Antibiotic Prescribing Practices Research Articles

A Narrative Review of Antibiotic Prescribing Practices in Primary Care Settings in South Africa and Potential Ways Forward to Reduce Antimicrobial Resistance.

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.

Early-life antibiotic usage and impact on the gut microbiota, including emergence of antimicrobial resistant Enterococcus

The early-life microbiota is an ‘immature’ and highly dynamic microbial ecosystem, which is central to infant health. Both perinatal and postnatal factors can impact the gut microbiota, with antibiotics proposed to cause short and longer-term disturbances. Antibiotics not only impact microbial community composition but also contribute to the overall antibiotic resistance profile, i.e. the ‘resistome’, and they may also enhance carriage of multi-drug-resistant bacteria. Given high antibiotic prescription practices in pregnant women and newborns this also contributes to the global threat of antimicrobial resistance. This review summarises the current literature on antibiotic usage and how this may impact the developing gut microbiota during early-life, including the influence of horizontal gene transfer on contributions to pathogenicity and resistance of gut bacteria. We also focus on Enterococcus spp. given their high levels in infants and their link with opportunistic infections that are a significant cause of morbidity and mortality during early-life. Finally, a perspective on the importance to antibiotic stewardship, and harnessing the microbiota itself for anti-infection therapies for reducing antibiotic usage are also covered.

Quality improvement initiative improves the empiric antibiotic prescribing practices in a tertiary care children’s hospital in India

IntroductionInfections are a common cause of paediatric morbidity. Antibiotics are vital in treating them. Erratic prescribing practices are an important cause for the development of antibiotic resistance. Our objective was...

Point prevalence probing of antimicrobial prescription patterns from a developing country

ABSTRACT Background Irrational use of antibiotics intensifies resistance and jeopardizes advances made in modern medicine. We aimed to conduct a baseline gap analysis survey on antibiotic prescription practices across Pakistan. Research Design and Methods This multi-centered cross-sectional survey was conducted at six public sector tertiary care hospitals from February 2021 to March 2021. Data related to various variables including hospital infrastructure, policies and practices, monitoring and feedback, and epidemiological, clinical, and antibiotic prescription for surveyed patients was collected using World Health Organization (WHO) Point Prevalence Survey (PPS) methodology. Results In a survey of 837 inpatients, 78.5% were prescribed antibiotics. Most commonly prescribed antimicrobial was ceftriaxone (21.7%), followed by metronidazole (17.3%), cefoperazone-sulbactam (8.4%), amoxicillin-clavulanate (6.3%), and piperacillin/tazobactam (5.9%). Surgical prophylaxis (36.7%) and community-acquired infections (24.7%) were the main reasons for antibiotic prescriptions. Single antibiotics were given to 46.7% of patients, 39.9% received a combination of two antibiotics, and 12.5% were prescribed three or more antibiotics. Among six hospitals surveyed, two had drug and therapeutic committees, three had infection prevention and control committees, and one had an antibiotic formulary. Conclusion Findings demonstrate high consumption of broad-spectrum antimicrobials and emphasize the importance of expanding antimicrobial stewardship programs among hospitals. Mentoring clinical teams could help rationalize antimicrobial use.

Assessment of Prescription Patterns and Appropriateness of Antibiotics for Prophylaxis in Dental Procedures: A Retrospective Study

There is a lack of data on dentists’ prescribing behaviors when it comes to the correct use of antibiotics in dental treatments. Antibiotic prescriptions made by dentists were analyzed from a diagnostic perspective in a countrywide study. This study retrospectively examined national health data from January 2018 through August 2019, collected through the Prescription Information System. The analysis only included prescriptions for a single illness and at least one systemic antibiotic. Antibiotic prescribing practices and the role of dental specialization and diagnosis were studied. A total of 9,214,956 prescriptions out of 9,293,410 matched the criteria for inclusion. An average course of antibiotic treatment consists of 1.01 pills. Antibiotics were prescribed most frequently for dental caries (16.2% of cases), dental examinations (20.7% of cases), and periapical abscess without sinuses (28.1% of cases). Antibiotics were prescribed for 96.6% of patients for illogical or confusing reasons, whereas just 3.4% were given based on a single, unambiguous diagnosis, such as cellulitis or a mouth abscess. The most commonly prescribed treatment for any medical issue was amoxicillin combined with an enzyme inhibitor (58.6%). Compared to unidentified dental practitioners (58.2%; p = 0.0001), dental specialists in Groups A and B significantly overprescribed amoxicillin plus an enzyme inhibitor (67.0 and 67.8%, respectively; p = 0.0001) (data not shown). The results of the study suggest that dentists routinely and arbitrarily prescribe antibiotics with questionable rationale in the contexts studied. These results emphasize the need for dentists to begin prescribing antibiotics more deliberately and evidence-based. Educational programs, awareness campaigns, and antibiotic stewardship programmes are just some of the interventions that may be implemented to improve prescribing practices and ensure the correct use of antibiotics in dental operations. The results of this countrywide study highlight problems with dentists’ procedures for prescribing dental antibiotics. The paper states that dentists should base their prescription practices on sound reasoning and empirical data. Dentists can help with global efforts to lower antibiotic resistance and improve patient care if they prescribe them in a more reasonable and responsible manner.

Antibiotic prescribing practices for acute respiratory illness in children less than 24 months of age in Kenema, Sierra Leone: is it time to move beyond algorithm driven decision making?

BackgroundLower respiratory tract infections are the leading cause of mortality in young children globally. In many resource-limited settings clinicians rely on guidelines such as IMCI or ETAT + that promote empiric antibiotic utilization for management of acute respiratory illness (ARI). Numerous evaluations of both guidelines have shown an overall positive response however, several challenges have also been reported, including the potential for over-prescribing of unnecessary antibiotics. The aims of this study were to describe the antibiotic prescribing practices for children less than 24 months of age with symptoms of ARI, that were admitted to Kenema Government Hospital (KGH) in the Eastern Province of Sierra Leone, and to identify the number of children empirically prescribed antibiotics who were admitted to hospital with ARI, as well as their clinical signs, symptoms, and outcomes.MethodsWe conducted a prospective study of children < 24 months of age admitted to the KGH pediatric ward with respiratory symptoms between October 1, 2020 and May 31, 2022. Study nurses collected data on demographic information, medical and medication history, and information on clinical course while hospitalized.ResultsA total of 777 children were enrolled. Prior to arrival at the hospital, 224 children (28.8%) reported taking an antibiotic for this illness without improvement. Only 15 (1.9%) children received a chest radiograph to aid in diagnosis and 100% of patients were placed on antibiotics during their hospital stay.ConclusionsDespite the lives saved, reliance on clinical decision-support tools such as IMCI and ETAT + for pediatric ARI, is resulting in the likely over-prescribing of antibiotics. Greater uptake of implementation research is needed to develop strategies and tools designed to optimize antibiotic use for ARI in LMIC settings. Additionally, much greater priority needs to be given to ensuring clinicians have the basic tools for clinical diagnosis, as well as greater investments in essential laboratory and radiographic diagnostics that help LMIC clinicians move beyond the sole reliance on algorithm based clinical decision making.

Antibiotic Knowledge, Attitudes, and Practices Among Students at Kampala International University in Ishaka, Bushenyi District, Uganda

Antibiotics are drugs used to manage bacterial infections, but their abuse and irrational use have led to the development of resistant bacteria. Misuse of antibiotics, poor prescription behavior by physicians, and patients' wrong habits and lack of knowledge contribute to the spread of resistant strains. A study was conducted to evaluate the current knowledge, attitude, and behavior regarding antibiotic use among students at Kampala International University in Uganda. The data was collected using an interviewer-administered structured questionnaire. The majority of respondents believed that antibiotics were used to decrease fever, overcome pain, overcome malaise and fatigue, treat common colds, and treat infections. Most respondents agreed that starting antibiotics at home was acceptable, while others suggested starting them on doctors' prescription, pharmacists' advice, or buying from drug shops. During the drug use period, most respondents believed that antibiotics should be taken until the drug is finished, while others believed they should be taken until symptoms disappear. All respondents agreed that antibiotics should be taken as per health worker's advice. The study reveals a high rate of irrational antibiotic use among students, primarily due to misconceptions about when, what, who, and for how long to take antibiotics. This highlights the need for better prescription and regulation of antibiotic use and the need for more accurate information on antibiotic use and prescription practices. Keywords: Antibiotics, Bacterial infections, Self-medication, Self-prescription, Drugs.

Multidrug-Resistant Staphylococcus capitis: An Emerging Challenge in Clinical Settings Found in Adult Patients in Saudi Arabia

The study reveals crucial information on S. capitis, a potentially dangerous bacterium that can cause sepsis in hospitalized adult patients, including its frequency and patterns of drug resistance which could significantly contribute to the existing body of knowledge in this field. This retrospective study was conducted in the King Fahad Medical City (KFMC), Riyadh, Saudi Arabia, from June 2019 to November 2022. The comprehensive data collection and analysis provide valuable information on the prevalence of S. capitis in different infection sites, antibiotic sensitivity profiles, and the association with patient demographics. A total of 219 S. capitis isolates from hospitalized patients with sepsis tested positive. Infection was most common in venous blood (139 patients, 63.5%), followed by central blood (24 patients, 11%). Other locations included venipuncture (48 patients, 21.9%) and cerebrospinal fluid (three patients, 1.4%). The results highlight the clinical significance of S. capitis as a major contributor to sepsis, especially in male patients, and emphasize the need for appropriate antibiotic selection for effective treatment. Furthermore, this study raises concerns about the high rates of methicillin resistance observed in S. capitis isolates, emphasizing the urgency in tackling antibiotic resistance and promoting judicious antibiotic prescription practices. Moreover, the identification of a decreased susceptibility to vancomycin as a potential explanation for its reduced effectiveness in treating S. capitis infections adds a crucial aspect to the discussion of treatment options and underscores the need for alternative therapeutic strategies.

Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting?

Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting. This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics. Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]). The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance.

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest.

How decisions are made: Antibiotic stewardship in dentistry.

We performed a preimplementation assessment of workflows, resources, needs, and antibiotic prescribing practices of trainees and practicing dentists to inform the development of an antibiotic-stewardship clinical decision-support tool (CDST) for dentists. We used a technology implementation framework to conduct the preimplementation assessment via surveys and focus groups of students, residents, and faculty members. Using Likert scales, the survey assessed baseline knowledge and confidence in dental providers' antibiotic prescribing. The focus groups gathered information on existing workflows, resources, and needs for end users for our CDST. Of 355 dental providers recruited to take the survey, 213 (60%) responded: 151 students, 27 residents, and 35 faculty. The average confidence in antibiotic prescribing decisions was 3.2 ± 1.0 on a scale of 1 to 5 (ie, moderate). Dental students were less confident about prescribing antibiotics than residents and faculty (P < .01). However, antibiotic prescribing knowledge was no different between dental students, residents, and faculty. The mean likelihood of prescribing an antibiotic when it was not needed was 2.7 ± 0.6 on a scale of 1 to 5 (unlikely to maybe) and was not meaningfully different across subgroups (P = .10). We had 10 participants across 3 focus groups: 7 students, 2 residents, and 1 faculty member. Four major themes emerged, which indicated that dentists: (1) make antibiotic prescribing decisions based on anecdotal experiences; (2) defer to physicians' recommendations; (3) have limited access to evidence-based resources; and (4) want CDST for antibiotic prescribing. Dentists' confidence in antibiotic prescribing increased by training level, but knowledge did not. Trainees and practicing dentists would benefit from a CDST to improve appropriateness of antibiotic prescribing.

A retrospective study on bacteriological profile and antibiotics prescription practice in a tertiary level intensive care unit

BACKGROUND Antibiotics are the most commonly prescribed medicines in intensive care units (ICU). The irrational use of antibiotics leads to the development of multidrug-resistant organisms (MDR). The aim of the study is to determine the bacteriological profile of infections in our ICU and antibiotic prescription practice, before and after the culture results. METHODOLOGY This is a retrospective study conducted in a tertiary-level, 33-bedded ICU in Nepal to evaluate the bacteriological profile and antibiotic prescription practice. The patients who were admitted between a period of 3 months (January 2023 to March 2023) were enrolled. The data variables collected were; patients' details, culture samples sent (blood, urine, endotracheal (ET) aspirate, sputum, cerebrospinal fluid (CSF), wound swab, pleural fluid, ascitic fluid, tissue culture, and peritoneal fluid), gram stain results, culture sensitivity results, empirical antibiotics used, and change in antibiotics following culture results. RESULTS A total of 378 culture samples were obtained from 230 patients. A positive culture report was obtained for 165 (43.65%) of the 378 samples sent. Urine was the most common sample sent for microbiology (28%), followed by blood (25.3%) and sputum (22.75%). The percentage occurrence of gram-negative bacteria was 84%, while that of gram-positive bacteria was 16%. Methicillin- resistant coagulase-negative staphylococcus (MRCONS) was the most common gram-positive organism isolated (46.15%), and Klebsiella pneumoniae was the most common gram-negative organism (38.84%). Cephalosporin was the commonest group of empirical antibiotics used in our ICU, followed by carbapenem. Empirical antibiotic treatment was continued in 108 patients (47%), changed following the culture results in 92 patients (40%), and discontinued in 30 patients (13%). Escalation of antibiotics was done in 78 patients (85%) and de-escalation in 14 patients (15%). CONCLUSION Antimicrobial resistance and the irrational prescription of antibiotics can lead to a global economic burden. Hence, antibiotic stewardship programs are required to reduce the irrational prescribing patterns of antibiotics.

A Qualitative Assessment of a Training and Communication Intervention on Antibiotic Prescription Practices Among Health Workers and Outpatients at Public Health Facilities in Uganda.

Antibiotic prescribing practices are 1 of the contributing causes of antimicrobial resistance (AMR). The study explored the key drivers and barriers to adherence to prescribing instructions among healthcare workers and outpatient attendees with the aim of developing a training and communication intervention to improve adherence to prescription. Prior to randomized trials at 3 health centers in Uganda (Aduku, Kihihi, and Nagongera), a pre-intervention qualitative assessment was conducted to explore behavioral drivers for adherence to prescriptions and the communication of adherence messages. Based on the findings, a training and communication package was developed for healthcare workers and patients at Day 0 of the trial. During the trial's Day 7 patient follow-up, in-depth interviews were conducted to further investigate adherence behaviors. Five main themes were identified that acted as drivers or barriers to prescription adherence. Key drivers included: drug availability at health facility, health worker knowledge, and communication to patients. Barriers included: care-seeker use of treatment resorts and an inability by care-seeker to buy drugs. The T&C appeared to influence both health workers' and patients' behavior and improve adherence to prescription.The adapted T&C should be considered a toolkit to improve antibiotic use across health facilities accompanied with appropriate guidelines to mitigate AMR.

A Review on Rational Use of Antibiotics: Strategies and Interventions

The rational use of antibiotics is essential to combat the growing threat of anti-microbial resistance, improve patient outcomes, and optimize healthcare resources. Effective antibiotic stewardship programs play a crucial role in guiding healthcare professionals and patients towards appropriate antibiotic use. These programs encompass a range of interventions, including education and training, clinical guidelines, antimicrobial stewardship teams, and surveillance systems. By implementing these strategies, healthcare facilities can enhance antibiotic prescribing practices, reduce unnecessary antibiotic use, and prevent the emergence and spread of antibiotic-resistant bacteria. Additionally, public awareness campaigns are vital in empowering individuals to understand the appropriate use of antibiotics, emphasizing the importance of completing prescribed courses, and discouraging self-medication. Promoting awareness among the general population helps mitigate misconceptions and misuse, ensuring antibiotics are used judiciously and only when necessary. Keywords: AMR (Anti-microbial resistance), Anti-microbial Stewardship, rational use, health care professionals.

Antibiotic prescription practices among dentists treating children in the UK

Introduction There are limited paediatric specific data on antibiotic prescribing practices, which have been cited as one of the causes of general overuse and misuse of antibiotics in young patients. The aim of this study was to investigate prescribing practices among dentists with an interest in paediatric dentistry in the UK. Methods A prospective cross-sectional survey was distributed electronically to members of the British Society of Paediatric Dentistry between February and May 2021. The questions and scenarios were based on antibiotic prescribing guidelines in the UK. Results Two hundred and six dentists completed the survey (45% response rate). Most participants (93%) conformed to guidelines and prescribed amoxicillin as a first-line antibiotic for an odontogenic infection. For patients with a penicillin allergy, 16% of dentists reported clindamycin as their first-choice antibiotic. Seventeen per cent of those surveyed stated that they would prescribe antibiotics for local swelling without any additional factors indicating a persistent or spreading bacterial infection. Further insights into prescribing practices for prophylaxis, paediatric doses and non-clinical factors are described. Conclusions Antibiotics are part of the armamentarium that dentists can use to treat patients. The results of this survey highlight some positive trends as well as some variation in prescribing practice that requires correction and discussion for future research.

Waking Up to Antibiotic Resistance.

Antimicrobial resistance (AMR) has emerged as a global concern, particularly in developing countries where its causes seem to entrench the knowledge, attitude, and practice of healthcare professionals and patients toward the use of antimicrobials. This review aims to provide a compendious yet thorough overview of our understanding of antibiotic resistance pertaining to dentistry. Literature provides evidence of inadequate antibiotic prescribing practices by dental professionals. Considering the growing concern about antibiotic prescribing habits and patient's tendencies of improper use, we attempt to address the interventional efforts of dentists and patients in the context to focus on the root causes specifically to prevention of the antimicrobial resistance. Following the guidelines and flowchart depicted in this article, the members of dental professions will get clear views on the use of antibiotics. This will cause a definite decrease in the growing concern about antibiotic resistance.

Preventability of Adverse Drug Reactions Related to Antibiotics: An Assessment Based on Spontaneous Reporting System.

Antibiotics are commonly used in both outpatient and inpatient settings and are responsible for the majority of adverse drug reaction (ADR) reports. We aimed to characterize spontaneously reported ADRs associated with antibiotics and assessing the preventability of these ADRs in a Vietnamese setting. We conducted a retrospective descriptive study based on ADRs related to antibiotics spontaneously reported by healthcare workers to the National Pharmacovigilance Database of Vietnam (NPDV) between June 2018 and May 2019. The characteristics of included reports were descriptively analyzed. The preventability of reported ADRs was assessed using a standardized preventability scale. We identified the leading causes and described the characteristics associated with preventable ADRs (pADRs). We included 6385 antibiotic-related reports from a total of 12,056 reports submitted to the NPDV during the study period. Beta-lactam antibiotics, mostly broad-spectrum with parenteral route, were suspected in the majority cases. The most commonly reported pADRs were allergic reactions, mostly classified under skin and subcutaneous tissue disorders. Of all included cases, 537 cases (8.4%) were deemed as associated with pADRs. Major causes of pADRs include potentially inappropriate prescribing (352/537, 65.5%) and re-administration of antibiotics causing prior allergy/allergies (99/537, 18.4%). The majority of pADRs involved the use of beta-lactam antibiotics with inappropriate indications. ADRs related to antibiotic use represent more than half of ADRs spontaneously reported in Vietnam. Approximately one in every ten reported cases is associated with pADRs. The majority pADRs can be prevented through simple improvement in antibiotic prescribing practices.

P06 Improving antibiotic prescribing practice in a tertiary burns and plastic surgery department

Abstract Background Antimicrobial resistance is an ever-emerging global public health issue. In the healthcare setting, it is essential to use antimicrobials appropriately and manage infections effectively to help tackle antimicrobial resistance. Objectives To review local antibiotic resistance data, update the plastic surgery infection guidelines based on this data, implement interventions to facilitate compliance with the guidelines and re-audit to assess if these interventions have been effective. Methods A review was undertaken of the previous 3 months of antibiotic susceptibility results for significant staphylococci and streptococci species isolated from blood cultures and wound swabs, and the microbiology results of all local cases of necrotizing fasciitis over a 5-year period. The plastic surgery infection guidelines were updated to reflect the changes in local antibiotic resistance rates. Following implementation of the new guideline, various interventions were undertaken including provision of departmental teaching sessions, ensuring availability of appropriate antibiotics in the burns and plastics theatres and redesigning the guideline to include all plastic surgery and infection guidelines within the one document (previously multiple specific guidelines). Between each intervention, compliance with the guideline was measured to establish if the intervention had made a difference. Results Changes to the guideline included using clindamycin rather than doxycycline for the treatment of cellulitis in penicillin allergic patients, as 44% of Group A Streptococcus isolates identified in wound swabs were resistant to doxycycline. Other changes included the introduction of linezolid if the patient had received a recent or failed course of clindamycin, and the use of cefazolin rather than clindamycin for patients with severe cellulitis with a penicillin allergy, due to the increase in rates of clindamycin resistance. After the three intervention cycles, prescriber compliance with the guideline increased from 50% to 71% demonstrating the need for ongoing intervention and re-evaluation. Conclusions Co-amoxiclav and clindamycin were the most commonly prescribed antibiotics in those patients whose antibiotic prescriptions did not comply with the guidelines. The main reason for this is historical usage of these antibiotics within the specialty; this project demonstrates the challenges in changing established practices in individual clinicians. Interventions to ‘make it easy’ for prescribers to follow antibiotic guidelines (for example, the right antibiotic being easily available at the site of prescription), along with targeted education, can be effective but long-standing prescribing habits within specialist areas may be difficult to change.

Antibiotic therapy and necrotizing enterocolitis

Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.

Nurse practitioner and midwife antibiotic prescribing in Australia.

Antimicrobial resistance is of global significance. To reduce the risk of harm associated with antibiotic prescribing in Australia, a recent strategy to tackle antimicrobial resistance has included non-medical prescribers. Traditionally, antibiotic prescribing has been the domain of the medical profession but, more recently, nurse practitioners and endorsed midwives have been authorized to prescribe antibiotics. This study describes the antibiotic prescribing practices by nurse practitioners and endorsed midwives in Australia, with clinical implications for international settings. This was a retrospective analysis of routinely collected aggregated data of anonymous individuals. Data on dispensed prescriptions of antibiotics were obtained from the Australian Department of Human Services, for the period 2005-2016. All antibiotics were allocated to a spectrum class (narrow, moderate, broad). Analysis using descriptive statistics was undertaken to determine the antibiotic prescribing patterns of nurse practitioners and endorsed midwives. Nurse practitioners have been prescribing within Australia since 2000, and midwives since 2012. Nurse practitioner antibiotic written scripts increased from 3143 during 2005-2011 to 34615 in 2012-2016, while antibiotic written scripts by midwives increased from 2012 (n=2) to 2016 (n=469). Nurse practitioners and midwives prescribed similar classes of antibiotics. These professionals are important non-medical prescribers and are increasingly writing antibiotic prescriptions.Both nursing and midwifery cohorts complete accredited education programs, albeit with some differences in structure. When prescribing antibiotics, nurse practitioners and midwives are following evidenced-based therapeutic guidelines. They are increasingly relevant clinicians prescribing antibiotics, particularly in acute and primary care settings, which has relevance in global antimicrobial strategies.