Antibiotic dispensing practices and antimicrobial stewardship gaps in community pharmacies in Kakamega County, Kenya

The ability to predict upper respiratory infections (URI), lower respiratory infections (LRI), and gastrointestinal tract infections (GI) in independently living older persons would greatly benefit population and individual health. Social network parameters have so far not been included in prediction models. Data were obtained from The Maastricht Study, a population-based cohort study (N = 3074, mean age (±s.d.) 59.8 ± 8.3, 48.8% women). We used multivariable logistic regression analysis to develop prediction models for self-reported symptomatic URI, LRI, and GI (past 2 months). We determined performance of the models by quantifying measures of discriminative ability and calibration. Overall, 953 individuals (31.0%) reported URI, 349 (11.4%) LRI, and 380 (12.4%) GI. The area under the curve was 64.7% (95% confidence interval (CI) 62.6-66.8%) for URI, 71.1% (95% CI 68.4-73.8) for LRI, and 64.2% (95% CI 61.3-67.1%) for GI. All models had good calibration (based on visual inspection of calibration plot, and Hosmer-Lemeshow goodness-of-fit test). Social network parameters were strong predictors for URI, LRI, and GI. Using social network parameters in prediction models for URI, LRI, and GI seems highly promising. Such parameters may be used as potential determinants that can be addressed in a practical intervention in older persons, or in a predictive tool to compute an individual's probability of infections.

BackgroundRespiratory tract infections (RTIs) are the most common infections in patients with rheumatic diseases under immunosuppressive treatment. RTIs may cause significant morbidity with reduced quality of life (QOL), increased healthcare...

Background: Pediatric population is the most common among the populations at higher risk for infections and respiratory infections are the most common among the infections due to many reasons. Aim: To assess the nature of various respiratory infections in pediatric population. Study Design: Cross sectional study. Place and duration of study: Department of Pediatrics, Muhammad Medical College Hospital, Mirpur Khas from 1stJanuary 2018 to 31st December 2018. Methodology: Two thousand and ninety nine children with respiratory illness were included irrespective gender. Results: The males were more affected 1175 (56%) in comparison to 924 (44%) females and most cases were below the age of 5 years age 1428(68%) whereas children above the age of 5 years were 671 (32%). Common upper respiratory tract infections observed were pharyngitis, tonsillitis and otitis media which were collectively 1576 (75.10%) of the cases followed by lower respiratory tract infections (pneumonia) which was found in 523 (24.90%) patients. Conclusion: Upper respiratory infections were more common than lower respiratory infection in children and males are more affected than females. Keywords: Upper respiratory infections, Lower respiratory infections, Pediatric population

BackgroundAntibiotics represent one of the most prescribed therapeutic agents in the Emergency Department (ED). It is considered that 26% to 62% of outpatient antibiotic prescriptions are made in this area....

Acute febrile illnesses in sub-Saharan Africa are often attributed to malaria, yet many patients test negative for malaria parasites. The aetiology of nonmalarial fevers remains understudied. Here, we examine likely causes of febrile illnesses and their association with poor clinical outcomes in Angola. In September-October 2023 and May-June 2024 we enrolled 849 febrile patients with ages between 2 months and 94 years in two tertiary hospitals of Lubango city that serve 7 million people in southern Angola. We used clinical assessments and locally available laboratory diagnostics to assign likely causes of fever and applied logistic regression analysis to identify factors independently associated with an increased risk of hospital admission and death. Overall, 67.6% of the patients tested negative for malaria by microscopy, with upper (13.0%) and lower (19.5%) respiratory infections and gastrointestinal infections (16.7%) being leading causes of nonmalarial fever. The frequencies of gastrointestinal, upper respiratory, and genitourinary infections varied markedly with age, and malaria predominated at the beginning of the dry season. Malaria and lower respiratory infections were associated with increased risk of hospitalization (odds ratio [OR] = 3.20 and 5.17, p < 0.0001), while malaria and central nervous system infections were linked to significantly higher mortality (OR = 1.90 and 6.30, p < 0.0001). Empirical antibiotic use was widespread, even without clinical or laboratory evidence of bacterial infection. Most fevers in southern Angola are of nonmalarial origin, underscoring the need for better diagnostic strategies to guide specific treatment and reduce unnecessary antibiotic use.

Background: Antibiotic drug overuse and inappropriate antibiotic drug selection are associated with increased drug resistance among respiratory pathogens (most notably, Streptococcus pneumoniae), possible progression to chronic disease, and increased treatment costs.[1] The selection of an antibiotic for prophylaxis should be based on known or likely target pathogens, for a short duration of time.&#x0D; Objective: To evaluate Rational use of antibiotics in Paediatric patients suffering from Respiratory tract infections.&#x0D; Method: It was Prospective, observational study conducted by random selection of patients. Based on diagnosis, the study population was categorized into 2 groups: Upper respiratory tract infections and Lower respiratory tract infections. The study population was interviewed after obtaining written informed consent for information like demographics, diagnosis, treatment and antibiotics prescribed.&#x0D; Results and Discussion: In our study population, it was observed that male patient (74%) were higher than female patients (26%). Total number of antibiotics prescribed during the study period is 83. Most commonly prescribed antibiotic was Augmentin (Amoxicillin +Clavulanic acid) of dose (450mg IV BD) which is the combination drug, i.e, more effective than individual antibiotic drugs.&#x0D; Conclusion: In the present study it is observed that 4-different classes of antibiotics-Pencillins,Cephalosporins,Macrolides and Aminoglycosides were prescribed and used for different Respiratory diseases.The percentage of average antibiotic utilization is highest in Lower Respiratory Tract Infection with (55.22%).Mostly used Antibiotic in males for both LRTI and URTI is Augmentin with the percentage of (52%) and (80%) respectively.Where as in females it is observed that in both LRTI and URTI mostly used Antibiotic is Augmentin with percentage of (38.8%) and( 80%) respectively.Overall Second mostly used antibiotic is Ceftriaxone.&#x0D; Keywords: pediatrics, lower and upper respiratory tract infections, antibiotics.

Background Humoral immune responses to respiratory syncytial virus (RSV) infection in hematopoietic cell transplant (HCT) recipients have not been well characterized. We measured RSV pre-fusion F antibody (RSVpreF) titers in HCT recipients in 3 groups: upper respiratory tract infections (URTI) only, lower respiratory tract infections (LRTI) only, and those who progressed from URTI to LRTIs (progressors). Methods We evaluated adult and pediatric allogeneic HCT recipients who acquired RSV from 12/2011 to 12/2019. Prospective and leftover clinical serum specimens were collected from the Fred Hutchinson Cancer Center. Samples included baseline prior to infection, at RSV URTI or LRTI diagnosis, and after infection (both 4-6 and &amp;gt;8 weeks). Quantitative RSVpreF titers were determined using the MesoScale Discovery electrochemiluminescence assay. We compared longitudinal log10 RSVpreF titers among groups using linear mixed effect models with restricted cubic splines. Results A total of 129 samples from 39 patients were analyzed; 24 with URTI only, 8 progressors, and 7 with LRTI only. The median age at infection was 45 years, but HCT recipients with LRTI only had an overall higher median age of 54 (range 23-63) (Table 1). Most had acute leukemia (n=18, 46%) and received peripheral blood stem cells (n=27, 69%) as their cell source (Table 1). Median RSVpreF values were similar across the 3 different groups at each timepoint (Table 2). Trajectories of RSVpreF titers over time for each patient trended towards an increase following RSV diagnosis in all groups (Figure 1a). Predicted curves in RSVpreF titers over time did not differ significantly by group (Figure 1b, p=0.38).Table 2.Summary of RSVpreF titers among allogeneic transplant recipients before and after a post-HCT RSV infection. RSVpreF titers were obtained utilizing Meso Scale Discovery chemiluminescence assays. (A) RSVpreF titers for allogeneic HCT recipients with RSV infection. Each line represents a patient. The top panel shows patients with RSV URTI only, the middle panel shows patients who progressed from URTI to LRTI, and the bottom panel shows patients who presented with RSV LRTI. Open circles represent time points prior to RSV diagnosis, filled circles represent time points just prior to, on or after URTI, and asterisks represent time points just prior to, on, or after LRTI. (B) RSVpreF titers plotted by days from RSV diagnosis. Open circles represent observed values and lines represent model predicted trajectories. Black circles and lines correspond to patients with RSV URTI only, blue corresponds to patients who progressed from RSV URTI to LRTI, and dark orange represents patient who presented with RSV LRTI at diagnosis. An outlying observation at day -53 was excluded. Conclusion Among allogeneic HCT recipients with RSV infection, RSVpreF titers increased in response to RSV infection, but did not differ among patients with URTI only, progressors, or those with LRTI only across pre and post infection time points. Our novel immunoassay results are similar to those from previously described RSV neutralization assays, but extended the observation period beyond 4 weeks after infection, revealing a modest increase in RSVpreF titers. Further characterization of RSV humoral immunity, including mucosal immunity, is needed. Disclosures chikara Ogimi, MD, bioMerieux Japan Ltd.: Honoraria|Horiba: Honoraria|Pfizer: Honoraria Janet A. Englund, MD, Ark Biopharma: Advisor/Consultant|AstraZeneca: Advisor/Consultant|AstraZeneca: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Meissa Vaccines: Advisor/Consultant|Merck: Grant/Research Support|Moderna: Advisor/Consultant|Moderna: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Sanofi Pasteur: Advisor/Consultant Emily T. Martin, PhD, MPH, Merck: Grant/Research Support Michael J. Boeckh, MD PhD, Allovir: Advisor/Consultant|Amazon: Grant/Research Support|Ansun: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Moderna: Advisor/Consultant|Symbio: Advisor/Consultant Alpana Waghmare, MD, Allovir: Grant/Research Support|Amazon: Grant/Research Support|Ansun Biopharma: Grant/Research Support|GlaxoKlineSmith/Vir: Grant/Research Support|Kyorin Pharmaceuticals: Advisor/Consultant|Pfizer: Grant/Research Support|Vir Biotechnology: Advisor/Consultant

ObjectiveThere is limited study from low-and-middle income countries on the effect of perinatal exposure to air pollution and the risk of infection in infant. We assessed the association between perinatal exposure to traffic related air pollution and the risk of infection in infant during their first six months of life.MethodsA prospective cohort study was performed in Jakarta, March 2016–September 2020 among 298 mother-infant pairs. PM2.5, soot, NOx, and NO2 concentrations were assessed using land use regression models (LUR) at individual level. Repeated interviewer-administered questionnaires were used to obtain data on infection at 1, 2, 4 and 6 months of age. The infections were categorized as upper respiratory tract (runny nose, cough, wheezing or shortness of breath), lower respiratory tract (pneumonia, bronchiolitis) or gastrointestinal tract infection. Logistic regression models adjusted for covariates were used to assess the association between perinatal exposure to air pollution and the risk of infection in the first six months of life.ResultsThe average concentrations of PM2.5 and NO2 were much higher than the WHO recommended levels. Upper respiratory tract infections (URTI) were much more common in the first six months of life than diagnosed lower respiratory tract or gastro-intestinal infections (35.6%, 3.5% and 5.8% respectively). Perinatal exposure to PM2.5 and soot suggested increase cumulative risk of upper respiratory tract infection (URTI) in the first 6 months of life per IQR increase with adjusted OR of 1.50 (95% CI 0.91; 2.47) and 1.14 (95% CI 0.79; 1.64), respectively. Soot was significantly associated with the risk of URTI at 4–6 months age interval (aOR of 1.45, 95%CI 1.02; 2.09). All air pollutants were also positively associated with lower respiratory tract infection, but all CIs include unity because of relatively small samples. Adjusted odds ratios for gastrointestinal infections were close to unity.ConclusionOur study adds to the evidence that perinatal exposure to fine particles is associated with respiratory tract infection in infants in a low-middle income country.

A clinician’s guide to the appropriate and accurate use of antibiotics: the Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria

ObjectivesIn this study, we aimed to promote the appropriate use of antibiotics by analyzing antibiotic prescription rate grades for acute upper respiratory tract infections (URTIs) and lower respiratory tract infections (LRTIs) across healthcare institutions in the Republic of Korea. We also examined variations by institution type and region.MethodsThis study used data from the pharmaceutical benefit appropriateness evaluation published on the Health Insurance Review and Assessment Service website in 2023. Antibiotic prescription rate grades (Grades 1–5 and grade-exempt institutions) were analyzed according to healthcare institution type and region for acute URTIs and LRTIs. Additionally, changes in the prescription rate grades from 2020 to 2023 were compared.ResultsIn 2023, the overall proportion of Grades 1–5 among medical institutions was higher for acute LRTIs (65.0%) than for URTIs (55.8%). Tertiary hospitals had the highest proportion of Grade 1 levels for both infection types―94.7% for URTIs and 97.6% for LRTIs―and consistently maintained high grade levels (Grades 1 and 2) from 2020 to 2023. In contrast, clinics showed the highest proportion of lower grades (Grades 4 and 5) in 2023. Although regional variations among clinics was relatively small, the proportion of lower grades remained consistently high across regions.ConclusionsAntibiotic prescription grade distribution varied significantly according to the type of healthcare institution and region. Clinics, in particular, showed a need for improvement in antibiotic prescribing practices. Therefore, establishing tailored strategies that reflect the characteristics of infection and institution types and regions is necessary to promote the appropriate use of antibiotics. To this end, educational programs and guidelines that consider the varying levels of awareness regarding antibiotic use are essential.

Background The pre-fusion conformation of the F glycoprotein of respiratory syncytial virus (RSVpreF) has been the target of recent respiratory syncytial virus (RSV) therapies, including monoclonal antibodies for immunocompetent children and vaccines for the elderly. However, the utility of targeted therapies against RSVpreF is unknown in pediatric or adult hematopoietic cell transplant (HCT) recipients, and there are limited natural history studies characterizing humoral immune responses after RSV infection in HCT recipients. We utilized VirScan, a novel high-throughput profiling of antiviral antibody epitopes, to identify differences in global RSV-related epitope hits after an RSV infection. Methods We evaluated adult and pediatric allogeneic HCT recipients who acquired RSV from 12/2011 to 12/2019. Patients were categorized into 3 groups: upper respiratory tract infections (URTI) only, those who progressed from URTI to lower respiratory tract infections (progressors) and lower respiratory tract infections (LRTI) at diagnosis, and tested at baseline prior to infection (pre-RSV), at RSV URTI or LRTI diagnosis (RSV diagnosis), at LRTI progression (LRTI), 4-6 weeks after infection (Response 1) and &amp;gt;8 weeks after infection (Response 2), depending on sample availability. We interrogated the viral antibody repertoire using a serosurvey (VirScan) that detects immunoglobulin G responses to 206 viruses. VirScan metrics evaluated included: (1) number of RSV epitope hits, (2) log10 of the maximum RSV epitope binding signal (EBS), analogous to an antibody titer for each epitope, and (3) geometric mean of all RSV EBS. Kruskal-Wallis tests were used to compare groups for each VirScan metric at the different time points. Results A total of 129 samples from 39 patients were analyzed; 24 with URTI only, 8 progressors, and 7 with LRTI at diagnosis. At each time point, VirScan metrics were similar among the 3 patient groups (Table 1). Though patterns of VirScan metrics following RSV diagnosis varied by patient, most showed a modest increase in values (Figure 1). Conclusion In this preliminary study, we utilized the power of VirScan, a comprehensive serologic profiling tool of the entire human virome, to characterize RSV specific antibody changes after RSV infection in allogeneic HCT recipients. There were no differences in global RSV VirScan metrics between the 3 groups, suggesting that antibodies may not be the primary driver of viral infection attenuation in this population. Future analyses will focus on differences in individual epitope acquisition, including RSVpreF, between the 3 groups, and investigate possible interactions with humoral responses to other viruses. Figure 1. Longitudinal RSV VirScan metrics for each patient separated by 3 groups (top row: RSV URTI only; middle row: progressors from URTI to LRTI; bottom row: LRTI at diagnosis). Each line is an individual patient. The different panels show the changes in RSV related epitope hits (A), the log10 maximum epitope binding signal (EBS) among RSV epitopes (B), and the geometric mean of all the RSV related EBS (C). Open circles represent time points prior to RSV diagnosis, filled circles represent time points just prior to, on or after URTI, and asterisks represent time points just prior to, on, or after LRTI.

This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.

Purpose of the Study. To investigate the association between early childhood infections and subsequent development of asthma.Study Population. A total of 1314 children born in 1990 followed from birth to the age of 7 years.Methods. A total of 499 newborn infants were recruited with risk factors for atopy (elevated cord blood immunoglobulin E (IgE) or at least 2 atopic family members) and 815 newborn infants without these risk factors. The cohort of children were followed at the ages of 1, 3, 6, 12, and 18 months, and from then on at yearly intervals up to the age of 7 years. At each follow-up, parents were interviewed on respiratory symptoms, the child’s development, and assessment of childhood illnesses, including the frequency and number of antibiotic courses used. IgE to milk, egg, soy, wheat, dust mite, cat, dog, grass, and birch were determined by radioallergo-sorbent testing at age 1, 2, 3, 4, 5, 6, and 7 years. At age 7, bronchial histamine challenge was performed to assess bronchial hyperreactivity. Main outcome measures included asthma symptoms, atopic sensitization, and bronchial hyperreactivity.Results. The number of lower respiratory tract infections in the first 3 years of life showed a positive dose-response with doctor-diagnosed asthma and bronchial hyperreactivity at age 7, with the strongest effect for >4 lower respiratory infections (odds ratio [OR]: 3.37; 95% confidence interval [CI]: 1.92–4.92). The total number of infectious diseases other than lower respiratory tract infections in first 3 years of life was inversely related to a diagnosis of asthma by age 7 years (OR: 0.31; 95% CI: 0.11–0.85) to current wheeze at age 7 (OR: 0.55; 95% CI: 0.20–1.48), and to bronchial hyperreactivity at age 7 (OR: 0.40; 95% CI: 0.16–1.01). Children with <1 episode of rhinorrhea before age 1 compared with those with >2 episodes were less likely to have a doctor’s diagnosis of asthma at 7 years (OR: 0.52; 95% CI: 0.29–0.92) or to have wheeze at 7 years (OR: 0.60; 95% CI: 0.38–0.94) and were less likely to be atopic before the age of 5 years. Similarly, having >1 viral infection of the herpes type in the first 3 years of life was inversely associated with asthma at age 7 (OR: 0.48; 95% CI: 0.26–0.89).Conclusion. Repeated viral infections other than lower respiratory tract infections early in life may reduce the risk of developing asthma up to school age.Reviewer’s Comments. The “hygiene hypothesis” has been a recent hot topic in attempts to understand the role of infections in early childhood and suggestion has been made that infections may stimulate the immature immune system towards the Th1 phenotype and therefore reduce the risk of asthma and atopy. This study found that although lower respiratory infections may increase the risk of developing asthma, upper respiratory infections may actually reduce the risk and may further support this “hygiene hypothesis.” Additional long-term studies such as this would be useful in our understanding of the complicated mix of environmental and genetic factors that play important roles in the development of atopy and asthma.

Antibiotics for respiratory tract infections in primary care

Objective: The high frequency of prescribing oral antimicrobial agents, such as third-generation cephalosporins, macrolides, and fluoroquinolones, in local clinics is a major issue that can lead to the emergence of antimicrobial-resistant bacteria in the community. Hospitals have recently adopted the days of antibiotic spectrum coverage (DASC), which considers the antibacterial spectrum as a novel indicator of appropriate antimicrobial use. Although it has been used in inpatient settings, its applicability in community pharmacy settings remains unclear. Materials and Methods: The aim of this study was to determine whether the DASC is a valuable indicator of appropriate antimicrobial use in community pharmacies. We tabulated the use of antimicrobials dispensed at one of our pharmacies in Tokyo from 1 January 2018, to 31 December 2023. The DASC/100 prescriptions were calculated using the Antibiotic Spectrum Coverage score, which quantifies the extent of antimicrobial activity against key organisms. Higher scores indicate broader-spectrum agents, whereas lower scores indicate narrower-spectrum agents. Additionally, the days of therapy (DOT) value was calculated, along with the DOT/100 prescriptions, based on the dispensed prescriptions. Subgroup analyses were conducted for pediatric children aged < 6 years and the elderly (≥65 years). Results: The DASC/DOT was used to assess the appropriate use of antimicrobials. The DOT/100 and DASC/100 prescriptions in 2021–2023 were 50.1% and 51.5% lower, respectively, than those before 2020 (p < 0.05). During the same period, the DASC/DOT decreased by 0.7%, indicating that, despite the decrease in the number of antimicrobial prescriptions, the antimicrobial spectrum did not become narrower. In children < 6 years of age, DOT and DASC values declined significantly, possibly indicating a decrease in the number of antibiotic prescriptions for viral upper respiratory tract infections. In the elderly (≥65 years), the DASC/DOT remained relatively high, indicating their continued reliance on broad-spectrum agents, such as fluoroquinolones and macrolides. Conclusions: This study demonstrates the feasibility and benefits of the DASC/DOT as a spectrum-based indicator for appropriate antimicrobial use in community pharmacies. Therefore, the DASC/DOT serves as a practical and spectrum-sensitive indicator of outpatient antimicrobial use to guide antimicrobial stewardship in community settings. Furthermore, age-specific analyses highlighted the importance of targeted interventions to promote the judicious use of broad-spectrum antimicrobials, particularly among the elderly (≥65 years old).