Antibiotic prescribing for acute, non-complicated infections in primary care in Germany: baseline assessment in the cluster randomized trial ARena.

BACKGROUND: Antimicrobial resistance is fueled by inappropriate use of antibiotics. Global and national strategies support rational use of antibiotics to retain treatment options and reduce resistance. In Germany, the ARena project (Sustainable reduction of antibiotic-induced antimicrobial resistance) intended to promote rational use of antibiotics for acute non-complicated infections by addressing network-affiliated physicians, primary care teams and patients through multiple interacting interventions. The present study documented patterns of antibiotic prescribing for patients with acute non-complicated infections who consulted a physician in these networks at the start of the ARena project. It explored variation across subgroups of patients and draws comparisons to prescribing patterns of non-targeted physicians. METHODS: This retrospective cross-sectional analysis used mixed logistic regression models to explore factors associated with the primary outcome, which was the percentage of patient cases with acute non-complicated respiratory tract infections consulting primary care practices who were treated with antibiotics. Secondary outcomes concerned the prescribing of different types of antibiotics. Descriptive methods were used to summarize the data referring to targeted physicians in primary care networks, non-targeted physicians (reference group), and patient subgroups. RESULTS: Overall, antibiotic prescribing rates were 32.0% in primary care networks and 31.7% in the reference group. General practitioners prescribed antibiotics more frequently than other medical specialist groups (otolaryngologists vs. General practitioners OR = 0.465 CI = [0.302; 0.719], p < 0.001, pediatricians vs. General practitioners: OR = 0.369 CI = [0.135; 1.011], p = 0.053). Quinolone prescribing rates were 9.9% in primary care networks and 8.1% in reference group. Patients with comorbidities had a higher likelihood of receiving an antibiotic and quinolone prescription and were less likely to receive a guideline-recommended substance. Younger patients were less likely to receive antibiotics (OR = 0.771 CI = [0.636; 0.933], p = 0.008). Female gender was more likely to receive an antibiotic prescription (OR = 1.293 CI = [1.201, 1.392], p < 0.001). CONCLUSION: This study provided an overview of observed antibiotic prescribing for acute non-complicated respiratory tract infections in German primary care at the start of the ARena project. Findings indicate potential for improvement and will serve as comparator for the post-interventional outcome evaluation to facilitate describing of potential changes.

Factors associated with coverage of vitamin a supplementation among Bangladeshi children: mixed modelling approach.

BACKGROUND: Vitamin A deficiency (VAD) is a prominent and widespread public health problem in developing countries, including Bangladesh. About 2% of all deaths among under-five children are attributable to VAD. Evidence-based information is required to understand the influential factors to increase vitamin A supplementation (VAS) coverage and reduce VAD. We investigated the potential factors affecting VAS coverage and its significant predictors among Bangladeshi children aged 6 to 59 months using the VAS clustered data extracted from the latest Bangladesh Demographic and Health Survey 2014. METHODS: Data were analysed using mixed logistic regression (MLR) modelling approach in the generalised linear mixed model framework. The MLR model performs better than logistic regression for analysing the clustered data because of its minimum Akaike information criterion value. The likelihood ratio test showed that the variance component was significant. Therefore, the clustering effect among children was inevitable to use. RESULTS: VAS coverage among under-five children was 63.6%, which is not optimal and below the WHO's recommendation and the country's target of 90%. Children aged 25 to 36 months (AOR = 2.07, 95% CI: 1.711 to 2.513), who had higher educated mothers (AOR = 1.37, p = 0.033, 95% CI: 1.026-1.820) and fathers (AOR = 1.32, p = 0.027, 95% CI: 1.032-1.683), whose mothers had media exposure (AOR = 1.22, p = 0.006, 95% CI: 1.059-1.408) and NGO membership (AOR = 1.24, p = 0.002, 95% CI: 1.089-1.422) were more likely to consume VAS. CONCLUSION: The relevant authorities should create proactive awareness programs for highly vulnerable local communities, specifically targeted to educate the children's mothers about the necessity and benefits of childhood nutrition.

Risk factors for pregnancy related complications among urban slum and non-slum women in Bangladesh.

BACKGROUND: Bangladesh is facing a higher maternal mortality and morbidity than many other developing countries in the world. The majority of these maternal deaths occur due to pregnancy related complications. Although health facilities in urban areas in Bangladesh are widely available, women living in underprivileged urban areas are least likely to receive the maternal health services and as a result, they face more pregnancy related complications. Unfortunately, there are only a few studies on complications during maternal and delivery period in these areas. We aim to investigate the factors responsible for pregnancy related complications in urban slum and non-slum areas. METHODS: Data from the Urban Health Survey (UHS), 2013 were analyzed applying mixed logistic regression model. The response variable was complications during pregnancy, during/after delivery at the last birth and the total sample size was 6137. The adjusted odds ratios (AORs) along with their 95% confidence intervals (CIs) were also calculated to compare the magnitude of different risk factors for the pregnancy related complications. RESULTS: Younger mothers (age < 18 years) at the birth of their children had 24% (OR = 1.24, 95% CI: 1.01, 1.54) more odds to experience complications during pregnancy/delivery or after delivery compared to older mothers aged 18 to 35 years. The increased risk of complications was found among primiparous women. Women living in urban slum areas had higher pregnancy related complications than women living elsewhere. Migrant mothers faced more complications than women-who were not migrants. Women had greater pregnancy related complications when they delivered boy child than girl child, presumably from an increased size of the baby and resultant birth obstruction, assisted delivery and post partum haemorrhage. Moreover, a wanted pregnancy had fewer significant complications during pregnancy/delivery or after delivery than an unwanted pregnancy. CONCLUSIONS: The study associates early maternal age, primiparity, unwanted pregnancy, women living in slum areas, women migrating from other cities or non-urban areas and NGO membership with increased risk of pregnancy related complications among urban women in Bangladesh. It is likely that addressing these risk factors for complications to the policymakers may help to reduce the maternal mortality and morbidity in Bangladesh.

Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena.

The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.