Prescribing Antibiotics for Children with Acute Conditions in Public Primary Care Clinics in Singapore: A Retrospective Cohort Database Study.

Data on primary care antibiotic prescription practices for children in Singapore, which are essential for health care policy, are lacking. We aimed to address this gap and to benchmark prescription practices against international standards. A retrospective cohort database study on antibiotic prescriptions for children (aged < 18 years) who visited six public primary care clinics in Singapore between 2018 and 2021 was conducted. Data were categorised according to the World Health Organization's Access, Watch, Reserve (WHO AWaRe) classification. Quality indicators from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) and the National Institute for Health and Care Excellence (NICE) guidelines were used as a measure of appropriateness of antibiotic prescribing at the individual and overall patient level. In 831,669 polyclinic visits by children between 2018 and 2021, there was a significant reduction in mean antibiotics prescribed per month during pandemic years (2020-2021) compared to pre-pandemic (2018-2019) (MD 458.3, 95% CI 365.9-550.7). Most prescriptions (95.8%) for acute conditions fell within the WHO AWaRe "Access" group. Antibiotic prescription significantly exceeded (55.2%) the relevant quality indicator for otitis media (0-20%). The proportion of children receiving appropriate antibiotics for acute respiratory infections (n = 4506, 51.3%) and otitis media (n = 174, 49.4%) was low compared to the quality indicator (80-100%). There is a need to develop local evidence-based primary care antibiotic guidelines, as well as to support the development of stewardship programmes.

Integrated image-based deep learning and language models for primary diabetes care.

Primary diabetes care and diabetic retinopathy (DR) screening persist as major public health challenges due to a shortage of trained primary care physicians (PCPs), particularly in low-resource settings. Here, to bridge the gaps, we developed an integrated image-language system (DeepDR-LLM), combining a large language model (LLM module) and image-based deep learning (DeepDR-Transformer), to provide individualized diabetes management recommendations to PCPs. In a retrospective evaluation, the LLM module demonstrated comparable performance to PCPs and endocrinology residents when tested in English and outperformed PCPs and had comparable performance to endocrinology residents in Chinese. For identifying referable DR, the average PCP's accuracy was 81.0% unassisted and 92.3% assisted by DeepDR-Transformer. Furthermore, we performed a single-center real-world prospective study, deploying DeepDR-LLM. We compared diabetes management adherence of patients under the unassisted PCP arm (n = 397) with those under the PCP+DeepDR-LLM arm (n = 372). Patients with newly diagnosed diabetes in the PCP+DeepDR-LLM arm showed better self-management behaviors throughout follow-up (P < 0.05). For patients with referral DR, those in the PCP+DeepDR-LLM arm were more likely to adhere to DR referrals (P < 0.01). Additionally, DeepDR-LLM deployment improved the quality and empathy level of management recommendations. Given its multifaceted performance, DeepDR-LLM holds promise as a digital solution for enhancing primary diabetes care and DR screening.

Prescribing Antibiotics in Public Primary Care Clinics in Singapore: A Retrospective Cohort Study.

BACKGROUND: Antibiotic prescription practices in primary care in Singapore have received little scholarly attention. In this study, we ascertained prescription prevalence and identified care gaps and predisposing factors. METHODS: A retrospective study was conducted on adults (>21 years old) at six public primary care clinics in Singapore. Prescriptions >14 days were excluded. Descriptive statistics were used to showcase the prevalence data. We used chi-square and logistic regression analyses to identify the factors affecting care gaps. RESULTS: A total of 141,944 (4.33%) oral and 108,357 (3.31%) topical antibiotics were prescribed for 3,278,562 visits from 2018 to 2021. There was a significant reduction in prescriptions (p < 0.01) before and after the pandemic, which was attributed to the 84% reduction in prescriptions for respiratory conditions. In 2020 to 2021, oral antibiotics were most prescribed for skin (37.7%), genitourinary (20.2%), and respiratory conditions (10.8%). Antibiotic use in the "Access" group (WHO AWaRe classification) improved from 85.6% (2018) to 92.1% (2021). Areas of improvement included a lack of documentation of reasons for antibiotic use, as well as inappropriate antibiotic prescription for skin conditions. CONCLUSION: There was a marked reduction in antibiotic prescriptions associated with the onset of the COVID-19 pandemic. Further studies could address the gaps identified here and evaluate private-sector primary care to inform antibiotic guidelines and the local development of stewardship programs.

Antibiotic treatment failure of uncomplicated urinary tract infections in primary care.

BACKGROUND: Higher resistance rates of > 20% have been noted in Enterobacteriaceae urinary isolates towards ciprofloxacin and co-trimoxazole (C + C) in Singapore, compared with amoxicillin-clavulanate and nitrofurantoin (AC + N). This study examined if treatment failure varied between different antibiotics, given different resistant rates, for uncomplicated urinary tract infections (UTIs) managed in primary care. We also aimed to identify gaps for improvement in diagnosis, investigations, and management. METHODS: A retrospective cohort study was conducted from 2019 to 2021 on female patients aged 18-50 with uncomplicated UTIs at 6 primary care clinics in Singapore. ORENUC classification was used to exclude complicated UTIs. Patients with uncomplicated UTIs empirically treated with amoxicillin-clavulanate, nitrofurantoin, ciprofloxacin or co-trimoxazole were followed-up for 28 days. Treatment failure was defined as re-attendance for symptoms and antibiotic re-prescription, or hospitalisation for UTI complications. After 2:1 propensity score matching in each group, modified Poisson regression and Cox proportional hazard regression accounting for matched data were used to determine risk and time to treatment failure. RESULTS: 3194 of 4253 (75.1%) UTIs seen were uncomplicated, of which only 26% were diagnosed clinically. Urine cultures were conducted for 1094 (34.3%) uncomplicated UTIs, of which only 410 (37.5%) had bacterial growth. The most common organism found to cause uncomplicated UTIs was Escherichia coli (64.6%), with 92.6% and 99.4% of isolates sensitive to amoxicillin-clavulanate and nitrofurantoin respectively. Treatment failure occurred in 146 patients (4.57%). Among 1894 patients treated with AC + N matched to 947 patients treated with C + C, patients treated with C + C were 50% more likely to fail treatment (RR 1.49, 95% CI 1.10-2.01), with significantly higher risk of experiencing shorter time to failure (HR 1.61, 95% CI 1.12-2.33), compared to patients treated with AC + N. CONCLUSION: Treatment failure rate was lower for antibiotics with lower reported resistance rates (AC + N). We recommend treating uncomplicated UTIs in Singapore with amoxicillin-clavulanate or nitrofurantoin, based on current local antibiograms. Diagnosis, investigations and management of UTIs remained sub-optimal. Future studies should be based on updating antibiograms, highlighting its importance in guideline development.

General Public's knowledge, awareness, and perception of Cardiometabolic diseases: data from a Singapore study population.

Background: Health literacy and illness perception play crucial roles in tackling the cardiometabolic disease epidemic. We aim to compare the attitudes, knowledge, self-perceived risks and actions taken, between individuals with and without metabolic risk factors (MFs). Methods: From 5 June to 5 October 2022, participants of the general public were invited to complete a self-administered questionnaire. MF status was defined as the presence of hypertension, hyperlipidemia, diabetes mellitus and/or current/previous smoking. Participants were assessed based on four categories (knowledge-based, attitude-based, perceived risk, and action-based) of questions pertaining to four cardiometabolic diseases - diabetes mellitus, hypertension, hyperlipidemia, and non-alcoholic fatty liver disease. Results: A total of 345 participants were enrolled, of whom 34.5% had at least one MF. Compared to those without MFs, participants with MFs had lower knowledge scores, but higher perceived risk scores across all cardiometabolic diseases. The largest knowledge gap pertained to hypertension-related questions. After adjustment, linear regression demonstrated that the presence of MFs (ß:2.752, 95%CI: 0.772-4.733, p = 0.007) and higher knowledge scores (ß:0.418, 95%CI: 0.236-0.600, p < 0.001) were associated with higher perceived risk. Despite increased perceived risk in those with MFs, this translated to only few increased self-reported preventive actions, when compared to those without MFs, namely the reduction in red meat/processed food consumption (p = 0.045) and increase in fruits/vegetables consumption (p = 0.009). Conclusion: This study identified a vulnerable subpopulation living with MFs, with high perceived risks, and discordant levels of knowledge and preventive actions taken. Nationwide efforts should be channeled into addressing the knowledge-to-action gap.

COVID-19 Vaccine Booster Hesitancy among Healthcare Workers: A Retrospective Observational Study in Singapore.

BACKGROUND: COVID-19 booster uptake remained poor among healthcare workers (HCW) despite evidence of improved immunity against Delta and Omicron variants. While most studies used a questionnaire to assess hesitancy, this study aimed to identify factors affecting booster hesitancy by examining actual vaccine uptake across time. METHOD: COVID-19 vaccination database records among HCW working at seven Singaporean public primary care clinics between January to December 2021 were extracted, with sex, profession, place of practice, vaccination type, and dates. Time to booster was calculated from the date of vaccination minus date of eligibility. Chi-square test was used to compare the relationship between first dose and booster hesitancy, Kaplan-Meier method and log-rank test were adopted to evaluate differences in cumulative booster uptake. Multivariate Cox regression was used to investigate predictors for timely booster vaccination. Vaccination rate was charted across time and corroborated with media releases pertaining to legislative changes. RESULTS: A total of 877 of 891 (98.9%) primary care HCW were fully vaccinated, 73.8% of eligible HCW had taken the booster. HCW were less booster hesitant [median 16 (5-31.3) days] compared to the first dose [median 39 (13-119.3) days]. First dose-hesitant HCW were more likely to be booster hesitant (OR = 3.66, 95%CI 2.61-5.14). Adjusting for sex, workplace, and time to first dose, ancillary (HR = 1.53, 95%CI 1.03-2.28), medical (HR = 1.8, 95%CI 1.18-2.74), and nursing (HR = 1.8, 95%CI 1.18-2.37) received boosters earlier compared with administrative staff. No temporal relationship was observed between booster uptake, legislative changes, and COVID-19 infection numbers. CONCLUSION: Vaccine hesitancy among HCW had improved from first dose to booster, with timely booster vaccination among medical and nursing staff. Tailored education, risk messaging, and strategic legislation might help to reduce delayed booster vaccination.

COVID-19 vaccine acceptance and hesitancy among primary healthcare workers in Singapore.

BACKGROUND: Factors affecting COVID-19 vaccine acceptance and hesitancy among primary healthcare workers (HCW) remain poorly understood. This study aims to identify factors associated with vaccine acceptance and hesitancy among HCW. METHODS: A multi-centre online cross-sectional survey was performed across 6 primary care clinics from May to June 2021, after completion of staff vaccination exercise. Demographics, profession, years working in healthcare, residential status, presence of chronic medical conditions, self-perceived risk of acquiring COVID-19 and previous influenza vaccination were collected. HCW who accepted vaccine were then asked to rank their top 5 reasons for vaccine acceptance; HCW who were vaccine hesitant had to complete the 15-item 5C scale on psychological antecedents of vaccination. RESULTS: Five hundred fifty seven out of 1182 eligible HCW responded (47.1%). Twenty nine were excluded due to contraindications. Among 528 respondents, vaccine acceptance rate was 94.9% (n = 501). There were no statistically significant differences in COVID-19 vaccine acceptance between sex, age, ethnicity, profession, number of years in healthcare, living alone, presence of chronic diseases, self-perceived risk or previous influenza vaccination. The top 3 reasons for COVID-19 vaccine acceptance ranked by 501 HCW were to protect their family and friends, protect themselves from COVID-19 and due to high risk of acquiring COVID-19 because of their jobs. HCW with suspected or confirmed COVID-19 exposure were 3.4 times more likely to rank 'high risk at work' as one of the top reasons for vaccine acceptance (χ2 = 41.9, p < 0.001, OR = 3.38, 95%C.I. 2.32-4.93). High mean scores of 'Calculation' (5.79) and low scores for 'Constraint' (2.85) for 5C components among vaccine hesitant HCW (n = 27) highlighted that accessibility was not a concern; HCW took time to weigh vaccine benefits and consequences. CONCLUSION: COVID-19 vaccine hesitancy is a minute issue among Singapore primary HCW, having achieved close to 95% acceptance rate. COVID-19 exposure risk influences vaccine acceptance; time is required for HCW to weigh benefits against the risks. Future studies can focus on settings with higher hesitancy rates, and acceptance of booster vaccinations with the emergence of delta and omicron variants.