Validity and Reliability of a Questionnaire on Attitudes, Knowledge, and Perceptions of Pharmacy Students Regarding the Training Received on Antibiotics and Antimicrobial Resistance during Their University Studies.

BACKGROUND: Antimicrobial resistance is a major public health issue today. Therefore, it is essential to focus on the education of pharmacists as future dispensers. The objective of this study was to validate a questionnaire that assesses the knowledge, attitudes, and perceptions of pharmacy students regarding the education received during their university degree on the use and dispensation of antibiotics, as well as bacterial resistance. METHODS: An online questionnaire was developed and distributed via RedCap v.13.7.1 to pharmacy students at the University of Santiago de Compostela using the WhatsApp social network. The questionnaire consisted of 28 items evaluating 5 dimensions: "quality of care", "communication skills", "antibiotic resistance", "teaching methodology", and "education on antibiotics at the faculty". The questionnaire validation was conducted in 2 steps: Step 1 involved content and appearance validation, and Step 2 involved reliability analysis. RESULTS: A total of 61 completed questionnaires were received. The mean age was 21.82 ± 3.81 years, with 20 males (32.8%) and 41 females (67.2%). Content validation was performed through a nominal group of 5 experts, and appearance validation was conducted by a focus group of 6 university pharmacy students. The questionnaire demonstrated a Cronbach's alpha value of 0.80 and adequate item discrimination capability. Confirmatory factor analysis was performed to assess construct validity, confirming the 5 predefined dimensions. CONCLUSIONS: A questionnaire has been developed and validated with high reliability and validity. Its use will help identify areas for improvement in the university education of pharmacy students, ultimately contributing to better use and dispensation of antibiotics and thereby improving antimicrobial resistance.

Antibiotic Use and Antimicrobial Resistance: A Global Public Health Crisis.

The discovery of antibiotics revolutionized modern medicine, effectively treating bacterial infections that were once fatal [...].

Exploring CD26-/lo subpopulations of lymphocytes in asthma phenotype and severity: A novel CD4+ T cell subset expressing archetypical granulocyte proteins.

BACKGROUND: Asthma pathology may induce changes in naïve/memory lymphocyte proportions assessable through the evaluation of surface CD26 (dipeptidyl peptidase 4/DPP4) levels. Our aim was to investigate the association of asthma phenotype/severity with the relative frequency of CD26-/lo, CD26int and CD26hi subsets within different lymphocyte populations. METHODS: The proportion of CD26-/lo, CD26int and CD26hi subsets within CD4+ effector T cells (Teff), total CD4- lymphocytes, γδ-T cells, NK cells and NKT cells was measured in peripheral blood samples from healthy (N = 30) and asthma (N = 119) donors with different phenotypes/severities by flow cytometry. We performed K-means clustering analysis and further characterised the CD4+CD26-/lo Teff cell subset by LC-MS/MS and immunofluorescence. RESULTS: Cluster analysis including clinical and flow cytometry data resulted in four groups, two of them with opposite inflammatory profiles (neutrophilic vs. eosinophilic). Neutrophilic asthma presented reduced CD4-CD26hi cells, which negatively correlated with systemic inflammation. Eosinophilic asthma displayed a general expansion of CD26-/lo subsets. Specifically, CD4+CD26-/lo Teff expansion was confirmed in asthma, especially in atopic patients. Proteomic characterisation of this subset with a TEM/TEMRA phenotype revealed upregulated levels of innate (e.g. MPO and RNASE2) and cytoskeleton/extracellular matrix (e.g. MMP9 and ACTN1) proteins. Immunofluorescence assays confirmed the presence of atypical proteins for CD4+ T cells, and an enrichment in 'flower-like' nuclei and MMP9/RNASE2 levels in CD4+CD26-/lo Teff compared to CD4+ T lymphocytes. CONCLUSION: There is an association between CD26 levels in different lymphocyte subsets and asthma phenotype/severity. CD4+CD26-/loTEMRA cells expressing innate proteins specific to eosinophils/neutrophils could be determinant in sustaining long-term inflammation in adult allergic asthma.

Factors Associated with Exclusive Breastfeeding during Admission to a Baby-Friendly Hospital Initiative Hospital: A Cross-Sectional Study in Spain.

BACKGROUND: Breastfeeding is the optimal nourishment for infants and it is recommended that children commence breastfeeding within the first hour of birth and be exclusively breastfed for the initial 6 months of life. Our objective was to determine which factors related to mothers could influence the degree of exclusive breastfeeding during hospitalization, as well as to assess breastfeeding mothers' attitudes towards breastfeeding. METHODS: A multicenter cross-sectional study was undertaken in the healthcare area of Santiago de Compostela, Spain. The necessary variables were collected using a specially designed ad hoc questionnaire. The researcher responsible for recruitment conducted the interviews with the participants. The reduced Iowa Infant Feeding Attitude Scale (IIFAS-s) was employed to gauge maternal attitudes toward feeding their baby. RESULTS: In total, 64 women were studied. The overall score of IIFAS-s (mean ± standard deviation) was 36.95 ± 5.17. A positive attitude towards breastfeeding was therefore observed in our sample. No use of a pacifier by the newborn was associated with a positive attitude for breastfeeding. Having previous children (Ora = 6.40; IC95% 1.26-32.51) and previous experience with breastfeeding (Ora = 6.70; IC95% 1.31-34.27) increased the likelihood of exclusive breastfeeding during admission. CONCLUSIONS: In our study, exclusive breastfeeding during hospitalization is associated with having previous children and prior breastfeeding experience.

Knowledge, Attitudes and Practice Regarding Antibiotic Prescription by Medical Interns: A Qualitative Study in Spain.

Antibiotic resistance is an issue of growing importance in the public health sphere. Medical interns are of great relevance when it comes to the source of this problem. This study therefore sought to ascertain which factors influence the management of antibiotic therapy by this population, in order to pinpoint the possible causes of misprescribing habits. We conducted a qualitative study based on focus group techniques, with groups consisting of medical interns from the Santiago de Compostela Clinical University Teaching Hospital. Our study identified factors which the participants considered to be determinants of antibiotic use and their relationship with the appearance of resistance. The single most repeated factor was the influence of the attending physician's judgement; other factors included a high healthcare burden or prescribing inertia. This stage is an opportunity to correct misprescribing habits, by implementing educational interventions aimed at modifying the identified factors.

Knowledge, Perceptions, and Perspectives of Medical Students Regarding the Use of Antibiotics and Antibiotic Resistance: A Qualitative Research in Galicia, Spain.

Antibiotic resistance is a significant public health concern, with numerous studies linking antibiotic consumption to the development of resistance. As medical students will play a pivotal role in prescribing antibiotics, this research aimed to identify their perceptions of current use and factors that could influence future inappropriate use of antibiotics. The study employed a qualitative research approach using Focus Group discussions (FGs) consisting of students from the final theoretical course of the Medicine degree. The FGs were conducted based on a pre-script developed from factors contributing to antibiotic misuse identified in previous studies. All sessions were recorded and transcribed for analysis by two independent researchers, with all participants signing informed consent. Seven focus groups were conducted, with a total of 35 participants. The study identified factors that could influence the future prescription of antibiotics, including the low applicability of knowledge, insecurity, clinical inertia, difficulties in the doctor-patient relationship, unawareness of available updates on the topic, and inability to assess their validity. The students did not perceive antibiotic resistance as a current problem. However, the study found several modifiable factors in medical students that could explain the misuse of antibiotics, and developing specific strategies could help improve their use.

Seguimiento de pacientes COVID-19 en aislamiento domiciliario mediante telemonitorización desde Atención Primaria / Follow-up for COVID-19 patients in home isolation through telemonitoring by Primary Care

El objetivo de este artículo es dar a conocer la experiencia de la implantación de la herramienta de teleseguimiento “TELEA” en el ámbito de Atención Primaria (AP) para la gestión de los casos COVID-19 en aislamiento domiciliario, así como describir su primer mes de implantación en el Área Sanitaria de Santiago de Compostela y Barbanza (septiembre de 2020).La herramienta TELEA existía previamente para el seguimiento de personas con patología crónica y se adaptó al seguimiento en casos COVID-19. El servicio incluía una clasificación inicial de los pacientes tras la notificación automática e inmediata de pruebas diagnósticas positivas de COVID: asintomático, bajo riesgo, con factores de riesgo o con signos de alarma. En los tres primeros casos se ofrecía a los pacientes seguimiento y monitorización mediante una plataforma digital donde registraban datos biométricos y síntomas respiratorios tres veces al día. Esos datos estaban enlazados a la historia clínica y eran monitorizados por la enfermera de AP. Alternativamente se realizó seguimiento telefónico proactivo por parte de la enfermera. Si presentaban signos de alarma eran derivados al hospital de referencia.Se hizo seguimiento en 220 de las 229 personas candidatas (el 78,6%; n= 173 mediante TELEA). El tiempo medio de seguimiento fue de 13,8 días, mayor en los pacientes incluidos en TELEA que en el seguimiento telefónico (p< 0,01). Ingresaron durante el seguimiento el 6,8 % de los pacientes, ninguno falleció.El teleseguimiento con telemonitorización domiciliaria basada en el control proactivo y protocolizado por parte de la enfermera de AP permitió un seguimiento clínicamente útil de pacientes con COVID-19 en aislamiento domiciliario.(AU)

The objective of this article is to make public the experience of implementing the telemonitoring tool “TELEA” in the Primary Care (PC) setting for the management of COVID-19 cases in home isolation, as well as to describe its first month of implementation at the Santiago de Compostela and Barbanza Health Area (September 2020).The TELEA tool was previously used for the follow-up of persons with chronic conditions, and was then adapted for the follow-up of COVID-19 cases. The service included an initial classification of patients after the automatic and immediate report of positive COVID diagnostic tests: asymptomatic, low risk, with risk factors or with warning signs. In the three first cases, patients were offered follow-up and monitoring through a digital platform where biometric data and respiratory symptoms were registered three times per day. These data were linked with the clinical record and monitored by the PC nurse. Alternatively, there was proactive follow-up by telephone by the nurse. If patients presented warning signs, they were referred to the hospital of reference.Follow-up was conducted for 220 of the 229 adequate persons (78.6%; n= 173 through TELEA). The mean follow-up time was 13.8 days, higher for the patients included in TELEA than for those with follow-up by telephone (p< 0.01). During follow-up, 6.8% of patients were admitted to hospital; none of them died.Remote follow-up with home telemonitoring based on the proactive management under protocol by the PC nurse allowed a clinically useful follow-up of patients with COVID-19 in home isolation.(AU)

Análisis de los problemas relacionados con la medicación en pacientes polimedicados mayores de 64 años en atención primaria. Un estudio descriptivo transversal / Analysis of drug-related problems in polymedicated patients over the age of 64 in primary care. A cross-sectional descriptive study

OBJETIVO: Identificar los problemas relacionados con la medicación mediante los criterios STOPP/START en pacientes polimedicados mayores de 64 años con 12 o más fármacos. MÉTODO: Estudio descriptivo transversal. Se analizaron 172 casos seleccionados aleatoriamente del registro de 1.500 pacientes polimedicados del Programa de Mejora de la Calidad en el Paciente Crónico y Polimedicado del Servicio Gallego de Salud para el área de Santiago en el 2017. Se registraron los problemas relacionados con los medicamentos y los resultados negativos asociados a la medicación. El incumplimiento terapéutico se evaluó mediante el test de Morisky-Green-Levine. Las intervenciones enfermeras se registraron a partir del informe enfermero del programa. Se realizó análisis bivariante de los datos y la asociación entre las variables se estimó mediante el cálculo de la odds ratio. RESULTADO: El 56,4% de las pacientes eran mujeres. La media de edad fue de 77,34±10,11 años. El problema más habitual fue la probabilidad de presentar efectos adversos, observándose en el 64,1% de los pacientes. Las mujeres presentaron mayor probabilidad de presentar este problema que los varones (OR: 1,37; IC 95%: 1,06-1,78). Un 18% de los pacientes se consideraron no cumplidores del tratamiento prescrito, según el test de Morisky-Green-Levine. Un 25,6% de los pacientes recibieron intervenciones de educación sanitaria. CONCLUSIONES: La enfermera debe reevaluar periódicamente la medicación de los pacientes para comprobar adherencia al tratamiento y conocer si están provocando algún tipo de efecto adverso, así como incorporar a su actividad intervenciones de educación para la salud en este campo

OBJECTIVE: To identify drug-related problems using the STOPP/START criteria of patients over 64 years polymedicated with 12 or more drugs. METHOD: Descriptive cross-sectional. We analysed 172 cases randomly selected from the register of 1500 polymedicated patients of the Quality Improvement Programme for Chronic and Polymedicated Patients of the Galician Health Service for the area of Santiago in 2017. Drug-related problems and the negative results associated with medication were recorded. Treatment compliance was assessed by the Morisky-Green-Levine test. Nursing interventions were recorded based on the Programme's nursing report. Bivariate analysis of the data was performed and the association between the variables was estimated by calculating the odds ratio (OR). RESULTS: The 56.4% of the patients were women. The mean age was 77.34±10.11 years. The most common problem was the likelihood of presenting adverse effects, observed in 64.1% of the patients. Women were more likely to have this problem than men (OR: 1.37; 95% CI: 1.06-1.78). Eighteen percent of the patients were considered non-compliant with the prescribed treatment, according to the Morisky-Green-Levine test. Of the patients, 25.6% had received health education interventions. CONCLUSIONS: Nurses must periodically re-evaluate patient medication to check adherence to treatment and determine whether it is causing any type of adverse effect, as well as incorporate health education interventions in this field into their activity

Factors determining antibiotic use in the general population: A qualitative study in Spain.

BACKGROUND: Antibiotic resistance is an important Public Health problem and many studies link it to antibiotic misuse. The population plays a key role in such misuse. OBJECTIVE: The aim of this study was thus to explore the factors that might influence antibiotic use and resistance in the general population. METHODS: Qualitative research using the focus group (FG) method. Groups were formed by reference to the following criteria: age (over and under 65 years); place of origin; and educational/professional qualifications. FG sessions were recorded, transcribed and then separately analysed by two researchers working independently. Written informed consent was obtained from all participants. RESULTS: Eleven FGs were formed with a total of 75 participants. The principal factors identified as possible determinants of antibiotic misuse were: (i) lack of knowledge about antibiotics; (ii) doctor-patient relationship problems; (iii) problems of adherence; and, (iv) use without medical prescription. Antibiotic resistance is a phenomenon unknown to the population and is perceived as an individual problem, with the term "resistance" being confused with "tolerance". None of the groups reported that information about resistance had been disseminated by the health care sector. CONCLUSIONS: The public is unaware of the important role it plays in the advance of antimicrobial resistance. There is evidence of diverse factors, many of them modifiable, which might account for antibiotic misuse. Better understanding these factors could be useful in drawing up specific strategies aimed at improving antibiotic use.

Analysis of drug-related problems in polymedicated patients over the age of 64 in primary care. A cross-sectional descriptive study. / Análisis de los problemas relacionados con la medicación en pacientes polimedicados mayores de 64 años en atención primaria. Un estudio descriptivo transversal.

OBJECTIVE: To identify drug-related problems using the STOPP/START criteria of patients over 64 years polymedicated with 12 or more drugs. METHOD: Descriptive cross-sectional. We analysed 172 cases randomly selected from the register of 1500 polymedicated patients of the Quality Improvement Programme for Chronic and Polymedicated Patients of the Galician Health Service for the area of Santiago in 2017. Drug-related problems and the negative results associated with medication were recorded. Treatment compliance was assessed by the Morisky-Green-Levine test. Nursing interventions were recorded based on the Programme's nursing report. Bivariate analysis of the data was performed and the association between the variables was estimated by calculating the odds ratio (OR). RESULTS: The 56.4% of the patients were women. The mean age was 77.34±10.11 years. The most common problem was the likelihood of presenting adverse effects, observed in 64.1% of the patients. Women were more likely to have this problem than men (OR: 1.37; 95% CI: 1.06-1.78). Eighteen percent of the patients were considered non-compliant with the prescribed treatment, according to the Morisky-Green-Levine test. Of the patients, 25.6% had received health education interventions. CONCLUSIONS: Nurses must periodically re-evaluate patient medication to check adherence to treatment and determine whether it is causing any type of adverse effect, as well as incorporate health education interventions in this field into their activity.

Impact of a multifaceted intervention to improve antibiotic prescribing: a pragmatic cluster-randomised controlled trial.

OBJECTIVES: This study sought to assess the effectiveness and return on investment (ROI) of a multifaceted intervention aimed at improving antibiotic prescribing for acute respiratory infections in primary care. DESIGN: Large-sized, two-arm, open-label, pragmatic, cluster-randomised controlled trial. SETTING: All primary care physicians working for the Spanish National Health Service (NHS) in Galicia (region in north-west Spain). PARTICIPANTS: The seven spatial clusters were distributed by unequal randomisation (3:4) of the intervention and control groups. A total of 1217 physicians (1.30 million patients) were recruited from intervention clusters and 1393 physicians (1.46 million patients) from control clusters. INTERVENTIONS: One-hour educational outreach visits tailored to training needs identified in a previous study; an online course integrated in practice accreditation; and a clinical decision support system. MAIN OUTCOME MEASURES: Changes in the ESAC (European Surveillance of Antimicrobial Consumption) quality indicators for outpatient antibiotic use. We used generalised linear mixed and conducted a ROI analysis to ascertain the overall cost savings. RESULTS: Median follow-up was 19 months. The adjusted effect on overall antibiotic prescribing attributable to the intervention was - 4.2% (95% CI: - 5.3% to - 3.2%), with this being more pronounced for penicillins - 6.5 (95% CI: - 7.9% to - 5.2%) and for the ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides - 9.0% (95% CI: - 14.0 to - 4.1%). The cost of the intervention was €87 per physician. Direct savings per physician attributable to the reduction in antibiotic prescriptions was €311 for the NHS and €573 for patient contributions, with an ROI of €2.57 and €5.59 respectively. CONCLUSIONS: Interventions designed on the basis of gaps in physicians' knowledge of and attitudes to misprescription can improve antibiotic prescribing and yield important direct cost savings. TRIAL REGISTRATION: Current Controlled Trials ISRCTN24158380 . Registered 5 February 2009.

[Ethics Committee experience during COVID-19 emergency. A brief report.] / Experiencia de un Comité de Ética de la Investigación durante la pandemia por COVID-19.

OBJECTIVE: The health crisis caused by COVID-19 required the prompt launch of research in order to generate scientific evidence pertaining to the new disease oriented to control its devastating effects and continuous spread. Therefore, it was essential to adapt the work flow of Research Ethics Committees, to prioritize and to accelerate the evaluation of projects related to this disease. METHODS: This work analyses the evaluation conducted by our Regional Ethics Committees during the initial period of the health emergency (between 13th March and 28th May 2020). RESULTS: 81 research projects were evaluated, 73 of them of regional scope (62 single-centre), 4 national and 4 international. 57 projects obtained a favourable opinion, 4 were withdrawn by the sponsors, 6 did not require ethics approval and 14 did not respond to the clarifications requested up to the date of the study's closure. CONCLUSIONS: The most important research procedures to be analysed in this context are those related to the methodology and informed consent process. It is also essential to address aspects related to the privacy of personal data, and to take into account the workload of the researchers. As an improvement proposal, we think that greater collaboration between the different research teams should be encourage to obtain more robust results.

OBJETIVO: La crisis sanitaria motivada por la COVID-19 hace necesaria la puesta en marcha, con celeridad, de investigaciones encaminadas a generar evidencias científicas que incidan en el control de sus devastadores efectos. Por ello, fue necesario realizar ajustes en la dinámica de trabajo de los Comités de Ética de la Investigación, así como priorizar y agilizar la evaluación de los proyectos relacionados con dicha enfermedad. Este trabajo pretendió analizar la actividad la actividad evaluadora del Comité de Ética de la Investigación con Medicamentos de Galicia (CEIm-G) durante dicho período de emergencia sanitaria. METODOS: Se evaluaron 81 proyectos de investigación, 73 de ellos de ámbito autonómico (62 unicéntricos), 4 nacionales y 4 internacionales. RESULTADOS: En 57 proyectos el dictamen fue favorable, 4 fueron retirados por los promotores, en 6 no procedía dictamen y 14 no respondieron a las aclaraciones solicitadas hasta la fecha del cierre del estudio. CONCLUSIONES: Las causas más frecuentes de solicitud de aclaraciones están relacionadas con la metodología y, a continuación, con la hoja de información al paciente y el consentimiento informado. También es imprescindible abordar los aspectos relacionados con la intimidad de los datos personales y las muestras, e igualmente tener en cuenta la carga de trabajo de los investigadores. Como propuesta de mejora, consideramos que se debe incidir en una mayor coordinación entre los diferentes equipos de investigación para tratar de obtener resultados más robustos.

Parent-related factors influencing antibiotic use in a paediatric population: A qualitative study in Spain.

AIM: To explore the parent-related factors underlying antibiotic misuse/overuse and their implication in the development of resistance in the paediatric population. METHODS: Qualitative study using the focus group (FG) method in Galicia (Spain). FG sessions were conducted with the parents, 27 mothers and three fathers, of children under 12 years old. A discussion topic guide was developed to lead the sessions, which were then transcribed by the researcher and independently interpreted by two researchers working separately. The grounded theory approach was used. RESULTS: Five FG sessions were conducted. The principal factor detected among parents was fear, associated with the perception of poor parent-paediatrician communication. This factor was related to the following behaviours: (a) pressure on physicians; (b) lack of adherence to treatment; and (c) search for other ways of accessing antibiotics. No group highlighted antibiotic resistance as posing a real problem. All groups considered certain external agents to be responsible for such resistance. Four groups also acknowledged that patient behaviour can influence antibiotic resistance. CONCLUSION: Our study points to poor communication between the healthcare system and the population. Identifying the factors underlying the problem enables more efficient, tailor-made interventions to be designed for the purpose of improving antibiotic use and resistance.

Experiencia de un comité de ética de la investigación durante la pandemia por COVID-19 / Ethics Committee experience during COVID-19 emergency. A brief report

OBJETIVO: La crisis sanitaria motivada por la COVID-19 hace necesaria la puesta en marcha, con celeridad, de investigaciones encaminadas a generar evidencias científicas que incidan en el control de sus devastadores efectos. Por ello, fue necesario realizar ajustes en la dinámica de trabajo de los Comités de Ética de la Investigación, así como priorizar y agilizar la evaluación de los proyectos relacionados con dicha enfermedad. Este trabajo pretendió analizar la actividad la actividad evaluadora del Comité de Ética de la Investigación con Medicamentos de Galicia (CEIm-G) durante dicho período de emergencia sanitaria. MÉTODOS: Se evaluaron 81 proyectos de investigación, 73 de ellos de ámbito autonómico (62 unicéntricos), 4 nacionales y 4 internacionales. RESULTADOS: En 57 proyectos el dictamen fue favorable, 4 fueron retirados por los promotores, en 6 no procedía dictamen y 14 no respondieron a las aclaraciones solicitadas hasta la fecha del cierre del estudio. CONCLUSIONES: Las causas más frecuentes de solicitud de aclaraciones están relacionadas con la metodología y, a continuación, con la hoja de información al paciente y el consentimiento informado. También es imprescindible abordar los aspectos relacionados con la intimidad de los datos personales y las muestras, e igualmente tener en cuenta la carga de trabajo de los investigadores. Como propuesta de mejora, consideramos que se debe incidir en una mayor coordinación entre los diferentes equipos de investigación para tratar de obtener resultados más robustos

OBJECTIVE: The health crisis caused by COVID-19 required the prompt launch of research in order to generate scientific evidence pertaining to the new disease oriented to control its devastating effects and continuous spread. Therefore, it was essential to adapt the work flow of Research Ethics Committees, to prioritize and to accelerate the evaluation of projects related to this disease. METHODS: This work analyses the evaluation conducted by our Regional Ethics Committees during the initial period of the health emergency (between 13th March and 28th May 2020). RESULTS: 81 research projects were evaluated, 73 of them of regional scope (62 single-centre), 4 national and 4 international. 57 projects obtained a favourable opinion, 4 were withdrawn by the sponsors, 6 did not require ethics approval and 14 did not respond to the clarifications requested up to the date of the study's closure. CONCLUSIONS: The most important research procedures to be analysed in this context are those related to the methodology and informed consent process. It is also essential to address aspects related to the privacy of personal data, and to take into account the workload of the researchers. As an improvement proposal, we think that greater collaboration between the different research teams should be encourage to obtain more robust results

Pharmaceutical companies information and antibiotic prescription patterns: A follow-up study in Spanish primary care.

OBJECTIVES: To assess the impact of sources of drug information on antibiotic prescribing patterns (quantity and quality) among primary care physicians. METHODS: We conducted a cohort study on primary care physicians who were actively engaged in medical practice in 2010 in a region in north-west Spain (Galicia), fulfilling inclusion criteria (n = 2100). As the independent variable, we took the perceived utility of 6 sources of information on antibiotics, as measured by the validated KAAR-11 questionnaire. As dependent variables, we used: (1) a quality indicator (appropriate quality, defined as any case where 6 of the 12 indicators proposed by the European Surveillance of Antimicrobial Consumption Network [ESAC-Net] were better than the mean values for Spain); and, (2) a quantity indicator (high prescribing), defined as any case where defined daily doses (DDD) per 1 000 inhabitants per day of antibacterials for systemic use were higher than the mean values for Spain. The adjusted odds ratio for a change in the interquartile range (IqOR) for each sources of information on antibiotics was calculated using Generalized Linear Mixed Models. RESULTS: The questionnaire response rate was 68%. Greater perceived utility of pharmaceutical sales representatives increases the risk of having high prescribing (1/IqOR = 2.50 [95%CI: 1.63-3.66]) and reduces the probability of having appropriate quality (1/IqOR = 2.28 [95%CI: 1.77-3.01]). Greater perceived utility of clinical guidelines increases the probability of having appropriate quality (1/IqOR = 1.25 [95%CI: 1.02-1.54]) and reduces the probability of high prescribing (1/IqOR = 1.25 [95%CI: 1.02-1.54]). CONCLUSIONS: Sources of information on antibiotics are an important determinant of the quantity and quality of antibiotic prescribing in primary care. Commercial sources of information influence prescribing negatively, and clinical guidelines are associated with better indicators.

Magnitude and determinants of antibiotic dispensing without prescription in Spain: a simulated patient study.

Objectives: Excessive and inappropriate use of antibiotics increases antimicrobial resistance. The aim of this study was to determine the magnitude and determinants of antibiotic dispensing without prescription in Spain by the simulated patient technique. Methods: A cross-sectional study was conducted with all the pharmacies in a region of north-west Spain (n = 977), between December 2016 and January 2017. Four actors visited the pharmacies simulating a respiratory infection. Four incremental levels of pressure were used to obtain an antibiotic. The education and sex of the person who was dispensing and the area where the pharmacy was located were recorded. The effect of these independent variables on the dispensing of an antibiotic without prescription (1 = yes, 0 = no) was modelled by logistic regression. Results: An antibiotic was obtained in 18.83% (95% CI = 16.5%-21.41%) of the visits. The area influenced the dispensing of antibiotics without a medical prescription, with a greater likelihood of dispensing in rural (OR = 1.79; 95% CI = 1.20-2.68) or semi-rural (OR = 1.66; 95% CI = 1.13-2.44) areas than in urban areas. No association was found with the sex or the training of the person who dispensed the antibiotic. In the pharmacies in urban areas, a lower level of pressure was needed to obtain the antibiotic. Conclusions: This study shows that one-fifth of the pharmacies still dispense antibiotics without prescription, especially under patient pressure. A rural setting has been identified as a risk factor for dispensing without prescription, so it must be taken into account for future interventions.

Knowledge, attitudes, perceptions and habits towards antibiotics dispensed without medical prescription: a qualitative study of Spanish pharmacists.

OBJECTIVE: To investigate community pharmacists' knowledge, attitudes, perceptions and habits with regard to antibiotic dispensing without medical prescription in Spain. METHODS: A qualitative research using focus group method (FG) in Galicia (north-west Spain). FG sessions were conducted in the presence of a moderator. A topic script was developed to lead the discussions, which were audiorecorded to facilitate data interpretation and transcription. Proceedings were transcribed by an independent researcher and interpreted by two researchers working independently. We used the Grounded Theory approach. SETTING: Community pharmacies in Galicia, region Norwest of Spain. PARTICIPANTS: Thirty pharmacists agreed to participate in the study, and a total of five FG sessions were conducted with 2-11 pharmacists. We sought to ensure a high degree of heterogeneity in the composition of the groups to improve our study's external validity. Pharmacists' participation had no gender or age restrictions, and an effort was made to form FGs with pharmacists who were both owners and non-owners, provided in all cases that they were Official Colleges of Pharmacists-registered community pharmacists. For the purpose of conducting FG discussions, the basic methodological principle of allowing groups to attain their 'own structural identity' was applied. MAIN OUTCOME MEASUREMENTS: Community pharmacists' habits and knowledge with regard to antibiotics and identification of the attitudes and/or factors that influence antibiotic dispensing without medical prescription. RESULTS: Pharmacists attributed the problem of antibiotics dispensed without medical prescription and its relationship to antibiotic resistance to the following attitudes: external responsibility (doctors, dentists and the National Health Service (NHS)); acquiescence; indifference and lack of continuing education. CONCLUSIONS: Despite being a problem, antibiotic dispensing without a medical prescription is still a common practice in community pharmacies in Galicia, Spain. This practice is attributed to acquiescence, indifference and lack of continuing education. The problem of resistance was ascribed to external responsibility, including that of patients, physicians, dentists and the NHS.

Development and validation of the knowledge and attitudes regarding antibiotics and resistance (KAAR-11) questionnaire for primary care physicians.

OBJECTIVES: The aim of this study was to develop a novel, self-administered questionnaire to identify primary-care physicians' knowledge and attitudes regarding antibiotics and resistance (KAAR). METHODS: The study population comprised primary care physicians. The study was conducted in five phases. Phase I consisted of a systematic review and qualitative focus-group study (n = 33 physicians), in which items were formulated so as to be measured on a continuous, visual analogue scale (VAS); in Phase II, content validation and face validity were evaluated by a panel of experts, which reformulated, added and deleted items; Phase III consisted of a pilot study on a population possessing similar characteristics (n = 15); in Phase IV, we analysed reliability by means of a test-retest study (n = 91) and calculated the intraclass correlation coefficients (ICCs); and in Phase V, we assessed construct validity by applying the known-groups technique, measuring the differences between contrasting groups of physicians formed according to antibiotic prescription quality indicators (group 1, n = 156 versus group 2, n = 191). RESULTS: Following Phases I and II, the questionnaire contained 16 knowledge and attitude items. Participants in the pilot study (Phase III) reported no difficulty. The test-retest study (Phase IV) showed that 11 of the 16 initial knowledge and attitude items yielded an ICC > 0.5, while analysis of known-groups validity (Phase V) showed that 13 of the 16 initial items which assessed knowledge and attitudes discriminated between physicians with good and bad indicators of antibiotics prescription. CONCLUSION: The final 11 item KAAR questionnaire appears to be valid, reliable and responsive.

Effect of Physicians' Attitudes and Knowledge on the Quality of Antibiotic Prescription: A Cohort Study.

Resistance increases with the use and abuse of antibiotics. Since physicians are primarily responsible for the decision to use antibiotics, ascertaining the attitudes and knowledge that underlie their prescribing habits is thus a prerequisite for improving prescription. Three-year follow-up cohort study (2008-2010) targeting primary-care physicians (n = 2100) in Galicia, a region in NW Spain. We used data obtained from a postal survey to assess knowledge and attitudes. A physician was deemed to have demonstrated Appropriate Quality Prescription of Antibiotics (dependent variable) in any case where half or more of the indicators proposed by the European Surveillance of Antimicrobial Consumption had values that were better than the reference values for Spain. The mail-questionnaire response rate was 68·0% (1428/2100). The adjusted increase in the interquartile OR of displaying good prescribing of antibiotics for each attitude was: 205% for fear ("When in doubt, it is better to ensure that a patient is cured of an infection by using a broad-spectrum antibiotic"; 95%CI: 125% to 321%); 119% for better knowledge ("Amoxicillin is useful for resolving most respiratory infections in primary care"; 95%CI: 67% to 193%); and 21% for complacency with patients' demands ("Antibiotics are often prescribed due to patients' demands"; 95%CI: 0% to 45%). Due to the fact that physicians' knowledge and attitudes are potentially modifiable, the implementation of purpose-designed educational interventions based on the attitudes identified may well serve to improve antibiotic prescription.

Misprescription of antibiotics in primary care: a critical systematic review of its determinants.

BACKGROUND: Antibiotic resistance is one of the principal public health problems worldwide. Currently, inappropriate use of antibiotics is regarded as the principal determinant of resistance, with most of these drugs being prescribed outside a hospital setting. This systematic review sought to identify the factors, attitudes and knowledge linked to misprescription of antibiotics. METHODS: A systematic review was conducted using the MEDLINE-PubMed and EMBASE databases. The selection criteria required that papers: (1) be published in English or Spanish; (2) designate their objective as that of addressing attitudes/knowledge or other factors related with the prescribing of antibiotics; and (3) use quality and/or quantity indicators to define misprescription. The following were excluded: any paper that used qualitative methodology and any paper that included descriptive analysis only. RESULTS: A total of 46 papers that met the inclusion criteria were included in the review. They were very heterogeneous and displayed major methodological limitations. Doctors' socio-demographic and personal factors did not appear to exert much influence. Complacency (fulfilling what professionals perceived as being patients'/parents' expectations) and, to a lesser extent, fear (fear of possible complications in the patient) were the attitudes associated with misprescription of antibiotics. CONCLUSIONS: Before designing interventions aimed at improving the prescription and use of antibiotics, studies are needed to identify precisely which factors influence prescribing.