Antimicrobial stewardship capacity and manpower needs in the Asia Pacific.

OBJECTIVES: Antimicrobial stewardship is a strategy to combat antimicrobial resistance in hospitals. Given the burden and impact of antimicrobial resistance in the Asia Pacific, it is important to document capacity and gaps in antimicrobial stewardship programmes (ASP). We aimed to understand existing capacities and practices, and define the resources needed to establish antimicrobial stewardship where it is lacking. METHODS: An anonymous online survey, consisting of questions on antimicrobial control at country, hospital and programme levels, was circulated to healthcare providers in the field of infectious diseases and microbiology through Asian Network for Surveillance of Resistant Pathogens, ReAct Group and the Australasian Society for infectious Diseases. RESULTS: 139 participants from 16 countries or regions completed the survey. The majority of participants were adult infectious diseases physicians (61/139, 43.9%) and microbiologists (31/139, 22.3%). Participants from 7 countries reported that antimicrobials can be obtained without prescriptions. Despite the high percentage (75.5%) of respondents working in large hospitals, only 22/139 participants (15.8%) from Australia, China, Singapore, Taiwan, Thailand and Vietnam reported having more than 10 infectious diseases physicians. Hospital empiric antimicrobial guidelines for common infections were available according to 110/139 (79.1%) participants. Pre-authorisation of antimicrobials was reported by 88/113 (77.9%) respondents while prospective audit and feedback was reported by 93/114 (81.6%). Automatic stop orders and culture-guided de-escalation were reported by only 52/113 (46.0%) and 27/112 (24.1%) respectively. CONCLUSION: The survey reveals a wide range of ASP development in Asia Pacific. Establishing national workgroups and guidelines will help advance antimicrobial stewardship in this diverse region.

Medical and psychosocial factors associated with antibiotic prescribing in primary care: survey questionnaire and factor analysis.

BACKGROUND: Acute upper respiratory infections (AURI) are the leading causes of antibiotic prescribing in primary care although antibiotics are often not indicated. AIM: To gain an understanding of the knowledge, attitudes, and practices (KAP) of GPs in Singapore and the associated latent factors to guide the implementation of an effective programme to reduce antibiotic use in primary care. DESIGN AND SETTING: An anonymous survey on the KAP of antibiotic use in AURI of GPs in Singapore. METHOD: KAP survey questionnaires were posted to all GPs from a database. To ascertain the latent factors affecting prescribing patterns, exploratory factor analysis was performed. RESULTS: Among 427 responses, 351 (82.2%) were from GPs working in private practice. It was found that 58.4% of GPs in the private versus 72.4% of those in the public sector recognised that >80% of AURIs were caused by viruses (P = 0.02). The majority of GPs (353/427; 82.7%) felt that antibiotics were overprescribed in primary care. Significant factors associated with low antibiotic prescribing were good medical knowledge and clinical competency (adjusted odds ratio [aOR] 3.2, 95% confidence interval [CI] = 2.4 to 4.3), good clinical practice (aOR 2.7 [95% CI = 2.0 to 3.6]), availability of diagnostic tests (aOR 1.4 [95% CI = 1.1 to 1.8]), and desire to improve clinical practice (aOR 1.5 [95% CI = 1.2 to 1.9]). The conservative practice of giving antibiotics 'to be on the safe side' is significantly less likely to be associated with low antibiotic prescribing (aOR 0.7 [95% CI = 0.5 to 0.9]). CONCLUSION: This is the first KAP survey on antibiotic prescribing for AURI among GPs in Singapore. With the latent factors identified, future interventions should be directed at addressing these factors to reduce inappropriate antibiotic prescribing.

The Significance of Prolonged and Saddleback Fever in Hospitalised Adult Dengue.

Dengue fever is gaining importance in Singapore with an increase in the number of cases and mortality in recent years. Although prolonged and saddleback fever have been reported in dengue fever, there are no specific studies on their significance in dengue. This study aims to examine the prevalence of prolonged and saddleback fever in dengue as well as their associations with dengue severity. A total of 2843 polymerase-chain reaction (PCR) confirmed dengue patients admitted to Tan Tock Seng Hospital from 2004 to 2008 were included in the study. Sixty-nine percent of them were male with a median age of 34 years. Prolonged fever (fever > 7 days duration) was present in 572 (20.1%) of patients. Dengue hemorrhagic fever (DHF), dengue shock syndrome (DSS) and severe dengue (SD) were significantly more likely to occur in patients with prolonged fever. Mucosal bleeding, anorexia, diarrhea, abdominal pain, nausea or vomiting, lethargy, rash, clinical fluid accumulation, hepatomegaly, nosocomial infection, leukopenia, higher neutrophil count, higher hematocrit, higher alanine transaminase (ALT) and aspartate transaminase (AST), higher creatinine, lower protein and prolonged activated partial thromboplastin time (APTT) were significantly associated with prolonged fever but not platelet count or prothrombin time (PT). Saddleback fever was present in 165 (5.8%). Although DHF and SD were more likely to occur in patients in those with saddleback fever, DSS was not. Compared with prolonged fever, saddleback fever did not show many significant associations except for diarrhea, abdominal pain, clinical fluid accumulation, hematocrit and platelet change, and lower systolic blood pressure. This study demonstrates that prolonged fever may be associated with various warning signs and more severe forms of dengue (SD, DSS, DHF), while saddleback fever showed associations with DHF and SD but not DSS. The presence of prolonged or saddleback fever in dengue patients should therefore prompt detailed evaluation for complications of dengue, as well as early investigation to evaluate for development of nosocomial infection.