Measuring Antimicrobial Prescribing Quality and Driving Behavioral Change: A Call to Action Against Antimicrobial Resistance.

1The Review on AMR was an expert panel commissioned by the UK Government in 2014 tasked with analysing the economic and social impacts of AMR and proposing solutions to these. 2NICE is a UK non-departmental public body that sponsored by but separate from the Department of Health that produces evidence-based guidance for health practitioners. 3NHS England is a non-departmental public body sponsored by the Department of Health that oversees planning and delivery of health services in England. 4Note that circulation of the News of the World ceased in July 2011; the Sun on Sunday was launched by the same newsgroup in 2012, but is unavailable on the Nexis database.

Objective The aim of the present study was to describe the process of establishment and coordination of the national Antimicrobial Use and Resistance in Australia (AURA) surveillance system. Methods Existing surveillance programs conducted by health organisations at state or multi-jurisdictional levels were reviewed, and gaps and opportunities identified for the development of a national system. In view of the time frame available as part of the Australian Government Department of Health funding agreement, the strategy used by the Australian Commission on Safety and Quality in Health Care was to commence work with existing surveillance programs, expanding and enhancing them and developing new systems where gaps were identified. Using the specifications of the AURA national system, the data from each of these elements were then analysed and reported. The system provides coverage for the acute and community sectors for antimicrobial use and antimicrobial resistance. Results The AURA surveillance system integrates eight streams of surveillance activities, including passive and targeted surveillance of antimicrobial use and resistance from hospitals (public and private) and the community (general practitioners and aged care homes). A gap was identified in timely surveillance of critical antimicrobial resistances (CARs), which resulted in the development of the national CARAlert system. The first comprehensive analyses of data across the surveillance programs was published in June 2016, providing baseline data for future reports to build on. Conclusion The AURA surveillance system has established the framework and foundation systems for an integrated and comprehensive picture of both antimicrobial use and resistance in Australia over time. National coordination and support will improve data collection, standardisation and analysis, and will facilitate collaboration across the states and territories, the Australian Government and the private sector. AURA publications will inform policy development and clinical decision making and improve consumer awareness of antimicrobial use and resistance. The system will continue to develop as a comprehensive system, with additional data over time, and appropriate clinical and epidemiological review. What is known about this topic? Surveillance of antimicrobial use and resistance is critical to inform effective policy development and public health responses to the growing problem of antimicrobial resistance. Until now, surveillance of antimicrobial use and resistance in Australia has been fragmented, with state and territory and professional group differences in data collection, analysis and reporting. What does this paper add? This paper profiles the development of the AURA surveillance system, the first nationally coordinated surveillance system for antimicrobial use and resistance, and its use of a partnership approach with contributing programs in order to promote participation and to obtain data to inform strategies to prevent and contain antimicrobial resistance. This paper highlights the establishment phase, noting that the system continues to be improved with growing participation from all sectors. What are the implications for practitioners? National surveillance data from the AURA surveillance system provides evidence for action to guide improvements in infection control, antimicrobial prescribing and the prevention and control of antimicrobial resistance across all healthcare sectors. It will also enable trends to be identified and reported on, and have the capability of determining the effect of interventions to improve and rationalise antimicrobial prescribing.

Health crises such as viral pandemics arise suddenly and require immediate actions and responses; others come to light more slowly and are more inconspicuous and intractable. An example of the latter is antimicrobial resistance (AMR), which was reported shortly after the introduction of the first effective antimicrobial agent and has been declared as one of the top ten global public health threats facing humanity by WHO in 2019.

Background: Antimicrobial resistance (AMR) is a global health challenge that has escalated due to the inappropriate use of antimicrobials in humans, animals, and the environment. Developing and implementing strategies to reduce and combat AMR is critical. Purpose: This study aimed to highlight some global strategies that can be implemented to address AMR using a One Health approach. Methods: This study employed a narrative review design that included studies published from January 2002 to July 2023. The study searched for literature on AMR and antimicrobial stewardship (AMS) in PubMed and Google Scholar using the 2020 PRISMA guidelines. Results: This study reveals that AMR remains a significant global public health problem. Its severity has been markedly exacerbated by inappropriate use of antimicrobials in humans, animals, and the broader ecological environment. Several strategies have been developed to address AMR, including the Global Action Plan (GAP), National Action Plans (NAPs), AMS programs, and implementation of the AWaRe classification of antimicrobials. These strategies also involve strengthening surveillance of antimicrobial consumption and resistance, encouraging the development of new antimicrobials, and enhancing regulations around antimicrobial prescribing, dispensing, and usage. Additional measures include promoting global partnerships, combating substandard and falsified antimicrobials, advocating for vaccinations, sanitation, hygiene and biosecurity, as well as exploring alternatives to antimicrobials. However, the implementation of these strategies faces various challenges. These challenges include low awareness and knowledge of AMR, a shortage of human resources and capacity building for AMR and AMS, in adequate funding for AMR and AMS initiatives, limited laboratory capacities for surveillance, behavioural change issues, and ineffective leadership and multidisciplinary teams. Conclusion: In conclusion, this study established that AMR is prevalent among humans, animals, and the environment. Successfully addressing AMR calls for a collaborative, multifaceted One Health approach. Despite this, some gaps remain effectively implementing strategies currently recommended to combat AMR. As a result, it is essential to reinforce the strategies that are deployed to counter AMR across the human, animal, and environmental sectors.

Background Understanding physicians' perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians' perceptions in Pakistan. Objective Assess physicians' perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.

Antimicrobial selection, prescribing, and resistance are global health issues resulting from the overuse and misuse of antimicrobials in the healthcare and agricultural sectors. It raises healthcare costs, prolongs diseases, and escalates mortality. The current study objective was to specifically explore how Artificial Intelligence and Machine Learning affect the selection of antimicrobials, address antimicrobial resistance, and strengthen antimicrobial stewardship programs through a structured scoping review. The aim was to clarify what direct impacts AI/ML have in these areas and how they contribute to improvements and challenges in practice. A literature search was conducted in PubMed, Cochrane Library, Ovid Embase, Scopus, and CINAHL. A detailed search approach was developed to guarantee that all relevant studies were included. The entire electronic search strategy included terms such as “Artificial intelligence-AI,” “digital health,” “selection/prescribing of antimicrobials, “antimicrobial stewardship-AMS, “antimicrobial resistance-AMR, “Machine Learning-ML”, and “telemedicine,”. A critical appraisal of sources of evidence from the included studies was conducted using the Newcastle-Ottawa Quality Assessment Form. For this review, 70 sources related to artificial intelligence’s impact on antimicrobial selection/prescribing, resistance, and stewardship were initially screened. Of these, 33 were assessed for eligibility, resulting in 16 studies included in the review. Seventeen were excluded for lack of direct information relevant to AI’s effect on antimicrobial prescribing, resistance, and stewardship. This scoping review summarizes how artificial intelligence improves the accuracy of therapy selection, helps reduce inappropriate prescriptions by predicting necessity, and aids clinical decision-making (CDSS). It also details specific barriers, such as integration challenges, and facilitators like improved workflow, to incorporating artificial intelligence technologies in real-world clinical settings. The reviewed studies showed that Artificial Intelligence and Machine Learning improve selection, prescribing, antimicrobial resistance, and antimicrobial stewardship. The use of artificial intelligence and Machine Learning models in selection, prescribing, antimicrobial resistance, and antimicrobial stewardship has a profound impact on clinical outcomes. The utilization of Artificial Intelligence and Machine Learning enhances prescription accuracy in AMS programs. The use of Machine Learning optimizes antimicrobial selection and predicts resistance. Future research should examine the implementation of Artificial Intelligence, Machine Learning, and AI-CDSS over a more extended period to understand its long-term effects on professional practices and organizational structures.

Corresponding Author: Shannon Hamilton, DO. Ryan White Center for Pediatric Infectious Diseases, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, Indiana, USA, Email: shhami@iu.edu Abbreviations: primary care center (PCC), Sources of funds: This work was supported by the Pediatric Infectious Diseases Society Health Disparities Fellowship funded by Sanofi Pasteur. No conflict of interest Background There are few studies investigating the drivers of health disparities in pediatric antimicrobial prescription. The purpose of this study is to assess baseline knowledge, parental expectations and provider bias in relationship to antimicrobial prescription and resistance. Methods This is an anonymous, voluntary exploratory survey of parents of pediatric patients at a primary care center (PCC) and healthcare providers at a pediatric emergency department and PCC in Indianapolis, IN between April and June 2023. Parents were enrolled in the waiting room of the PCC and completed a paper survey. Providers completed a unique, electronically delivered survey. The survey collected demographic/ socioeconomic data and information on knowledge/expectations of antibiotic use and resistance. Results A total of 100 parents and 54 providers participated. Overall, parents disagreed that a doctor’s decision to prescribe antibiotics could be influenced by bias based on race/ethnicity or a family’s level of income (74.4% and 75.9%, respectively). Over 80% had heard the term “antibiotic resistance” and 54.9% agreed that it is a “big problem.” In multivariable analyses controlling for age and place of birth, parents born in the United States were less likely to agree with being worried about the impact of antibiotic resistance on personal/family’s health (OR 0.11, 95% CI 0.03, 0.41, p=0.001). For physician respondents, about 85% agreed that antimicrobial resistance is a significant problem for children in their community while only about 52% agreed that there are disparities in antibiotic prescribing across racial/ethnic groups and income levels. Eighty-seven percent of physicians agreed that parental expectations to receive an antibiotic may influence provider decision-making. Conclusions This exploratory survey revealed that most parents and providers were not concerned about disparate antimicrobial prescription practices, while most parents had heard of the term antimicrobial resistance and most providers agreed it is a significant problem. Larger studies are needed to further investigate the role of provider bias and parental perception in antimicrobial prescription and resistance.

Introduction: The menace of antimicrobial abuse and resistance has enveloped the entire world. As the medical students are the future prescribers so their knowledge and attitude in relation to public usage of antimicrobials and rational prescription of antimicrobials will make them important fighters against antimicrobial resistance. Hence the present study was designed and undertaken with an objective to determine the knowledge, attitude and practice of medical undergraduates on usage of antimicrobials and antimicrobial resistance. Materials and Methods: A cross-sectional questionnaire based observational study was conducted among the undergraduates from 4th to 9th semester of MBBS. A total of 350 students were enrolled in the study and they were required to fill up the questionnaire which contained questions regarding knowledge, attitude and practice of antimicrobial usage and antimicrobial resistance. Results: Majority of the students (96.57%) were aware of the fact that antimicrobial resistance is a serious global public health issue. Only 9.41% felt the need of antimicrobials to treat common cold, while as (95.71%) students realised the importance of antimicrobial policy in the hospital to achieve rational antimicrobial usage. Only half of the students always consulted a doctor before starting an antimicrobial agent. Conclusion: The knowledge of the students regarding antimicrobials was adequate, though the attitude was little lax towards it. They seemed to be a bit perplexed about the use of antimicrobials on themselves. Appropriate educational interventions and strategies can be introduced to tackle this weak aspect of our students. Keywords: Antimicrobial use, Antimicrobial resistance, Medical undergraduates, Knowledge, Attitude, Practice.

“Superbugs” are the antimicrobial-resistant microorganisms. Bacteria, viruses, fungi, and parasites acquire the ability to evade the antimicrobial drug effects, not only to survive but also, in some cases, become more virulent. As such, the existing antimicrobial drugs are no longer effective and useful in treating the infections (used to be treatable). Superbug-induced infections are the major worldwide health concern with higher human mortality and an increased financial burden on society. The underlying mechanism of the evolvement of drug-sensitive to drug-resistant microorganisms is an extremely complex phenomenon. It is partly related to microorganism's unique ability to modify their genetic structures and biochemical functionality to survive and keep growing even in the presence of antimicrobial drugs. Since there are multiple factors involved in developing antimicrobial drug resistance, it cannot be reversed by adopting a single prevention strategy. Of importance, certain bacterium may not require antimicrobial drug exposure to develop resistance, as surrounding environmental exposure can facilitate the resistance. Consistent misuse and overuse of antimicrobial drugs by healthcare professionals and consumers with its extensive use in food and meat production have put human health at risk. Lack of resources for research and low interest in developing the newer generation of antimicrobial drugs are also contributing to the evolution of superbugs. Without global involvement, partnership and collaboration, superbug-induced morbidity and mortality will be unmanageable in the future. To address this impending global health crisis, in May 2015, the World Health Organization (WHO) assembly adopted a global action plan to combat the antimicrobial resistance, that include (1) to increase the awareness of antimicrobial resistance, (2) to advance research and surveillance, (3) to cut down the rate of infections through preventive measures, (4) to ensure the optimal use of antimicrobial drugs, and (5) to develop sustainable investment, taking into account the needs of the countries, to develop novel interventions. Unfortunately, implementing such WHO measures have both financial and logistic hurdles, and the rates of superbug-induced infections are alarmingly increasing. A recently published article in “Frontiers in Public Health” has highlighted the importance of microbial resistance movements to reduce the burden of superbug-induced infections (1). The authors have elaborated on the genesis of antimicrobial drugs and listed the challenges of producing the newer generation of drugs to combat existing drug-resistant pathogens (1). Although the authors briefly touched on the irrational prescription of antimicrobial drugs in the both developed and developing countries, the review article did not discuss in depth the regulatory enforcement procedures to minimize the antimicrobial resistance (1). The opportunities and challenges of global standardization of the antimicrobial prescription processes were not explained in detail in the publication (1). Another critical area that was not emphasized enough in the article was the use of the antimicrobial drugs on animals and its potential consequences in developing antimicrobial resistance. This commentary will briefly elaborate on the cross-species transmission of resistant pathogens from animal to human. Appreciating that one single review article cannot cover all the aspects of antimicrobial resistance, the authors have fittingly highlighted the scientific and economic challenges that are hindering the novel antimicrobial drug development (1). The publication has justifiably concluded that antimicrobial resistance is a multifaced issue driven by numerous interrelated factors, and therefore, the use of any single intervention would have limited success (1). Recent publications have also emphasized why implementing an antimicrobial stewardship program is necessary to prepare the future medical professionals to enhance their awareness and knowledge of antimicrobial resistance to reduce the disease burden related to superbug-mediated infections (Figure 1) (2, 3). Open in a separate window Figure 1 Schematic diagram showing the main steps needed to be implemented to minimize the antimicrobial drug resistance (2).

Antimicrobial use on Australian dairy cattle farms – A survey of veterinarians

Antimicrobial resistance (AMR) is a public health emergency. There is insufficient information on AMR in the context of humanitarian settings. An understanding of behavioral and institutional-level factors can strengthen antimicrobial stewardship. This study used a semistructured questionnaire to assess both knowledge, attitudes, and practices (KAP) on antimicrobial use, resistance and stewardship, and options to improving prescribing, among prescribers at the Primary Healthcare facilities of the United Nations Relief and Works Agency Jordan field office. Responses to the KAP questions were evaluated using the Capability, Opportunity, Motivation, Behavior (COM-B) framework and Bloom's cutoffs. For each framework component, Blooms cutoffs and interpretations were as follows: > 80%, "good"; 60-79%, "moderate"; and < 60%' "poor." Fourteen options to improve prescribing were each assessed using 5-point Likert scales from very unhelpful to very helpful, aggregated by helpful and very helpful and ranked as follows: > 90%, best/most acceptable; > 80-90%, acceptable; and 70-80% as maybe acceptable/good. The questionnaire response rate was 59% (37/63) with a completion rate of 92% (34/37). Aggregate scores for real knowledge on AMR was 97%; opportunity to improve prescribing 88%; and motivation 16%-participants did not believe that there was a connection between their prescribing and AMR or that they had a key role in helping control AMR. Good options (74% aggregate score) to improving prescribing were the availability of guidelines and resistance data. There was good knowledge of AMR and good opportunities, but poor motivation for rational prescribing or behavioral change. There is a clinical need for AMR data to promote rational antibiotic prescribing.

The purpose of this study was to examine current nurse practitioner (NP) curricula in the United States with regard to antibiotics and antimicrobial resistance and assess the need for a web-based module for instruction on antimicrobial resistance and appropriate prescribing of antibiotics. A 22-item, anonymous, self-administered, web-based survey was sent to 312 NP programs; 149 (48%) responded. Survey items included questions related to NP specialties offered, program accreditation, format of pharmacology course(s), lecture hours related to antimicrobial therapy, and whether the participant would use a Web-based module to teach NP students about antimicrobial resistance, if one were available. Most NP programs (99.3%) required a pharmacology course, and 95% had lectures dedicated to antimicrobial therapy. Half of the programs (53.5%) devoted >or=4 lecture hours to antimicrobial therapy in the pharmacology course, and most (84.8%) reported covering antimicrobial therapy in nonpharmacology courses as well. Approximately half of the programs (45.3%) reported <4 h of lecture on antimicrobial therapy in nonpharmacology courses. Many programs (51.9%) did not offer a microbiology course; 39.2% required microbiology as a prerequisite. Most respondents (86.7%) were familiar with the Centers for Disease Control and Prevention antimicrobial resistance program, and 92.6% reported that they would use an electronic module regarding resistance. NP curricula generally include <10 h of content on antimicrobial therapy. An electronic module regarding antimicrobial resistance is likely to be a useful and relevant adjunct to current curricula.

Antimicrobial Resistance (AMR) presents a pressing public health challenge globally which has been compounded by the COVID-19 pandemic. Elucidation of the impact of the pandemic on AMR evolution using population-level data that integrates clinical, laboratory and prescription data remains lacking. Data was extracted from the centralized electronic platform which captures the health records of 60,551 patients with a confirmed infection across the network of public healthcare facilities in Dubai, United Arab Emirates. For all inpatients and outpatients diagnosed with bacterial infection between 01/01/2017 and 31/05/2022, structured and unstructured Electronic Health Record data, microbiological laboratory data including antibiogram, molecular typing and COVID-19 testing information as well as antibiotic prescribing data were extracted curated and linked. Various analytical methods, including time-series analysis, natural language processing (NLP) and unsupervised clustering algorithms, were employed to investigate the trends of antimicrobial usage and resistance over time, assess the impact of prescription practices on resistance rates, and explore the effects of COVID-19 on antimicrobial usage and resistance. Our findings identified a significant impact of COVID-19 on antimicrobial prescription practices, with short-term and long-lasting over-prescription of these drugs. Resistance to antimicrobials increased the odds ratio of all mortality to an average of 2.18 (95% CI: 1.87–2.49) for the most commonly prescribed antimicrobials. Moreover, the effects of antimicrobial prescription practices on resistance were observed within one week of initiation. Significant trends in antimicrobial resistance, exhibiting fluctuations for various drugs and organisms, with an overall increasing trend in resistance levels, particularly post-COVID-19 were identified. This study provides a population-level insight into the evolution of AMR in the context of COVID-19 pandemic. The findings emphasize the impact of COVID-19 on the AMR crisis, which remained evident even two years after the onset of the pandemic. This underscores the necessity for enhanced antimicrobial stewardship to address the evolution of AMR.

Antimicrobial Resistance (AMR) presents a pressing public health challenge globally which has been compounded by the COVID-19 pandemic. Elucidation of the impact of the pandemic on AMR evolution using population-level data that integrates clinical, laboratory and prescription data remains lacking. Data was extracted from the centralized electronic platform which captures the health records of 60,551 patients with a confirmed infection across the network of public healthcare facilities in Dubai, United Arab Emirates. For all inpatients and outpatients diagnosed with bacterial infection between 01/01/2017 and 31/05/2022, structured and unstructured Electronic Health Record data, microbiological laboratory data including antibiogram, molecular typing and COVID-19 testing information as well as antibiotic prescribing data were extracted curated and linked. Various analytical methods, including time-series analysis, natural language processing (NLP) and unsupervised clustering algorithms, were employed to investigate the trends of antimicrobial usage and resistance over time, assess the impact of prescription practices on resistance rates, and explore the effects of COVID-19 on antimicrobial usage and resistance. Our findings identified a significant impact of COVID-19 on antimicrobial prescription practices, with short-term and long-lasting over-prescription of these drugs. Resistance to antimicrobials increased the odds ratio of all mortality to an average of 2.18 (95% CI: 1.87-2.49) for the most commonly prescribed antimicrobials. Moreover, the effects of antimicrobial prescription practices on resistance were observed within one week of initiation. Significant trends in antimicrobial resistance, exhibiting fluctuations for various drugs and organisms, with an overall increasing trend in resistance levels, particularly post-COVID-19 were identified. This study provides a population-level insight into the evolution of AMR in the context of COVID-19 pandemic. The findings emphasize the impact of COVID-19 on the AMR crisis, which remained evident even two years after the onset of the pandemic. This underscores the necessity for enhanced antimicrobial stewardship to address the evolution of AMR.

To describe antimicrobial use in hospitalised Australian children and to analyse the appropriateness of this antimicrobial use. Multicentre single-day hospital-wide point prevalence survey, conducted in conjunction with the Antimicrobial Resistance and Prescribing in European Children study. Eight children's hospitals across five Australian states, surveyed during late spring and early summer 2012. Children and adolescents who were inpatients at 8am on the day of the survey. Quantity and quality of antimicrobial prescribing. Of 1373 patients, 631 (46%) were prescribed at least one antimicrobial agent, 198 (31%) of whom were <1 year old. The highest antimicrobial prescribing rates were in haematology and oncology wards (76% [95/125]) and paediatric intensive care units (55% [44/80]). Of 1174 antimicrobial prescriptions, 550 (47%) were for community-acquired infections, 175 (15%) were for hospital-acquired infections and 437 (37%) were for prophylaxis. Empirical treatment accounted for 72% of antimicrobial prescriptions for community-acquired infections and 58% for hospital-acquired infections (395 and 102 prescriptions, respectively). A total of 915 prescriptions (78%) were for antibacterials; antifungals and antivirals were predominantly used for prophylaxis. The most commonly prescribed antibacterials were narrow-spectrum penicillins (18% [164 prescriptions]), β-lactam-β-lactamase inhibitor combinations (15% [136]) and aminoglycosides (14% [128]). Overall, 957 prescriptions (82%) were deemed appropriate, but this varied between hospitals (range, 66% [74/112]) to 95% [165/174]) and specialties (range, 65% [122/187] to 94% [204/217]). Among surgical patients, 65 of 187 antimicrobial prescriptions (35%) were deemed inappropriate, and a common reason for this was excessive prophylaxis duration. A point prevalence survey is a useful cross-sectional method for quantifying antimicrobial use in paediatric populations. The value is significantly augmented by adding assessment of prescribing quality.