Mothers' acceptability of using novel technology with video and audio recording during newborn resuscitation: A cross-sectional survey.

OBJECTIVE: This study aims to assess the acceptability of a novel technology, MAchine Learning Application (MALA), among the mothers of newborns who required resuscitation. SETTING: This study took place at Bharatpur Hospital, which is the second-largest public referral hospital with 13 000 deliveries per year in Nepal. DESIGN: This is a cross-sectional survey. DATA COLLECTION AND ANALYSIS: Data collection took place from January 21 to February 13, 2022. Self-administered questionnaires on acceptability (ranged 1-5 scale) were collected from participating mothers. The acceptability of the MALA system, which included video and audio recordings of the newborn resuscitation, was examined among mothers according to their age, parity, education level and technology use status using a stratified analysis. RESULTS: The median age of 21 mothers who completed the survey was 25 years (range 18-37). Among them, 11 mothers (52.4%) completed their bachelor's or master's level of education, 13 (61.9%) delivered first child, 14 (66.7%) owned a computer and 16 (76.2%) carried a smartphone. Overall acceptability was high that all participating mothers positively perceived the novel technology with video and audio recordings of the infant's care during resuscitation. There was no statistical difference in mothers' acceptability of MALA system, when stratified by mothers' age, parity, or technology usage (p>0.05). When the acceptability of the technology was stratified by mothers' education level (up to higher secondary level vs. bachelor's level or higher), mothers with Bachelor's degree or higher more strongly felt that they were comfortable with the infant's care being video recorded (p = 0.026) and someone using a tablet when observing the infant's care (p = 0.046). Compared with those without a computer (n = 7), mothers who had a computer at home (n = 14) more strongly agreed that they were comfortable with someone observing the resuscitation activity of their newborns (71.4% vs. 14.3%) (p = 0.024). CONCLUSION: The novel technology using video and audio recordings for newborn resuscitation was accepted by mothers in this study. Its application has the potential to improve resuscitation quality in low-and-middle income settings, given proper informed consent and data protection measures are in place.

Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal.

BACKGROUND: Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. OBJECTIVE: This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. METHODS: The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. RESULTS: Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. CONCLUSION: The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.

Main findings: Before the Moyo implementation, foetal heart rate monitoring was sub-optimal in the hospitals, which changed after introduction of the device, as it helped early display of foetal heart rate in the monitor and supported communication with women during the labour and delivery.Added knowledge: Implementation of Moyo in low-resource setting requires an interdisciplinary approach with continuous support to health care providers on how to correctly read Moyo, maintenance of device and management of false reading.Global health impact for policy and action: The global efforts to accelerate reduce preventable intrapartum related neonatal death requires contextual understanding of clinical context for effective implementation of Moyo.

NeuroMotion smartphone application for remote General Movements Assessment: a feasibility study in Nepal.

OBJECTIVES: To evaluate the feasibility of using the NeuroMotion smartphone application for remote General Movements Assessment for screening infants for cerebral palsy in Kathmandu, Nepal. METHOD: Thirty-one term-born infants at risk of cerebral palsy due to birth asphyxia or neonatal seizures were recruited for the follow-up at Paropakar Maternity and Women's Hospital, 1 October 2021 to 7 January 2022. Parents filmed their children at home using the application at 3 months' age and the videos were assessed for technical quality using a standardised form and for fidgety movements by Prechtl's General Movements Assessment. The usability of the application was evaluated through a parental survey. RESULTS: Twenty families sent in altogether 46 videos out of which 35 had approved technical quality. Sixteen children had at least one video with approved technical quality. Three infants lacked fidgety movements. The level of agreement between assessors was acceptable (Krippendorf alpha 0.781). Parental answers to the usability survey were in general positive. INTERPRETATION: Engaging parents in screening of cerebral palsy with the help of a smartphone-aided remote General Movements Assessment is possible in the urban area of a South Asian lower middle-income country.

Facilitators and barriers for implementation of a novel resuscitation quality improvement package in public referral hospitals of Nepal.

BACKGROUND: Improving the healthcare providers (HCP) basic resuscitation skills can reduce intrapartum related mortality in low- and middle-income countries. However, the resuscitation intervention's successful implementation is largely dependent on proper facilitation and context. This study aims to identify the facilitators and barriers for the implementation of a novel resuscitation package as part of the quality improvement project in Nepal. METHODS: The study used a qualitative descriptive design. The study sites included four purposively chosen public hospitals in Nepal, where the resuscitation package (Helping Babies Breathe [HBB] training, resuscitation equipment and NeoBeat) had been implemented as part of the quality improvement project. Twenty members of the HCP, who were trained and exposed to the package, were selected through convenience sampling to participate in the study interviews. Data were collected through semi-structured interviews conducted via telephone and video calls. Twenty interview data were analyzed with a deductive qualitative content analysis based on the core components of the i-PARiHS framework. RESULTS: The findings suggest that there was a move to more systematic resuscitation practices among the staff after the quality improvement project's implementation. This positive change was supported by a neonatal heart rate monitor (NeoBeat), which guided resuscitation and made it easier. In addition, seeing the positive outcomes of successful resuscitation motivated the HCPs to keep practicing and developing their resuscitation skills. Facilitation by the project staff enabled the change. At the same time, facilitators provided extra support to maintain the equipment, which can be a challenge in terms of sustainability, after the project. Furthermore, a lack of additional resources, an unclear leadership role, and a lack of coordination between nurses and medical doctors were barriers to the implementation of the resuscitation package. CONCLUSION: The introduction of the resuscitation package, as well as the continuous capacity building of local multidisciplinary healthcare staff, is important to continue the accelerated efforts of improving newborn care. To secure sustainable change, facilitation during implementation should focus on exploring local resources to implement the resuscitation package sustainably. TRIAL REGISTRATION: Not applicable.

Association between usage of household cooking fuel and congenital birth defects-18 months multi-centric cohort study in Nepal.

BACKGROUND: - An estimated 240,000 newborns die worldwide within 28 days of birth every year due to congenital birth defect. Exposure to poor indoor environment contributes to poor health outcomes. In this research, we aim to evaluate the association between the usage of different type household cooking fuel and congenital birth defects in Nepal, as well as investigate whether air ventilation usage had a modifying effect on the possible association. METHODS: - This is a secondary analysis of multi-centric prospective cohort study evaluating Quality Improvement Project in 12 public referral hospitals of Nepal from 2017 to 2018. The study sample was 66,713 women with a newborn, whose information was available in hospital records and exit interviews. The association between cooking fuel type usage and congenital birth defects was investigated with adjusted multivariable logistic regression. To investigate the air ventilation usage, a stratified multivariable logistic regression analysis was performed. RESULTS: -In the study population (N = 66,713), 60.0% used polluting fuels for cooking and 89.6% did not have proper air ventilation. The prevalence rate of congenital birth defect was higher among the families who used polluting fuels for cooking than those who used cleaner fuels (5.5/1000 vs. 3.5/1000, p < 0.001). Families using polluting fuels had higher odds (aOR 1.49; 95% CI; 1.16, 1.91) of having a child with a congenital birth defect compared to mothers using cleaner fuels adjusted with all available co-variates. Families not using ventilation while cooking had even higher but statistically insignificant odds of having a child with congenital birth defects (aOR 1.34; 95% CI; 0.86, 2.07) adjusted with all other variates. CONCLUSION: - The usage of polluted fuels for cooking has an increased odds of congenital birth defects with no significant association with ventilation. This study adds to the increasing knowledge on the adverse effect of polluting fuels for cooking and the need for action to reduce this exposure.

Recent Progress in Neonatal Global Health Quality Improvement.

Quality improvement methodologies, coupled with basic neonatal resuscitation and essential newborn care training, have been shown to be critical ingredients in improving neonatal mortality. Innovative methodologies, such as virtual training and telementoring, can enable the mentorship and supportive supervision that are essential to the continued work of improvement and health systems strengthening that must be done after a single training event. Empowering local champions, building effective data collection systems, and developing frameworks for audits and debriefs are among the strategies that will create effective and high-quality health care systems.

Observational study comparing heart rate in crying and non-crying but breathing infants at birth.

BACKGROUND: Stimulating infants to elicit a cry at birth is common but could result in unnecessary handling. We evaluated heart rate in infants who were crying versus non-crying but breathing immediately after birth. METHODS: This was single-centre observational study of singleton, vaginally born infants at ≥33 weeks of gestation. Infants who were crying or non-crying but breathing within 30 s after birth were included. Background demographic data and delivery room events were recorded using tablet-based applications and synchronised with continuous heart rate data recorded by a dry-electrode electrocardiographic monitor. Heart rate centile curves for the first 3 min of life were generated with piecewise regression analysis. Odds of bradycardia and tachycardia were compared using multiple logistic regression. RESULTS: 1155 crying and 54 non-crying but breathing neonates were included in the final analyses. There were no significant differences in the demographic and obstetric factors between the cohorts. Non-crying but breathing infants had higher rates of early cord clamping <60 s after birth (75.9% vs 46.5%) and admission to the neonatal intensive care unit (13.0% vs 4.3%). There were no significant differences in median heart rates between the cohorts. Non-crying but breathing infants had higher odds of bradycardia (heart rate <100 beats/min, adjusted OR 2.64, 95% CI 1.34 to 5.17) and tachycardia (heart rate ≥200 beats/min, adjusted OR 2.86, 95% CI 1.50 to 5.47). CONCLUSION: Infants who are quietly breathing but do not cry after birth have an increased risk of both bradycardia and tachycardia, and admission to the neonatal intensive care unit. TRIAL REGISTRATION NUMBER: ISRCTN18148368.

Association of disrespectful care after childbirth and COVID-19 exposure with postpartum depression symptoms- a longitudinal cohort study in Nepal.

BACKGROUND: The COVID-19 pandemic has led to unprecedented mental stress to women after childbirth. In this study, we assessed the association of disrespectful care after childbirth and COVID-19 exposure before/during labour with postpartum depression symptoms assessed at 7 and 45 days in Nepal. METHODS: A longitudinal cohort study was conducted in 9 hospitals of Nepal among 898 women. The independent data collection system was established in each hospital to collection information on disrespectful care after birth via observation, exposure to COVID-19 infection before/during labour and other socio-demographic via interview. The information on depressive symptoms at 7 and 45 days was collected using the validated Edinburg Postnatal Depression Scale (EPDS) tool. Multi-level regression was performed to assess the association of disrespectful care after birth and COVID-19 exposure with postpartum depression. RESULT: In the study, 16.5% were exposed to COVID-19 before/during labour and 41.8% of them received disrespectful care after childbirth. At 7 and 45 days postpartum, 21.3% and 22.4% of women reported depressive symptoms respectively. In the multi-level analysis, at the 7th postpartum day, women who had disrespectful care and no COVID-19 exposure still had 1.78 higher odds of having depressive symptom (aOR, 1.78; 95% CI; 1.16, 2.72). In the multi-level analysis, at 45th postpartum day, women who had disrespectful care and no COVID-19 exposure had 1.37 higher odds of having depressive symptoms (aOR, 1.37; 95% CI; 0.82, 2.30), but not statistically significant. CONCLUSION: Disrespectful care after childbirth was strongly associated with postpartum depression symptoms irrespective of COVID-19 exposure during pregnancy. Caregivers, even during the global pandemic, should continue to focus their attention for immediate breast feeding and skin-to-skin contact, as this might reduce the risk for depressive symptoms postpartum.

Improved obstetric management after implementation of a scaled-up quality improvement intervention: A nested before-after study in three public hospitals in Nepal.

BACKGROUND: We assessed the change in obstetric management after implementation of a quality improvement intervention, the Nepal Perinatal Quality Improvement Package (NePeriQIP). METHODS: The Nepal Perinatal Quality Improvement Package was a stepped-wedge cluster-randomized controlled trial conducted in 12 public hospitals in Nepal between April 2017 and October 2018. In this study, three hospitals allocated at different time points to the intervention were selected for a nested before-after analysis. We used bivariate and multivariate analyses to compare obstetric management in the control vs intervention group. RESULTS: There were 25 977 deliveries in the three hospitals during the study period: 10 207 (39%) in the control and 15 770 (61%) in the intervention group. After adjusting for maternal age, ethnicity, education, gestational age, stage of labor at admission, complications during labor, and birthweight, the intervention group had a higher proportion of fetal heart rate monitoring performed as per protocol (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.12-1.27), shorter time intervals between each fetal heart rate monitoring (aOR 2.09, 95% CI 1.96-2.23), a higher likelihood of abnormal fetal heart rate being detected (aOR 1.53, 95% CI 1.25-1.68), progress of labor more often being recorded immediately after per vaginal examination (aOR 2.73, 95% CI 2.55-2.93), and partograph filled as per standards (aOR 3.18, 95% CI 2.98-3.50). The cesarean birth rate was 2.5% in the control group and 8.2% in the intervention group (aOR 3.12, 95% CI 2.64-3.68). CONCLUSIONS: The NePeriQIP intervention has potential to improve obstetric care, especially intrapartum fetal surveillance, in similar low-resource settings.

Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries.

Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from -90% to +30%, were reported in many countries following early COVID-19 pandemic response measures ('lockdowns'). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95-0.98, P value <0.0001), second (0.96, 0.92-0.99, 0.03) and third (0.97, 0.94-1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96-1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88-1.14, 0.98), third (0.99, 0.88-1.12, 0.89) and fourth (1.01, 0.87-1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02-1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03-1.15, 0.002), third (1.10, 1.03-1.17, 0.003) and fourth (1.12, 1.05-1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways.

Increased risk of bradycardia in vigorous infants receiving early as compared to delayed cord clamping at birth.

OBJECTIVE: To compare HR pattern of vigorous newborns during the first 180 s with early (≤60 s, ECC) or delayed (>60 s, DCC) cord clamping. STUDY DESIGN: Observational study including dry-electrode ECG monitoring of 610 vaginally-born singleton term and late-preterm (≥34 weeks) who were vigorous after birth. RESULTS: 198 received ECC while 412 received DCC with median cord clamping at 37 s and 94 s. Median HR remained stable from 30 to 180 s with DCC (172 and 170 bpm respectively) but increased with ECC (169 and 184 bpm). The proportion with bradycardia was higher among ECC than DCC at 30 s and fell faster in the DCC through 60 s. After adjusting for factors affecting timing of cord clamping, ECC had significant risk of bradycardia compared to DCC (aRR 1.51; 95% CI; 1.01-2.26). CONCLUSION: Early heart instability and higher risk of bradycardia with ECC as compared to DCC supports the recommended clinical practice of DCC.

Usability, acceptability and feasibility of a novel technology with visual guidance with video and audio recording during newborn resuscitation: a pilot study.

OBJECTIVE: Inadequate adherence to resuscitation for non-crying infants will have poor outcome and thus rationalise a need for real-time guidance and quality improvement technology. This study assessed the usability, feasibility and acceptability of a novel technology of real-time visual guidance, with sound and video recording during resuscitation. SETTING: A public hospital in Nepal. DESIGN: A cross-sectional design. INTERVENTION: The technology has an infant warmer with light, equipped with a tablet monitor, NeoBeat and upright bag and mask. The tablet records resuscitation activities, ventilation sound, heart rate and display time since birth. Healthcare providers (HCPs) were trained on the technology before piloting. DATA COLLECTION AND ANALYSIS: HCPs who had at least 8 weeks of experience using the technology completed a questionnaire on usability, feasibility and acceptability (ranged 1-5 scale). Overall usability score was calculated (ranged 1-100 scale). RESULTS: Among the 30 HCPs, 25 consented to the study. The usability score was good with the mean score (SD) of 68.4% (10.4). In terms of feasibility, the participants perceived that they did not receive adequate support from the hospital administration for use of the technology, mean score (SD) of 2.44 (1.56). In terms of acceptability, the information provided in the monitor, that is, time elapsed from birth was easy to understand with mean score (SD) of 4.60 (0.76). CONCLUSION: The study demonstrates reasonable usability, feasibility and acceptability of a technological solution that records audio visual events during resuscitation and provides visual guidance to improve care.

Incidence and outcomes of intrapartum-related neonatal encephalopathy in low-income and middle-income countries: a systematic review and meta-analysis.

AIM: To examine the incidence of intrapartum-related neonatal encephalopathy, and neonatal mortality and neurodevelopmental outcomes associated with it in low-income and middle-income countries. METHODS: Reports were included when neonatal encephalopathy diagnosed clinically within 24 hours of birth in term or near-term infants born after intrapartum hypoxia-ischaemia defined as any of the following: (1) pH≤7.1 or base excess ≤-12 or lactate ≥6, (2) Apgar score ≤5 at 5 or 10 min, (3) continuing resuscitation at 5 or 10 min or (4) no cry from baby at 5 or 10 min. Peer-reviewed articles were searched from Ovid MEDLINE, Cochrane, Web of Science and WHO Global Index Medicus with date limits 1 November 2009 to 17 November 2021. Risk of bias was assessed using modified Newcastle Ottawa Scale. Inverse variance of heterogenicity was used for meta-analyses. RESULTS: There were 53 reports from 51 studies presenting data on 4181 children with intrapartum-related neonatal encephalopathy included in the review. Only five studies had data on incidence, which ranged from 1.5 to 20.3 per 1000 live births. Neonatal mortality was examined in 45 studies and in total 636 of the 3307 (19.2%) infants died. Combined outcome of death or moderate to severe neurodevelopmental disability was reported in 19 studies and occurred in 712 out of 1595 children (44.6%) with follow-up 1 to 3.5 years. CONCLUSION: Though there has been progress in some regions, incidence, case mortality and morbidity in intrapartum-related neonatal encephalopathy has been static in the last 10 years. PROSPERO REGISTRATION NUMBER: CRD42020177928.

Service readiness and availability of perinatal care in public hospitals - a multi-centric baseline study in Nepal.

BACKGROUND: Poor quality of maternal and newborn care contributes to nearly two million deaths of mothers and their newborns worldwide annually. Assessment of readiness and availability of perinatal care services in health facilities provides evidence to underlying bottlenecks for improving quality of care. This study aimed to evaluate the readiness and availability of perinatal care services in public hospitals of Nepal using WHO's health system framework. METHODS: This was a mixed methods study conducted in 12 public hospitals in Nepal. A cross-sectional study design was used to assess the readiness and availability of perinatal care services. Three different data collection tools were developed. The tools were pretested in a tertiary maternity hospital and the discrepancies in the tools were corrected before administering in the study hospitals. The data were collected between July 2017 to July 2018. RESULTS: Only five out of 12 hospitals had the availability of all the basic newborn care services under assessment. Kangaroo mother care (KMC) service was lacking in most of the hospitals (7 out of 12). Only two hospitals had all health workers involved in perinatal care services trained in neonatal resuscitation. All of the hospitals were found not to have all the required equipment for newborn care services. Overall, only 60% of the health workers had received neonatal resuscitation training. A small proportion (3.2%) of the newborn infants with APGAR < 7 at one minute received bag and mask ventilation. Only 8.2% of the mothers initiated breastfeeding to newborn infants before transfer to the post-natal ward, 73.4% of the mothers received counseling on breastfeeding, and 40.8% of the mothers kept their newborns in skin-to-skin contact immediately after birth. CONCLUSION: The assessment reflected the gaps in the availability of neonatal care services, neonatal resuscitation training, availability of equipment, infrastructure, information system, and governance. Rapid scale-up of neonatal resuscitation training and increased availability of equipment is needed for improving the quality of neonatal care services.

Effect of a perinatal care quality improvement package on patient satisfaction: a secondary outcome analysis of a cluster-randomised controlled trial.

OBJECTIVE: To investigate the effect of a quality improvement (QI) package on patient satisfaction of perinatal care. DESIGN: Secondary analysis of a stepped-wedge cluster-randomised controlled trial. Participating hospitals were randomised by size into four different wedges. SETTING: 12 secondary-level public hospitals in Nepal. PARTICIPANTS: Women who gave birth in the hospitals at a gestational age of ≥22 weeks, with fetal heart sound at admission. Adverse outcomes were excluded. One hospital was excluded due to data incompleteness and four low-volume hospitals due to large heterogeneity. The final analysis included 54 919 women. INTERVENTION: Hospital management was engaged and facilitators were recruited from within hospitals. Available perinatal care was assessed in each hospital, followed by a bottle-neck analysis workshop. A 3-day training in essential newborn care was carried out for health workers involved in perinatal care, and a set of QI tools were introduced to be used in everyday practice (skill-checks, self-assessment checklists, scoreboards and weekly Plan-Do-Study-Act meetings). Refresher training after 6 months. OUTCOME MEASURE: Women's satisfaction with care during childbirth (a prespecified secondary outcome). RESULTS: The likelihood of women being overall satisfied with care during childbirth increased after the intervention (adjusted OR (aOR): 1.66, 95% CI: 1.59 to 1.73). However, the proportions of overall satisfaction were low (control 58%, intervention 62%). Women were more likely to be satisfied with education and information from health workers after intervention (aOR: 1.34, 95% CI: 1.29 to 1.40) and to have been treated with dignity and respect (aOR: 1.81, 95% CI: 1.52 to 2.16). The likelihood of having experienced abuse during the hospital stay decreased (aOR: 0.42, 95% CI: 0.34 to 0.51) and of being satisfied with the level of privacy increased (aOR: 1.14, 95% CI: 1.09 to 1.18). CONCLUSIONS: Improvements in patient satisfaction were indicated after the introduction of a QI-package on perinatal care. We recommend further studies on which aspects of care are most important to improve women's satisfaction of perinatal care in hospitals in Nepal. TRIAL REGISTRATION NUMBER: ISRCTN30829654.

Antibiotic Use before, during, and after Seeking Care for Acute Febrile Illness at a Hospital Outpatient Department: A Cross-Sectional Study from Rural India.

Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients' presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including ß-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). 'Watch' antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%).