Raising AWaRe-ness of Antimicrobial Stewardship Challenges in Pediatric Emergency Care: Results from the PERFORM Study Assessing Consistency and Appropriateness of Antibiotic Prescribing Across Europe.

BACKGROUND: Optimization of antimicrobial stewardship is key to tackling antimicrobial resistance, which is exacerbated by overprescription of antibiotics in pediatric emergency departments (EDs). We described patterns of empiric antibiotic use in European EDs and characterized appropriateness and consistency of prescribing. METHODS: Between August 2016 and December 2019, febrile children attending EDs in 9 European countries with suspected infection were recruited into the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management) study. Empiric systemic antibiotic use was determined in view of assigned final "bacterial" or "viral" phenotype. Antibiotics were classified according to the World Health Organization (WHO) AWaRe classification. RESULTS: Of 2130 febrile episodes (excluding children with nonbacterial/nonviral phenotypes), 1549 (72.7%) were assigned a bacterial and 581 (27.3%) a viral phenotype. A total of 1318 of 1549 episodes (85.1%) with a bacterial and 269 of 581 (46.3%) with a viral phenotype received empiric systemic antibiotics (in the first 2 days of admission). Of those, the majority (87.8% in the bacterial and 87.0% in the viral group) received parenteral antibiotics. The top 3 antibiotics prescribed were third-generation cephalosporins, penicillins, and penicillin/ß-lactamase inhibitor combinations. Of those treated with empiric systemic antibiotics in the viral group, 216 of 269 (80.3%) received ≥1 antibiotic in the "Watch" category. CONCLUSIONS: Differentiating bacterial from viral etiology in febrile illness on initial ED presentation remains challenging, resulting in a substantial overprescription of antibiotics. A significant proportion of patients with a viral phenotype received systemic antibiotics, predominantly classified as WHO Watch. Rapid and accurate point-of-care tests in the ED differentiating between bacterial and viral etiology could significantly improve antimicrobial stewardship.

Impact of a package of point-of-care diagnostic tests, a clinical diagnostic algorithm and adherence training on antibiotic prescriptions for the management of non-severe acute febrile illness in primary health facilities during the COVID-19 pandemic in Burkina Faso.

OBJECTIVE: To assess the impact of an intervention package on the prescription of antibiotic and subsequently the rate of clinical recovery for non-severe acute febrile illnesses at primary health centers. METHODS: Patients over 6 months of age presenting to primary health care centres with fever or history of fever within the past 7 days were randomized to receive either the intervention package constituted of point-of-care tests including COVID-19 antigen tests, a diagnostic algorithm and training and communication packages, or the standard practice. The primary outcomes were antibiotic prescriptions at Day 0 (D0) and the clinical recovery at Day 7 (D7). Secondary outcomes were non-adherence of participants and parents/caregivers to prescriptions, health workers' non-adherence to the algorithm, and the safety of the intervention. RESULTS: A total of 1098 patients were enrolled. 551 (50.2%) were randomized to receive the intervention versus 547 (49.8%) received standard care. 1054 (96.0%) completed follow-up and all of them recovered at D7 in both arms. The proportion of patients with antibiotic prescriptions at D0 were 33.2% (183/551) in the intervention arm versus 58.1% (318/547) under standard care, risk difference (RD) -24.9 (95% CI -30.6 to -19.2, p < 0.001), corresponding to one more antibiotic saved every four (95% CI: 3 to 5) consultations. This reduction was also statistically significant in children from 6 to 59 months (RD -34.5; 95% CI -41.7 to -27.3; p < 0.001), patients over 18 years (RD -35.9; 95%CI -58.5 to -13.4; p = 0.002), patients with negative malaria test (RD -46.9; 95% CI -53.9 to -39.8; p < 0.001), those with a respiratory diagnosis (RD -48.9; 95% CI -56.9 to -41.0, p < 0.001) and those not vaccinated against COVID-19 (-24.8% 95%CI -30.7 to -18.9, p-value: <0.001). A significant reduction in non-adherence to prescription by patients was reported (RD -7.1; 95% CI -10.9 to -3.3; p < 0.001). CONCLUSION: The intervention was associated with significant reductions of antibiotic prescriptions and non-adherence, chiefly among patients with non-malaria fever, those with respiratory symptoms and children below 5 years of age. The addition of COVID-19 testing did not have a major impact on antibiotic use at primary health centers. TRIAL REGISTRATION: Clinitrial.gov; NCT04081051 registered on 06/09/2019.

Drivers of district-level differences in outpatient antibiotic prescribing in Germany: a qualitative study with prescribers.

BACKGROUND: Previous studies have identified substantial regional variations in outpatient antibiotic prescribing in Germany, both in the paediatric and adult population. This indicates inappropriate antibiotic prescribing in some regions, which should be avoided to reduce antimicrobial resistance and potential side effects. The reasons for regional variations in outpatient antibiotic prescribing are not yet completely understood; socioeconomic and health care density differences between regions do not fully explain such differences. Here, we apply a behavioural perspective by adapting the Theoretical Domains Framework (TDF) to examine regional factors deemed relevant for outpatient antibiotic prescriptions by paediatricians and general practitioners. METHODS: Qualitative study with guideline-based telephone interviews of 40 prescribers (paediatricians and general practitioners) in outpatient settings from regions with high and low rates of antibiotic prescriptions, stratified by urbanity. TDF domains formed the basis of an interview guide to assess region-level resources and barriers to rational antibiotic prescription behaviour. Interviews lasted 30-61 min (M = 45 min). Thematic analysis was used to identify thematic clusters, and relationships between themes were explored through proximity estimation. RESULTS: Both paediatricians and general practitioners in low-prescribing regions reported supporting contextual factors (in particular good collegial networks, good collaboration with laboratories) and social factors (collegial support and low patient demand for antibiotics) as important resources. In high-prescribing regions, poor coordination between in-patient and ambulatory health services, lack of region-level information on antimicrobial resistance, few professional development opportunities, and regional variations in patient expectations were identified as barriers to rational prescribing behaviour. CONCLUSIONS: Interventions targeting professional development, better collaboration structures with laboratories and clearer and user-friendly guidelines could potentially support rational antibiotic prescribing behaviour. In addition, better networking and social support among physicians could support lower prescription rates.

Decision support systems for antibiotic prescription in hospitals: a survey with hospital managers on factors for implementation.

BACKGROUND: Inappropriate antimicrobial use, such as antibiotic intake in viral infections, incorrect dosing and incorrect dosing cycles, has been shown to be an important determinant of the emergence of antimicrobial resistance. Artificial intelligence-based decision support systems represent a potential solution for improving antimicrobial prescribing and containing antimicrobial resistance by supporting clinical decision-making thus optimizing antibiotic use and improving patient outcomes. OBJECTIVE: The aim of this research was to examine implementation factors of artificial intelligence-based decision support systems for antibiotic prescription in hospitals from the perspective of the hospital managers, who have decision-making authority for the organization. METHODS: An online survey was conducted between December 2022 and May 2023 with managers of German hospitals on factors for decision support system implementation. Survey responses were analyzed from 118 respondents through descriptive statistics. RESULTS: Survey participants reported openness towards the use of artificial intelligence-based decision support systems for antibiotic prescription in hospitals but little self-perceived knowledge in this field. Artificial intelligence-based decision support systems appear to be a promising opportunity to improve quality of care and increase treatment safety. Along with the Human-Organization-Technology-fit model attitudes were presented. In particular, user-friendliness of the system and compatibility with existing technical structures are considered to be important for implementation. The uptake of decision support systems also depends on the ability of an organization to create a facilitating environment that helps to address the lack of user knowledge as well as trust in and skepticism towards these systems. This includes the training of user groups and support of the management level. Besides, it has been assessed to be important that potential users are open towards change and perceive an added value of the use of artificial intelligence-based decision support systems. CONCLUSION: The survey has revealed the perspective of hospital managers on different factors that may help to address implementation challenges for artificial intelligence-based decision support systems in antibiotic prescribing. By combining factors of user perceptions about the systems´ perceived benefits with external factors of system design requirements and contextual conditions, the findings highlight the need for a holistic implementation framework of artificial intelligence-based decision support systems.

A Randomized Trial to Assess the Impact of a Package of Diagnostic Tools and Diagnostic Algorithm on Antibiotic Prescriptions for the Management of Febrile Illnesses Among Children and Adolescents in Primary Health Facilities in Burkina Faso.

BACKGROUND: Low- and middle-income countries face significant challenges in differentiating bacterial from viral causes of febrile illnesses, leading to inappropriate use of antibiotics. This trial aimed to evaluate the impact of an intervention package comprising diagnostic tests, a diagnostic algorithm, and a training-and-communication package on antibiotic prescriptions and clinical outcomes. METHODS: Patients aged 6 months to 18 years with fever or history of fever within the past 7 days with no focus, or a suspected respiratory tract infection, arriving at 2 health facilities were randomized to either the intervention package or standard practice. The primary outcomes were the proportions of patients who recovered at day 7 (D7) and patients prescribed antibiotics at day 0. RESULTS: Of 1718 patients randomized, 1681 (97.8%; intervention: 844; control: 837) completed follow-up: 99.5% recovered at D7 in the intervention arm versus 100% in standard practice (P = .135). Antibiotics were prescribed to 40.6% of patients in the intervention group versus 57.5% in the control arm (risk ratio: 29.3%; 95% CI: 21.8-36.0%; risk difference [RD]: -16.8%; 95% CI: -21.7% to -12.0%; P < .001), which translates to 1 additional antibiotic prescription saved every 6 (95% CI: 5-8) consultations. This reduction was significant regardless of test results for malaria, but was greater in patients without malaria (RD: -46.0%; -54.7% to -37.4%; P < .001), those with a respiratory diagnosis (RD: -38.2%; -43.8% to -32.6%; P < .001), and in children 6-59 months old (RD: -20.4%; -26.0% to -14.9%; P < .001). Except for the period July-September, the reduction was consistent across the other quarters (P < .001). CONCLUSIONS: The implementation of the package can reduce inappropriate antibiotic prescription without compromising clinical outcomes. CLINICAL TRIALS REGISTRATION: clinicaltrials.gov; NCT04081051.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children.

BACKGROUND: Antibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications. METHODS: Our trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2-14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost. RESULTS: DAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD. CONCLUSIONS: When clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy. TRIAL REGISTRATION: This trial has been registered at www. CLINICALTRIALS: gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

Dental implant procedures contribution to the total antibiotic use in Swedish dentistry. A register-based study.

OBJECTIVE: To study the influence of demographic and organizational factors to antibiotic utilization in dental implant surgery in Sweden. MATERIAL AND METHODS: Descriptive statistics regarding antibiotic prescription between 2009 and 2019 was retrieved from two national registers, the Swedish Prescribed Drug Register and the Dental Health register, both administered by the National Board of Health and Welfare. RESULTS: During the years 2009-2019 a significant decrease of the proportion of prescriptions of systemic antibiotics in conjunction with implant surgical procedures occurred in all patient groups where the most common procedure was the insertion of a single implant. The proportion of dental visits when implant surgical treatment was performed which resulted in a prescription of antibiotics decreased significantly from 1/3 to approximately 1/5. However, comparing Public and Private dental care providers, the reduction was significantly greater in Public dental care. Patients with low level of education in urban regions, treated in Private dental clinics were more likely to receive antibiotics in conjunction to implant surgery compared to other groups. Phenoxymethylpenicillin is the most widely used substance in conjunction with implant surgery. CONCLUSION: There is still room for improvement in reduction of antibiotic prescriptions in conjunction to implant surgical procedures in Sweden.

Antibiotic prescriptions among dentists across Norway and the impact of COVID-19 pandemic.

BACKGROUND: The prescription of antibiotics in dental practice contributes significantly to the total use of antibiotics in primary healthcare. This study aimed to evaluate antibiotic prescription in dental practice during the years 2016-2021 in Norway and their relative contribution to national outpatient consumption and to investigate the influence of age, gender, geographic region, and COVID-19. A further aim was to review differences in prescribing patterns to verify effect of governmental strategies to reduce over-prescribing of antibiotics. METHODS: This register study investigated the national antibiotic prescription between 2016 and 2021. Data was obtained from the Norwegian prescription register, the Norwegian Institute of Public Health and Statistics Norway. The consumption of 12 common antibiotics was measured using WHO defined daily doses (DDDs), DDD per 1000 inhabitants per day (DIDs 1000). RESULTS: A total of 6,049,445 antibiotic prescriptions of the 12 investigated compounds were issued in primary care during the study period. Dentists accounted for 942,350 prescriptions corresponding to 15.6% of the total. An overall decrease in the number of prescriptions by health professions other than dentists during the 5 years (IRR = 0.92, 95% CI:0.92-0.93, p < 0.001) was observed. For dentists a slight increase in the number of prescriptions (IRR = 1.01, 95% CI: 1.01-1.01, p < 0.001) was seen over the study period. The increase of antibiotic prescriptions in dentistry was more pronounced during the COVID-19 pandemic. The 4 most prescribed type of antibiotics based on average number of DDDs of the total period 2016-2021 were in descending order; phenoxymethylpenicillin (1,109,150) followed by amoxicillin (126,244), clindamycin (72,565), and metronidazole (64,599). An unexpected finding was that the prescription of the combination compound amoxicillin/clavulanic acid had significantly increased in dentistry during the last 5 years. Geographic, gender, and age differences in the rates of prescriptions were also seen. The data revealed that there are seasonal variations in dental prescriptions. CONCLUSIONS: Noticeable differences exist in prescribing patterns of antibiotics in the last 5 years. Restricted access to dental care due to COVID-19 may have resulted in increased antibiotic prescribing in dentistry as opposed to an otherwise downward trend. Despite national guidelines there is still a need for improvement of antibiotic stewardship in dentistry and to define effective methods to disseminate information.

Assessment of knowledge, attitude, and practice of antibiotics prescription among healthcare residents at King Abdulaziz medical City, Jeddah, Saudi Arabia.

Introduction: Antibiotic resistance (ABR) is defined as bacteria's resistance to therapy despite therapeutic levels of antibiotics. It is a global health concern. Data on the antibiotic prescription practice of physicians, in general, are limited in Saudi Arabia. Therefore, we aim to assess the knowledge, attitude, and practice of antibiotic prescription between surgical and non-surgical residents at King Abdulaziz Medical City (KAMC). Methods: A cross-sectional study was conducted at KAMC in Jeddah, Saudi Arabia, from September 2019, until March 2020. The questionnaire contained demographic information and 31 questions based on the studied variables: knowledge (17), attitude (4), and practice (10). Results: The response rate was 83 %. Male to female response rates were 54 % and 46 %, respectively. The majority of respondents (72 %) were non-surgical residents. Positive practice skills showed that 55 % of all healthcare residents always used practice guidelines for antibiotic prescription in their daily work (P-value < 0.001). Most residents (50 %) sometimes used delayed prescriptions. Non-surgical residents discussed ABR with patients more than surgical residents (P-value = 0.028). Lack of patient interest was the common cause for not discussing ABR with patients (42 %). Non-surgical residents had significantly more training on antibiotic prescription (p-value = 0.001). The fear of infection spread due to not prescribing an antibiotic was significantly higher in non-surgical residents (P-value < 0.001). Non-surgical residents (76 %) took a past medical history of antibiotic consumption more than surgical residents (24 %) (P-value = 0.003). Antibiotic prescription for residents was not influenced by advertisements (91 %). The most common resistant organisms reported by residents were insignificant between the two groups. The results also showed that the residents' common choice of antibiotics was not statistically different between surgical and non-surgical residents in most antibiotic classes. Conclusions: We found that practice guidelines, formal training, and taking patients' past medical histories were significantly higher among non-surgical residents. In contrast, surgical residents were prescribing more antibiotics due to the fear of the spread of the infection. Proper training is essential for all healthcare residents to overcome differences among different specialties.

Impact of educational training and C-reactive protein point-of-care testing on antibiotic prescribing in rural and urban family physician practices in Latvia: a randomised controlled intervention study.

BACKGROUND: Although self-limiting viral infections are predominant, children with acute infections are often prescribed antibiotics by family physicians. The aim of the study is to evaluate the impact of two interventions, namely C-reactive protein point-of-care testing and educational training, on antibiotic prescribing by family physicians. METHODS: This randomised controlled intervention study included acutely ill children consulted by 80 family physicians from urban and rural practices in Latvia. The family physicians were divided into two groups of 40. The family physicians in the intervention group received both interventions, i.e. C-reactive protein point-of-care testing and educational training, whereas the family physicians in the control group continued to dispense their standard care. The primary outcome measure was the antibiotic prescribing at the index consultation (delayed or immediate prescription) in both study groups. The secondary outcome was CRP testing per study group. Patient- and family physician- related predictors of antibiotic prescribing were analysed as associated independent variables. Practice location effect on the outcomes was specially addressed, similar to other scientific literature. RESULTS: In total, 2039 children with acute infections were enrolled in the study. The most common infections observed were upper and lower respiratory tract infections. Overall, 29.8% (n = 607) of the study population received antibiotic prescription. Our binary logistic regression analysis did not find a statistically significant association between antibiotic prescriptions and the implemented interventions. In the control group of family physicians, a rural location was associated with more frequent antibiotic prescribing and minimal use of CRP testing of venous blood samples. However, in the intervention group of family physicians, a rural location was associated with a higher level of C-reactive protein point-of-care testing. Furthermore, in rural areas, a significant reduction in antibiotic prescribing was observed in the intervention group compared with the control group (29.0% (n = 118) and 37.8% (n = 128), respectively, p = 0.01). CONCLUSION: Our results show that the availabilty of C-reactive protein point-of-care testing and educational training for family physicians did not reduce antibiotic prescribing. Nevertheless, our data indicate that regional variations in antibiotic-prescribing habits exist and the implemented interventions had an effect on family physicians practices in rural areas.

Antibiotic utilization in emergency dental care in Stockholm 2016: a cross sectional study.

OBJECTIVES: To investigate systemic antibiotics utilization in emergency dental care and to determine the most common treatment measures performed during emergency visits in public versus private emergency care in Sweden. MATERIAL AND METHODS: Two questionnaires were answered by dentists at one large public and one large private emergency dental clinic in Stockholm, Sweden. The first questionnaire pertained to the emergency care provided to patients (n = 1023) and the second concerned the dentists' (n = 13) own knowledge and attitudes towards antibiotic treatment and oral infections. The results of the questionnaires were tested using a Chi-square test. RESULTS: Sixteen percent of all patients seeking emergency dental treatment received antibiotics. The most common overall reason for visiting an emergency clinic was pain (52%, n = 519). The most common diagnoses made by the participating dentists in the public clinic were tooth/filling fracture (17%, n = 91) and gingivitis (14%, n = 76), while in the private clinic they were tooth fracture (29%, n = 146) and symptomatic apical periodontitis (15%, n = 72). Although the number of patients with infection was higher in the public care clinic, there was no significant difference in total number of antibiotic prescriptions between the two clinics. The rate of patients receiving antibiotic prescription as sole treatment was 41% (n = 34) in private care and 31% (n = 18) in public care. Thirty-one percent (n = 4) of dentists prescribed antibiotics for patients with diagnoses normally not requiring antibiotics, citing reasons such as time limitation, patient request, patient travel, patient safety, and follow-up not possible. CONCLUSION: Although antibiotic prescription frequency among the Swedish emergency care dentists participating in this study was low, areas for improvement could include providing education to improve dentists' knowledge on both antibiotic prescription in emergency dental care and treatment of acute oral infections.

Audit to optimize antibiotics use in neonatal septicemia.

Objectives: To assess appropriate antibiotics use in neonatal sepsis and to highlight the need for developing an Antibiotic stewardship program at local levels. Methods: A clinical audit was conducted in the neonatal ward of the tertiary care hospital of Lahore for one year from May 2019 to May 2020. Reports of blood culture and drugs susceptibility were gathered from the microbiology department, and clinical records were evaluated about the choice of the antimicrobials, dosage, frequency, and clinical prognosis. The statistics were applied using SPSS software. Results: Eighty five neonates with the mean age of five days were treated in tertiary care hospital for septicemia. Every patient received more than one antibiotic empirically. The most prescribed drug combination (90.6%) was Cefotaxime and Amikacin. Optimum antibiotics dose was prescribed in only 70.2% of cases. Blood isolates showed gram-negative bacilli in 69 (81.2%) cases, gram positive cocci in 14 (16.5%) cases, two (2.3%) culture susceptibility reports showed growth of candida. Gram negative organisms were most susceptible to Imipenem (54%), Piperacillin-Tazobactam (48%) and Gentamicin (48%). Gram-positive organisms showed the most susceptibility to Vancomycin (100%), Amikacin (92%), and Co-amoxiclav (85%). Meropenem (39%), Linezolid (28%), and Vancomycin (27%) were the most commonly given alternate antibiotics. All the patients (n=10, 11.8%) whose culture sensitivity reporting showed susceptibility to empirical therapy survived. Conclusion: Due to poor availability of latest data about local antibacterial resistance pattern and lack of knowledge among pediatricians about latest antibiotic prescribing protocols, many inconsistencies were noted in the use of antibiotics in neonatal sepsis which resulted in a poor outcome hence, reflecting in international key health indicators (neonatal mortality rate) of country. Concerning the change in the resistance pattern of microorganisms to antimicrobials, it is high time to collect local data about antibacterial susceptibility and develop an antibiotic stewardship program to stop inappropriate use of antibiotics.

Endodontic Infections and the Extent of Antibiotic Overprescription among Italian Dental Practitioners.

The objectives of this study were to evaluate the pattern of antibiotic prescription for endodontic infections (EIs) among Italian dental practitioners (DPs) and to explore the role of potential predictors of antibiotic overprescription. A nationwide cross-sectional survey was conducted between 1 April and 30 October 2019 using a structured questionnaire. Information was gathered on demographics, professional characteristics, and practices regarding antibiotic prescription for both therapeutic and prophylactic purposes. Of the 1,250 invited DPs, 563 answered the general questionnaire (response rate of 52.6%). The proportions of DPs who prescribed an antibiotic without indication for therapeutic and prophylactic purposes were 33.3% and 30.2%, respectively. Acute alveolar abscess without systemic involvement represents the clinical scenario at a high risk of overprescription for therapeutic purposes. Possible predictors of overprescribing included demographics and professional characteristics. Moreover, overprescribing was found to be higher for EIs without an indication than for the cases in which the prescription is indicated for therapeutic purposes. The odds of overprescription for prophylactic purposes were higher for cases of acute apical periodontitis and lower for cases of symptomatic irreversible pulpitis than for acute and chronic alveolar abscesses, for which prescription is indicated. The main findings of the present study provide up-to-date insight into the pattern of antibiotic prescriptions for EIs and evidence useful to identify opportunities to reduce overprescription among DPs through tailored interventions. The development of practical antibiotic prescribing guidelines with a clear description of indications and regimen ease of use is strongly needed.

Antibiotic prescriptions for children younger than 5 years with acute upper respiratory infections in China: a retrospective nationwide claims database study.

BACKGROUND: In China, there were few studies to estimate antibiotic use for children with upper respiratory infections at the national level. The aim of this study was to describe the antibiotic prescribing practice for children aged < 5 years old with upper respiratory infections (URIs) using a nationwide claims database. METHODS: This was a retrospective cross-sectional study using a sampled database from the China Health Insurance Research Association (CHIRA). Study subjects included children younger than 5 years with outpatient visits in 2015 that resulted in a diagnosis of a upper respiratory infection. We calculated the percentage of visits who received antibiotics, the proportion of injection formulations, the percentage of combined antibiotics and the proportion of each antibiotic class. The patterns of antibiotic prescription were also described by medical institution type, city level and geographical region. RESULTS: Among the 92,821 visits, 27.1% were prescribed antibiotics, of which 27.0% received injection formulations. The rate of antibiotic prescribing varied by age group (P < 0.001), with the lowest (16.0%) in infants and the highest in patients at age 3 to < 4 years (29.9%) and age 4 to < 5 years (32.5%). The Midwestern region, underdeveloped cities and low-level hospitals represented relatively higher rates of prescribing antibiotics (P < 0.001) and higher proportions of injection dosage forms (P < 0.001). The most 3 common antibiotic classes prescribed of all visits with antibiotic prescriptions were the third-generation cephalosporins (34.9%), macrolides (24.3%), and the second-generation cephalosporins (23.3%). CONCLUSIONS: In mainland China, the overall rate of antibacterial prescribing and the proportion of injection formulations prescribed in children under 5 years with URIs were at a low level, but still higher in underdeveloped regions and cities. Moreover, the overuse of the second and third generation cephalosporins, macrolides, remains a serious issue. Further efforts should be focused on reducing those non-first-line antibiotic prescribing and narrowing the gaps among regions and cities.

Prescription of antibiotics in the medical care of newly arrived refugees and migrants.

PURPOSE: Unnecessary and inappropriate use of antibiotics is a widespread problem in primary care. However, current data on the care of refugees and migrants in initial reception centers is pending. This article provides data on prescription frequencies of various antibiotics and associated diagnoses. METHODS: In this retrospective observational study, patient data of 3255 patients with 6376 medical contacts in two initial reception centers in Germany were analyzed. Patient data, collected by chart review, included sociodemographic characteristics, diagnoses, and prescriptions. Antibiotic prescription behavior and corresponding physician-coded diagnoses were analyzed. RESULTS: Nineteen percent of all patients in our study received systemic antibiotics during the observation period, with children below the age of 10 years receiving antibiotics most frequently (24%). The most commonly prescribed antibiotics were penicillins (65%), macrolides (12%), and cephalosporins (7%). The most frequent diagnoses associated with antibiotic prescription were acute tonsillitis (26%), bronchitis (21%), infections of the upper respiratory tract (14%), and urinary tract infections (10%). In case of acute bronchitis 74% of the antibiotic prescriptions were probably not indicated. In addition, we found a significant number of inappropriate prescriptions such as amoxicillin for tonsillitis (67%), and ciprofloxacin and cotrimoxazol for urinary tract infections (49%). CONCLUSION: Regarding inappropriate prescription of antibiotics in refugee healthcare, this study shows a rate ranging from 8% for upper respiratory tract infections to 75% for acute bronchitis. Unnecessary use of antibiotics is a global problem contributing to gratuitous costs, side effects, and antimicrobial resistance. This research contributes to the development of stringent antibiotic stewardship regiments in the particularly vulnerable population of migrants and refugees.

Trends and patterns in antibiotic prescribing for adult outpatients with acute upper respiratory tract infection in Japan, 2008-2018.

INTRODUCTION: This study aimed to characterize the patterns and trends in the use of major oral antibiotics prescribed for adult outpatients diagnosed with acute upper respiratory tract infections (AURTIs) in Japan between 2008 and 2018. METHODS: We analyzed administrative claims data for adults in Japan, between April 2008 and September 2018. The trends in oral antibiotic prescription were illustrated using the prescribing rate, and tested using interrupted time series analysis. We also assessed the factors associated with antibiotic prescription for AURTIs. RESULTS: Data on 7.54 million antibiotic prescriptions in 1,937,379 adults with AURTIs were analyzed; people ≥65-years old were scarcely included. The antibiotic prescribing rate declined from 49.9% in 2008 to 39.0% in 2018, and the rate of decrease accelerated after the national action plan on antimicrobial resistance was launched in April 2016. Acute nasopharyngitis was the most common indication. Cephalosporins (35.2%), macrolides (32.2%), fluoroquinolones (24.6%), and penicillins (5.88%) were the most commonly prescribed antibiotic classes. Sex, age, type and specialty of the facility, and season affected the likelihood of being prescribed antibiotics. The majority of antibiotics prescribed were broad-spectrum, but use of penicillins showed a higher rate of increase after 2016. CONCLUSIONS: The percentage of antibiotic prescriptions for AURTIs decreased significantly after implementing the action plan, indicating that it was effective to some extent. However, since the use of broad-spectrum antibiotics was high, there is scope for improving the prescribing pattern, including the types of antimicrobial agents; this is considered to be a future issue.

Gradual decline in outpatient antibiotic prescriptions in paediatrics: A data warehouse-based 11-year cohort study.

AIM: To describe trends in antibiotic (AB) prescriptions in children in primary care over 11 years, using a large data warehouse. METHODS: A retrospective cohort study assessed outpatient AB prescriptions 2007-2017, using the Massachusetts Health Disparities Repository. The evolution of paediatric outpatient AB prescriptions was assessed using time-series analyses through annual per cent change (APC) for the population and for children with or without comorbid condition. RESULTS: About 25 000 children were followed in primary care with 31 248 AB prescriptions reported in the data warehouse. The youngest children had more AB prescriptions. Penicillins were prescribed most frequently (46%), then macrolides (28%). One third of children had comorbid conditions, receiving significantly more antibiotics (30.3 vs 21.0 AB/100 child-years, relative risk: 1.43, 95% CI: 1.40, 1.46). Overall AB prescription decreased over the period (APC = -5.34%, 95% CI: -7.10, -3.54), with similar trends for penicillins (APC = -5.49; 95% CI: -8.27, -2.62) and macrolides (APC = -6.46; 95% CI: -8.37, -4.58); antibiotic prescribing declined more in children with comorbid conditions. CONCLUSION: Outpatient AB prescribing decline was gradual and consistent in paediatrics over the period. Prescription differences persisted between age groups, conditions and indication. The availability of routine care data through data warehouse fosters the surveillance automation, providing inexpensive fast tools to design appropriate antimicrobial stewardship.

Latvian Primary Care Management of Children with Acute Infections: Antibiotic-Prescribing Habits and Diagnostic Process Prior to Treatment.

Background and Objectives: Primary care physicians frequently prescribe antibiotics for acutely ill children, even though they usually have self-limiting diseases of viral etiology. The aim of this research was to evaluate the routine antibiotic-prescribing habits of primary care in Latvia, in response to children presenting with infections. Materials and Methods: This cross-sectional study included acutely ill children who consulted eighty family physicians (FP) in Latvia, between November 2019 and May 2020. The data regarding patient demographics, diagnoses treated with antibiotics, the choice of antibiotics and the use of diagnostic tests were collected. Results: The study population comprised 2383 patients aged between one month and 17 years, presenting an acute infection episode, who had a face-to-face consultation with an FP. Overall, 29.2% of these patients received an antibiotic prescription. The diagnoses most often treated with antibiotics were otitis (45.8% of all antibiotic prescriptions), acute bronchitis (25.0%) and the common cold (14.8%). The most commonly prescribed antibiotics were amoxicillin (55.9% of prescriptions), amoxicillin/clavulanate (18.1%) and clarithromycin (11.8%). Diagnostic tests were carried out for 59.6% of children presenting with acute infections and preceded 66.4% of antibiotic prescriptions. Conclusion: Our data revealed that a high level of antibiotic prescribing for self-limiting viral infections in children continues to occur. The underuse of narrow-spectrum antibiotics and suboptimal use of diagnostic tests before treatment decision-making were also identified. To achieve a more rational use of antibiotics in primary care for children with a fever, professionals and parents need to be better educated on this subject, and diagnostic tests should be used more extensively, including the implementation of daily point-of-care testing.

Antibiotic use and resistance: a nationwide questionnaire survey among French dentists.

The aim of this survey was to describe the attitudes and self-reported practices of French dentists towards antibiotic use and resistance and to compare practices with national guidelines. A nationwide cross-sectional internet-based survey was conducted among the 41,800 French dentists. The online questionnaire was distributed through professional networks from April 2017 to April 2018. Seven-hundred seventy-five dentists participated but only 455 questionnaires were complete enough to be included in the analyses. Amoxicillin was the most frequently prescribed antibiotic (65.8%, 1783/2711), followed by spiramycin + metronidazole fixed-dose combination (11.6%, 312/2711) and amoxicillin-clavulanic acid (10.3%, 279/2711). The main indications for use were abscess (349/423, 82.5%), cervicofacial cellulitis (74.2%, 314/423), and pericoronitis (58.6%, 239/408). Most dentists (90.5%, 381/421) considered that antibiotic resistance is of concern but only half of them (56.3%, 238/423) felt adequately informed about antibiotic use. Many dentists did not comply with the national guidelines: the majority of them declared inappropriate antibiotic prescriptions for 11/17 clinical situations. They did not prescribe antibiotics for 5/6 clinical situations requiring prophylaxis. They reported that the publication of clinical guidelines is the main factor influencing their prescriptions (71.0%, 299/421). They wished to receive regular updates of national guidelines in the form of practical sheets (93.0%, 172/185). French dentists should urgently be targeted by antibiotic stewardship initiatives.

Antibiotic prescriptions for Japanese outpatients with acute respiratory tract infections (2013-2015): A retrospective Observational Study.

OBJECTIVES: Appropriate antibiotic prescriptions for outpatients with acute respiratory tract infections (ARTIs) are urgently needed in Japan. However, the empirical proof of this need is under-documented. Therefore, we aimed to determine antibiotic prescription rates, and the proportions of antibiotic classes prescribed for Japanese patients with ARTIs. METHODS: We analysed health insurance claims data over 2013-2015 among Japanese patients aged <75 years and determined the following indicators: 1) visit rates for patients with ARTIs and antibiotic prescription rates per 1000 person-years, and 2) proportion of visits by antibiotic-prescribed patients with ARTIs. We defined broad-spectrum antibiotics using the WHO Anatomical Therapeutic Chemical classification 4 level codes. RESULTS: Among 8.65 million visits due to ARTIs at 6859 hospitals and 62,024 physicians' offices, the visit rate and antibiotic prescription rate per 1000 person-years were 990.6 (99% confidence interval [CI], 989.4-991.7) and 532.4 (99% CI, 531.6-533.3), respectively. The visit rates for patients aged 0-17, 18-59, and 60-74 years were 2410.0 (99% CI, 2407.2-2412.9), 683.6 (99% CI, 682.7-684.6), and 682.1 (99% CI, 678.2-686.0), and antibiotic prescription rates were 1093.3 (99% CI, 1091.4-1095.2), 434.1 (99% CI, 433.4-434.9), and 353.4 (99% CI, 350.7-356.1), respectively. The overall proportion of antibiotic prescriptions for ARTI visits was 52.7% and 91.3% of the antibiotics prescribed were broad-spectrum. CONCLUSIONS: Both the visit rates and antibiotic prescription rates for ARTIs were high in this Japanese cohort. The proportion of antibiotic prescriptions exceeded that recommended in the clinical guidelines. Thus, there might be a scope for reducing the current antibiotic prescription rate in Japan.