in 12 villages, and directly observed medicines stored in households for humans and pigs. Results: In total, 769 residents participated, including 330 backyard pig farmers. Respondents had low levels of knowledge about antibiotics. A quarter of participants had bought one or more antibiotics from a pharmacy without a prescription in the previous year, and this was more common among pig farmers who had bought antibiotics for their pigs without consulting a vet (49% versus 25%, P < 0.001). Stored antibiotics for human use were found in 42% of households, and 70% of participants from these households did not know they were storing antibiotics. Thirty-one percent of backyard pig farmers were storing antibiotics for pig use. Farmers who thought it was good to store leftover antibiotics for their pigs were more likely to have stored antibiotics for pigs (41% versus 20%) and for humans (47% versus 32%; both P < 0.01). A fifth of participants thought their own actions were important for controlling antibiotic resistance. Conclusions: We found differences in the KAP of backyard pig farmers and non-pig farmers to antibiotics, and parallels between pig farmers' attitudes and behaviours towards antibiotic use in pigs and in humans. Our findings reinforce the need for context-adapted multifaceted interventions to improve antibiotic use and provide suggestions for targeting educational approaches.

Are infection specialists recommending short antibiotic treatment durations? An ESCMID international cross-sectional survey.

Objectives: To evaluate the current practice and the willingness to shorten the duration of antibiotic therapy among infection specialists. Methods: Infection specialists giving at least weekly advice on antibiotic prescriptions were invited to participate in an online cross-sectional survey between September and December 2016. The questionnaire included 15 clinical vignettes corresponding to common clinical cases with favourable outcomes; part A asked about the antibiotic treatment duration they would usually advise to prescribers and part B asked about the shortest duration they were willing to recommend. Results: We included 866 participants, mostly clinical microbiologists (22.8%, 197/863) or infectious diseases specialists (58.7%, 507/863), members of an antibiotic stewardship team in 73% (624/854) of the cases, coming from 58 countries on all continents. Thirty-six percent of participants (271/749) already advised short durations of antibiotic therapy (compared with the literature) to prescribers for more than half of the vignettes and 47% (312/662) chose shorter durations in part B compared with part A for more than half of the vignettes. Twenty-two percent (192/861) of the participants declared that their regional/national guidelines expressed durations of antibiotic therapy for a specific clinical situation as a fixed duration as opposed to a range and in the multivariable analysis this was associated with respondents advising short durations for more than half of the vignettes (adjusted OR 1.5, P = 0.02). Conclusions: The majority of infection specialists currently do not advise the shortest possible duration of antibiotic therapy to prescribers. Promoting short durations among these experts is urgently needed.

Trends and patterns of antibiotic consumption in Shanghai municipality, China: a 6 year surveillance with sales records, 2009-14.

OBJECTIVES: The objective of this study was to identify the trends and patterns of total antibiotic use in Shanghai from 2009 to 2014. METHODS: Sales records were collected from a minimum of 160 hospitals and 241 primary healthcare settings and used as a proxy for consumption. Antibiotic sales expressed in DDD per 1000 inhabitants per day (DID) were calculated. We compared patterns of antibiotic use in the Shanghai municipality, populated by 24 million inhabitants, with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC). RESULTS: Total antibiotic use was highest at 25.9 DID in 2010, fell to 17.8 DID in 2012 and remained stable thereafter. The majority of this reduction occurred over 6 months in 2011. In 2014, two-thirds of the antibiotic sales were to hospitals (serving both inpatients and outpatients) and one-third to primary healthcare institutions. Cephalosporins accounted for 50.2% of total DID, followed by macrolides (18.2%), quinolones (16.0%) and penicillins (7.3%). A fifth of all antibiotics were used in parenteral form. CONCLUSIONS: We have successfully used aggregated sales data to monitor antibiotic usage across a large urban population over a 6 year period. A rapid, substantial and sustained reduction in antibiotic usage across the entire health system occurred. This coincided with several interventions across hierarchies in the health sector, including a national campaign. The patterns of antibiotic use indicate persistent preferences for cephalosporins, macrolides, quinolones and parenteral preparations. Further efforts are needed to investigate and improve the quality of antibiotic use.

Antibiotic use in rural China: a cross-sectional survey of knowledge, attitudes and self-reported practices among caregivers in Shandong province.

BACKGROUND: To improve antibiotic use globally, we must deepen our understanding of the public's knowledge, attitudes and practices (KAP) concerning antibiotics. Children are frequent users of antibiotics, and their caregivers play important roles in determining how antibiotics are used. The purpose of this study was to describe caregivers' KAP in a rural province in eastern China, and to identify socio-demographic factors associated with inappropriate antibiotic use. METHODS: A cross-sectional questionnaire based survey was conducted in 12 villages in one county in Shandong Province. A total of 727 individuals who were the primary day-to-day caregiver for a child aged 0-7 years were randomly selected and invited to participate. All caregivers were surveyed face-to-face using a semi-structured questionnaire focusing on the use of antibiotics in children. RESULTS: Almost all invited caregivers (99.3 %) completed the questionnaire in full. Caregivers expressed high levels of over-expectation for antibiotics for common childhood symptoms, stating that antibiotics were always or usually necessary when a child has a fever (46 %) or dry cough (42 %). Most caregivers (93 %) were aware that they should follow the doctor's advice when giving their children antibiotics. Many, however, reported that they had previously deviated from advice; this was most commonly through using antibiotics intermittently rather than regularly, but also by increasing and decreasing doses. Caregivers that were older and that had less formal education had higher levels of self-reported adherence (p < 0.01). A third of caregivers admitted to storing leftover antibiotics at home, and almost all of these caregivers (97 %) had used the antibiotics on a second occasion for their child. CONCLUSION: We have identified important gaps in knowledge, attitudes and practices concerning antibiotics among this rural population of caregivers. There is a clear need for multifaceted interventions that target village doctors, to improve prescribing and communication, as well as the general public, to improve health-seeking behaviours and promote responsible individual use of antibiotics.

European medical students: a first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance.

OBJECTIVES: To learn about medical students' knowledge of and perspectives on antibiotic prescribing and resistance, with the aim of helping to develop educational programmes. METHODS: Final-year students at seven European medical schools were invited to participate in an online survey in 2012. RESULTS: The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality). CONCLUSIONS: Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.

What makes people talk about antibiotics on social media? A retrospective analysis of Twitter use.

OBJECTIVES: Social media has reshaped individual and institutional communication. The unrestricted access to spontaneous views and opinions of society can enrich the evaluation of healthcare interventions. Antimicrobial resistance has been identified as a global threat to health requiring collaboration between clinicians and healthcare users. We sought to explore events and individuals influencing the discourse about antibiotics on Twitter. METHODS: A web-based tool (www.topsy.com) was used to detect daily occurrences of the word 'antibiotic' from 24 September 2012 to 23 September 2013 in worldwide Tweets. Activity peaks (message frequency over three times that of baseline) were analysed to identify events leading to the increase. RESULTS: Of 135 billion messages posted during the study period, 243000 (0.000002%) referred to 'antibiotic'. The greatest activity increases appeared after: (i) the UK Chief Medical Officer's (CMO's) declaration of antimicrobial resistance as a national risk (January 2013 and March 2013); (ii) the release of the US CDC's report on antimicrobial resistance (September 2013); and (iii) the US FDA announcement on azithromycin safety concerns (March 2013). The CMO report in March reached an estimated worldwide audience of 20 million users in a single day. However, the frequency of antibiotic Tweets returned to basal levels within 48 h of all four peaks in activity. CONCLUSIONS: Institutional events can rapidly amplify antibiotic discussions on social media, but their short lifespan may hinder their public impact. Multipronged strategies may be required to prolong responses. Developing methods to refine social media monitoring to evaluate the impact and sustainability of societal engagement in the antimicrobial resistance agenda remains essential.

2015 versus 2021: Self-Reported Preparedness to Prescribe Antibiotics Prudently among Final Year Medical Students in Sweden.

Cross-sectional surveys have found variations in how prepared medical students feel to prescribe antibiotics responsibly, but insights are lacking on the stability of these outcomes. In a 2015 survey, final-year Swedish medical students reported very high preparedness levels across a comprehensive range of relevant curriculum topics. We repeated this survey in 2021 to assess the stability of previous findings and to capture the potential impacts of the COVID-19 pandemic. Final-year students in 2015 and 2021 at all seven Swedish medical schools were eligible to participate in an online survey covering curricula topics, teaching methods and COVID-19 impacts (2021). Eligible students received email invitations and reminders from local coordinators. Students from six of seven medical schools participated in both surveys, with response rates of 24.1% (309/1281) in 2021 and 21.3% (239/1124) in 2015. The average global preparedness was 77.0% and 83.2%, respectively (p < 0.001), with lower preparedness levels in 24/27 curriculum topics in 2021. Students at certain universities reported COVID-19 impacts on antibiotic prescribing education (format, duration and perceived quality). Self-reported preparedness levels have fallen slightly but remain high compared with 2015 levels in other European countries. Students consistently reported lower preparedness in specific topics; improvement efforts should consider focusing on these areas, particularly in the context of the ongoing implementation of programmes leading to a full licence upon graduation.

Antimicrobial resistance in China across human, animal, and environment sectors - a review of policy documents using a governance framework.

Antimicrobial resistance (AMR) poses a multifaceted threat to the human, animal, and environment sectors. In response, China has formulated a series of policies since the 2000s. Thus far, there has been no comprehensive assessment of these policy documents. This study aims to review the content of AMR policy documents at the national level using a governance framework covering three areas: Policy Design; Implementation Tools; and Monitoring and Evaluation. We identified 44 AMR documents from 2003 to 2022 sourced from government agency websites. Our findings have revealed noticeable discrepancies across the three governance areas. The Policy Design and Monitoring and Evaluation areas should be strengthened, particularly in the domains of 'Coordination', 'Accountability', 'Sustainability', and 'Effectiveness'. From a 'One Health' perspective, the environment sector has received less attention compared to the human and animal sectors. Effectively addressing these challenges requires a stronger commitment and widespread support from diverse stakeholders.

Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China.

OBJECTIVE: This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China. METHODS: Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi's method were used to generate qualitative codes and identify themes. RESULTS: Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications. CONCLUSION: Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.

Antimicrobial Prescribing Preparedness of Croatian Medical Students-Did It Change between 2015 and 2019?

BACKGROUND: Antimicrobials are some of the most prescribed drugs by junior doctors, but studies suggest most medical graduates feel unprepared for their future prescribing tasks. The aim of the present study was to compare the self-reported preparedness to prudently prescribe antimicrobials of final-year medical students in Croatia in 2015 and 2019. METHODS: The same self-reported web-based survey on the preparedness to prescribe antibiotics was used in both 2015 and 2019. All final-year students at all four medical schools in Croatia (Osijek, Rijeka, Split, and Zagreb) were invited to participate in both 2015 and 2019. Preparedness scores were divided into "topic preparedness scores" and "global preparedness scores". Topic preparedness scores represented the percentage of students at a medical school who felt sufficiently prepared for each topic. They were first established at a medical school level and then at the national level. Global preparedness scores were determined for each student separately and then calculated at the medical school and national levels. RESULTS: The country's global preparedness score, representing the average proportion of topics in which students felt sufficiently prepared, was slightly higher in 2015 compared with the 2019 results (62.7% vs. 56.5%; p = 0.191). Croatian students reported higher preparedness in 2015 than in 2019 for 25 out of 27 topics included in the survey. The majority of students reported a need for more education on antibiotic use both in 2015 and 2019 (78.0% vs. 83.0%; p = 0.199). CONCLUSIONS: Despite increasing antimicrobial stewardship activities in various healthcare settings, medical students who are about to start prescribing antibiotics on their own do not feel sufficiently prepared to do so. Antimicrobial stewardship programs should be designed to incorporate undergraduate medical student education, for instance, as a specific, mandatory course or integrated into other courses, such as clinical pharmacology.

High prevalence of antibiotic resistance in commensal Escherichia coli among children in rural Vietnam.

BACKGROUND: Commensal bacteria represent an important reservoir of antibiotic resistance genes. Few community-based studies of antibiotic resistance in commensal bacteria have been conducted in Southeast Asia. We investigated the prevalence of resistance in commensal Escherichia coli in preschool children in rural Vietnam, and factors associated with carriage of resistant bacteria. METHODS: We tested isolates of E. coli from faecal samples of 818 children aged 6-60 months living in FilaBavi, a demographic surveillance site near Hanoi. Daily antibiotic use data was collected for participating children for three weeks prior to sampling and analysed with socioeconomic and demographic characteristics extracted from FilaBavi's re-census survey 2007. Descriptive statistics were generated, and a logistic regression model was used to identify contributions of the examined factors. RESULTS: High prevalences of resistance were found to tetracycline (74%), co-trimoxazole (68%), ampicillin (65%), chloramphenicol (40%), and nalidixic acid (27%). Two isolates were resistant to ciprofloxacin. Sixty percent of isolates were resistant to three or more antibiotics. Recent sulphonamide use was associated with co-trimoxazole resistance [OR 3.2, 95% CI 1.8-5.7], and beta-lactam use with ampicillin resistance [OR 1.8, 95% CI 1.3-2.4]. Isolates from children aged 6-23 months were more likely to be resistant to ampicillin [OR 1.8, 95% CI 1.3-2.4] and co-trimoxazole [OR 1.5, 95% CI 1.1-2.0]. Associations were identified between geographical areas and tetracycline and ampicillin resistance. CONCLUSIONS: We present high prevalence of carriage of commensal E. coli resistant to commonly used antibiotics. The identified associations with recent antibiotic use, age, and geographical location might contribute to our understanding of carriage of antibiotic resistant commensal bacteria.

The Effectiveness of an Educational Intervention on Knowledge, Attitudes and Reported Practices on Antibiotic Use in Humans and Pigs: A Quasi-Experimental Study in Twelve Villages in Shandong Province, China.

Our aim was to evaluate the effectiveness of an intervention for residents in rural China on knowledge, attitudes and reported practices (KAP) on antibiotic use in humans and pigs. A quasi-experimental study was conducted in 12 villages in rural Shandong province, divided into intervention and control groups, covering a two-year period from July 2015 to June 2017. A package of health education-based interventions including training sessions, speakerphone messages, posters and handbooks for residents was developed and implemented over a one-year period to improve the use of antibiotics in humans and pigs. The intervention net effects were evaluated by Difference-in-Difference (DID) analysis based on responses to a questionnaire concerning KAP towards antibiotic use in humans and pigs. A total of 629 participants completed both baseline and post-trial questionnaires, including 127 participants with backyard pig farms. Significant improvements were found in KAP towards antibiotic use in humans, but changes related to antibiotic use for pigs were not significant. Participants who were in the intervention group (p < 0.001) were more likely to have improved their knowledge on antibiotic use in humans. Participants who had higher attitude scores were less likely to report self-medicating with stored antibiotics in the previous year (p < 0.001). Our results suggest that our health education-based intervention was effective in improving KAP on human antibiotic use, but it had little effect regarding antibiotic use for pigs.

Towards a Better and Harmonized Education in Antimicrobial Stewardship in European Veterinary Curricula.

Education in antimicrobial stewardship (AMS) in veterinary medicine is essential to foster responsible antimicrobial use and control of antimicrobial resistance (AMR) in animals. AMS is listed by the EU and international organizations among the basic 'Day One Competences' required of veterinary students upon graduation. Our aim was to evaluate the quality of education of European veterinary students in AMS. We distributed a 27-item survey addressing the perceptions of preparedness and acquired skills on key topics related to AMS to final-year veterinary students in Europe. We collected 3423 complete answers from 89 veterinary schools in 30 countries. Selection of treatment strategies and awareness of emerging AMR problems were markedly different between countries. Overall, only one in four students was familiar with guidelines for antimicrobial use. The students perceived a medium-high impact of veterinary antimicrobial use on AMR in humans. Notably, 75% of the students felt the need for improved teaching on AMS, half of which also demanded more teaching on general antimicrobial therapy. Our results highlight several possible strategies to improve the quality of education, ranging from a better link between clinical rotations and the theory taught in pre-clinical modules, to a more effective introduction into best practices for antimicrobial use.

Variations in antibiotic prescribing among village doctors in a rural region of Shandong province, China: a cross-sectional analysis of prescriptions.

OBJECTIVES: To assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China. DESIGN, SETTING AND PARTICIPANTS: Almost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9. MAIN OUTCOME MEASURES: Proportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed. RESULTS: In total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%-88.0%), as well multiple antibiotic prescribing rates (1.3%-60.2%) and parenteral antibiotic prescribing rates (3.2%-62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002). CONCLUSIONS: All village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.