Antibiotics For Acute Respiratory Infections Research Articles

P12 Unjustified use of antibiotics in wartime conditions in Ukraine

Abstract Background The Ministry of Health of Ukraine reported that every second patient who takes antibiotics does not need such treatment, and every third uses them for viral diseases. In Ukraine, during the war, there has formed a resonance between the availability of broad-spectrum antibiotics and their belonging to the non-recommended category according to the AWaRe classification 2023. Therefore, the fight against antibiotic resistance continues to be a leading task of modern medicine. Objectives To investigate the expediency of use of ceftriaxone/levofloxacin among Ukrainian and foreigners settled in Ukraine. Subjects and methods A total of 180 (55% Ukrainians, 45% foreigners) responders were examined by questionnaire for ceftriaxone/levofloxacin use over 1 year with specification of reasons, expediency of use, possible reason for cancellation/replacement of antibiotic therapy and preventable usage cases. Results The sample included 63.9% women, 36.1% men, average age 18–25 years. The incidence of ceftriaxone/levofloxacin use was 58.97% among foreigners versus 12.74% among Ukrainians (P<0.001). The antibiotic use by physician’s prescription occurred among 28.3% foreigners and 92.3% Ukrainians (P < 0.05). The frequency of antibiotic use due to microbiological confirmation was significantly lower among foreign responders: 13.05% versus 76.9% in Ukrainians (P < 0.01). The reasons for choice of ceftriaxone/levofloxacin in the Ukrainian sample were acute respiratory infections 46%, fever 7.8% and diseases of bacterial origin 84.6%. At the same time foreigners used antibiotics for acute respiratory infections 41.3%, fever 19.7% and diseases of bacterial origin 63.1%. The analysis found that antibiotic use for ‘prophylaxis’ (mainly for viral diseases) was 2.95% among Ukrainians and 32.05% among foreigners (P<0.05). The predominant reasons for cancellation/replacement of antibiotic therapy, such as allergic reactions and antibiotic-associated diarrhoea, were found in 67.4% of foreigners and 7.69% of Ukrainians (P<0.05). Conclusions The lack of antibiotic prescription on the basis of microbiological confirmation, self-limited choice of antibiotics and unreasonable use for diseases of non-bacterial origin can be factors that promote multiple resistance in future and complicate the natural clinical course of most common infectious diseases.

Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial

BackgroundOverprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model.MethodsFollowing qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout.DiscussionThis study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings.Trial registrationClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303.

Appropriate use of antibiotics for acute respiratory infections at primary healthcare facilities in China: a nationwide cross-sectional study from 2017 to 2019

The appropriateness of antibiotic use for acute respiratory infections (ARIs) in Chinese primary healthcare facilities (PHFs) remained uncertain. We aimed to evaluate to what degree antibiotic prescribing for ARIs were aligned with guideline recommendations in primary settings across China. We collected outpatient prescriptions from 262 Chinese PHFs in 27 cities of six provinces between 2017 and 2019. The appropriate antibiotic prescribing was defined as prescribing antibiotic classes that were recommended by Chinese clinical guidelines, if patients were prescribed antibiotics. We evaluated the magnitude of antibiotics prescribed for acute upper respiratory infections (AURIs), acute bronchitis, and community-acquired pneumonia (CAP) and their appropriateness. Overall, 55.1% (87,684/159,150), 66.8% (30,836/46,153), and 68.5% (4615/6733) of outpatients with AURIs, acute bronchitis, and CAP treated at PHFs in China were prescribed with antibiotics. Of all antibiotic prescriptions, only 20.0% (17,542/87,684), 18.6% (5724/30,836) and 69.6% (3211/4615) used antibiotic classes that were recommended by the guidelines for AURIs, acute bronchitis, and CAP, respectively. Patients residing in the Chinese central region (17.0%, 15.4%, 69.3% for AURIs, acute bronchitis, and CAP, respectively) were less likely to be prescribed with antibiotics that were appropriately selected. Unnecessary antibiotics were widely prescribed for patients with AURIs or acute bronchitis and most patients with ARIs did not receive guideline-recommended antibiotic classes in Chinese PHFs. Interventions to promote evidence-based treatment and the appropriate use of antibiotics are urgently needed at the primary level across China. This work was supported by the National Natural Science Foundation of China [grant number 72074007, 81973294].

Sources of antibiotics for acute respiratory infection in children aged <5 years children in South Asia: A multicountry study

Background: In South Asia, a region of almost 2 billion people across 8 countries, acute respiratory infections (ARIs) are associated with significant morbidity and mortality in children aged <5 years. Although ~80% of ARIs are due to viral etiology and are often self-limiting, they remain the single largest reason for antibiotic use in children aged <5 years in South Asia. We investigated the sources and dispensing pattern of antibiotics for ARIs in children aged <5 years in South Asia. Methods: We analyzed nationally representative, population-based, publicly available household survey data from 6 South Asian countries’ Demographic and Health Surveys (DHS): Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. The outcome of interest was the source of antibiotics for children aged <5 years who reportedly had symptoms compatible with ARI (cough, fever, and runny nose) and had received antibiotics for the ARI episode in the 2 weeks preceding the survey. We used a generalized estimating equation with an exchangeable correlation structure to account for country-specific cluster-level correlation to estimate the odds of sources of antibiotics usage. Models were adjusted for age, sex, type of place of residence, wealth index, and parents’ education. To analyze the data, we used the sample weight supplied by the DHS to ensure that our results appropriately reflect the target population in each of the countries studied. Results: In total, across the 6 South Asian countries, 24,104 children aged <5 years had symptoms of ARI, 7,587 (31%; 95% CI, 30–33) from received antibiotics. A higher proportion of antibiotic usage for ARIs episodes occurred in Afghanistan (66%), followed by Maldives (53%), Pakistan (45%), and Nepal (43%). Regarding the source of antibiotics, a higher proportion of antibiotics was obtained from the private medical sector in India, followed by unqualified sources in Bangladesh, and the public sector in Afghanistan. Our adjusted multivariable analysis revealed that, in comparison to the public sector, participants were 2.6 times (aOR, 2.6; 95% CI, 1.6–4.3) more likely to receive antibiotics from private medical sector drug sources in Nepal and 1.3 times more likely (aOR, 1.3; 95% CI, 1.1–1.5) in Afghanistan. Conclusions: In South Asian countries, the private medical sector was the most common primary source of antibiotics for children with ARIs. Targeted efforts to create awareness around antibiotic dispensing and guidelines to improve practices may curtail the use of antibiotics for ARIs in children aged <5 years in South Asia.Disclosures: None

Prescription of antibiotics in acute respiratory infections non-pneumonia in a private outpatient practice

The over prescription of antibiotics for acute respiratory infections is a major public health problem worldwide. To evaluate the frequency of prescription of antibiotics for non-pneumonia acute respiratory infections in private outpatient clinics in individuals without chronic diseases or immunosuppression. All medical records of adult consultants in a national network of private ambulatory medical centers during May 2018 whose primary diagnosis corresponded to acute respiratory infections not pneumonia (ICD10) were identified and retrospectively analyzed, excluding those with chronic respiratory conditions or states of immunosuppression. Of the 38,072 consultants (aged 36 years, 63% women) who met this criterion, 54% (n = 20,499) received a prescription for at least one antibiotic. The diagnoses that most frequently received this prescription were acute bronchitis (28.7%), acute sinusitis (16.5%) and acute tonsillitis (16.2%). The most frequently prescribed antibiotic globally was azithromycin (37.4%), followed by amoxicillin (20.1%) and amoxicillin plus clavulanic acid (17.7%). Levofloxacin prescription reached 12.5% of total prescriptions. An antibiotic was prescribed in more than half of the non-pneumonia outpatient acute respiratory infections. Azithromycin was the most prescribed antibiotic, while levofloxacin exceeded 10% of prescriptions. These results reinforce the need to implement an antibiotic prescription surveillance system at the outpatient level.

Reynoutria japonica Houtt for Acute Respiratory Tract Infections in Adults and Children: A Systematic Review.

Introduction: Respiratory tract infections (RTIs) are a major cause of morbidity and mortality in some high-risk groups including children and older adults. There is evidence that Chinese herbal medicine has an effect on RTIs. Reynoutria japonica Houtt (better known under its synonym Fallopia japonica (Houtt.) Ronse Decr.) (F. japonica), a commonly used Chinese herbal medicine, has a high content of resveratrol and glycosides. In traditional Chinese medicine theory, F. japonica has the effect of clearing heat in the body, improving blood and qi circulation, eliminating phlegm, and relieving cough, so it may have an effect on RTIs. Methods: This systematic review was registered under PROSPERO CRD42020188604. Databases were searched for randomized controlled trials of F. japonica as a single herb, or as a component of a complex herbal formula for RTIs. Quality of methodology was assessed by two reviewers independently using the Cochrane Risk of Bias Tool. The primary outcome was symptom improvement rate. The secondary outcome measures were fever clearance time, Murray lung injury score and incidence of adverse effects. The extracted data were pooled and meta-analysed by RevMan 5.3 software. Results: Eight RCTs with 1,123 participants with acute RTIs were included in this systematic review, and all the RCTs used F. japonica as part of a herbal mixture. Only one included trial used F. japonica in a herbal mixture without antibiotics in the treatment group. The findings showed that herbal remedies that included F. japonica could increase the symptom improvement rate (risk ratio 1.14, 95% confidence intervals [1.09, 1.20], I2 = 0%, p < 0.00001, n = 7 trials, 1,013 participants), shorten fever duration, reduce Murray lung injury score and did not increase adverse events (RR 0.33, 95% CI [0.11, 1.00], I2 = 0%, p = 0.05, n = 5 trials, 676 participants). Conclusion: There is limited but some evidence that F. japonica as part of a herbal mixture may be an effective and safe intervention for acute RTIs in clinical practice. In future studies it would be preferable to evaluate the effectiveness and safety of using F. japonica without antibiotics for acute RTIs.

Effects of Computer-Aided Decision Support Systems on Appropriate Antibiotic Prescribing by Medical Interns: A Quasi-Experimental Study.

Literature suggests that the adoption of guidelines for antibiotic prescribing has a significant impact on improving prescription practices of physicians; thus, this study aimed to assess the effectiveness of computer-aided decision support systems (CA-DSS) on antibiotic prescribing among medical interns. A prospective before-and-after interventional study was conducted on 40 medical interns. The interns were asked to use the CA-DSS during a one-month internship course at the infectious disease department. The main outcome measure was the knowledge of medical interns regarding the type, name, volume, usual dosages, and administration route of antibiotics prescribed. Paired t-test was applied to assess the change of medical interns' knowledge before and after the study. There was a statistically significant difference between the mean score of interns' medical knowledge before 5.4±2 and after 9.1±2.8 using the CA-DSS (p = 0.000). CA-DSS as an IT-based training intervention was effective for the knowledge of medical interns to prescribe the right antibiotics for acute respiratory infections.

A retrospective review of antibiotic use for acute respiratory infections in urgent-care patients.

We examined the use of antibiotics for acute respiratory infections in an urgent-care setting. Retrospective database review. The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California. Visits for acute respiratory infections were identified based on presenting complaints. The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed. In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21-1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02-1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%. The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.

115. Variable Use of Diagnostic Codes for Acute Respiratory Infections Across Emergency Departments and Urgent Care Clinics in an Integrated Healthcare System: Implications for Accuracy of Antibiotic Stewardship Metrics

BackgroundAntibiotic stewardship initiatives can leverage metrics that make peer-peer comparisons. A commonly used metric measures how frequently a clinician prescribes antibiotics for acute respiratory infections (ARIs), as defined by diagnostic codes. However, it is unclear if clinicians differ in their use of ARI diagnostic codes. In this study, we evaluated differences in how frequently clinicians code for ARIs and factors that are associated with the use of ARI diagnostic codes in Emergency Department (ED) and Urgent Care (UC) visits across an integrated healthcare system.MethodsWe analyzed a retrospective cohort of all ED and UC patient-visits across 129 Veterans Affairs medical centers during 2016-2018. ARI visits were identified using ICD-10 codes for acute bronchitis, influenza, pharyngitis, sinusitis, and upper respiratory tract infections for clinicians with 100 or more visits. A generalized linear mixed model with a link logit function that accounted for clustering at the clinician and facility-level was used to calculate median odds ratios (OR) and to identify factors associated with increased likelihood of entering an ARI code.ResultsThere were 6,016,499 patient-visits, and 519,389 (8.6%) were coded as an ARI (Table 1). The mean rate of ARI diagnoses across all visits was 8.9% (SD 2.5%) at the facility-level and 7.4% (SD 4.5%) at the clinician-level (Table 2). The median OR was 2.19 (95% CI 2.18, 2.22), suggesting there was between-clinician variation in coding for ARI diagnoses. Visits were significantly more likely to be coded as ARIs if seen by an advanced practice provider (OR=2.36, 95% CI 2.19, 2.54), if a fever was recorded (OR=4.20, 95% CI 4.18, 4.29), and if the visit occurred between December-March (OR=1.97, 95% CI 1.96, 1.98). Approximately 2/5th of the variability (41.4%) in assigning an ARI diagnostic code was explained by differences across individual clinicians. ConclusionThere was substantial variability in how frequently ED and UC clinicians coded a visit as an ARI, and a large proportion of the variability was explained by differences across clinicians. Unmeasured factors could include different approaches to using diagnostic codes. ARI metrics based on diagnostic codes may need to account for differences in clinicians’ coding behavior.Disclosures All Authors: No reported disclosures

Unneeded antibiotics for acute respiratory infections in primary care: stop as early as possible

In the field of antibiotic treatment, some old dogmas are falling in the light of recent evidence. Some examples include the need to use bactericidal drugs or their intravenous administration for the whole treatment course, and the durations of treatment for specific types of infections, among others [1–3]. The long recommended practice to complete the course of an antibiotic once prescribed [4] was also based on the dogma that not doing so would promote the development of resistance. Again, this dogma has also been seriously challenged, as present knowledge suggests that antibiotics facilitate resistance mostly by selecting resistant bacteria from the colonizing flora, that the longer the exposure the bigger collateral damage and that the development of resistance of the bacteria causing the infection being treated is relevant only for some pathogens and situations [5,6].

Comparing the quantity and quality of randomised placebo-controlled trials of antibiotics for acute respiratory, urinary, and skin and soft tissue infections: a scoping review.

BackgroundThe management of acute respiratory infections (ARIs), urinary tract infections (UTIs), and skin and soft tissue infections (SSTIs) should be guided by high quality evidence.AimTo compare the quantity and quality of randomised placebo-controlled trials of antibiotics for ARIs, UTIs, and SSTIs.Design & settingA scoping review of the literature was performed using comprehensive search strategies.MethodPubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published studies from inception until 17 April 2019. Randomised controlled trials (RCTs) that compared participants in primary care or in the community who had uncomplicated acute ARI, UTI, or studies, and were randomised to antibiotic or placebo (or no active treatment), were eligible for inclusion. Two groups of researchers independently screened articles for inclusion, extracted data, and assessed the quality of included studies.ResultsA total of 108 eligible studies were identified: 80 on ARI, eight on UTI, and 20 on SSTI. The quality of studies varied with unclear risk of bias (RoB) prevalent in many domains. There was a gradual improvement in the quality of trials investigating ARIs over time, which could not be assessed in SSTI and UTI studies.ConclusionThis review highlights a sparsity of trials assessing the effectiveness of antibiotics in people with UTIs and SSTIs, compared to trials targeting ARIs. This gap in the evidence needs to be addressed by conducting further high quality trials on the effects of antibiotics in patients with UTI and SSTI.

Hospitalization for Acute Respiratory Tract Infection in a Low-Antibiotic-Prescribing Setting: Cross-Sectional Data from General Practice.

Background: Acute respiratory tract infections (ARTI) are the main cause of inappropriate antibiotic prescribing. To date, there is limited evidence concerning whether low levels of antibiotic prescribing may impact patient safety. We investigate whether antibiotic prescribing for patients seeking primary care for ARTI correlates with the odds for hospitalization. Methods: Analysis of patient baseline data (n = 3669) within a cluster-randomized controlled trial. Adult patients suffering from ARTI in German primary care are included. The main outcome measure is acute hospitalization for respiratory infection and for any acute disease from 0 to 42 days after initial consultation. Results: Neither the antibiotic status of individual patients (OR 0.91; 95% CI: 0.49 to 1.69; p-value = 0.769) nor the physician-specific antibiotic prescription rates for ARTI (OR 1.22; 95% CI: 1.00 to 1.49; p-value = 0.054) had a significant effect on hospitalization. The following factors increased the odds for hospitalization: patient’s age, the ARTI being defined as lower respiratory tract infections (such as bronchitis) by the physician, the physician’s perception of disease severity, and being cared for within group practices (versus treated in single-handed practices). Conclusions: In a low-antibiotic-prescribing primary care setting such as Germany, lack of treatment with antibiotics for ARTI did not result in higher odds for hospitalization in an adult population.

An antibiotic stewardship programme to reduce inappropriate antibiotic prescribing for acute respiratory infections in rural Chinese primary care facilities: study protocol for a clustered randomised controlled trial

BackgroundInappropriate prescribing of antibiotics for acute respiratory infections at the primary care level represents the major source of antibiotic misuse in healthcare, and is a major driver for antimicrobial resistance worldwide. In this study we will develop, pilot and evaluate the effectiveness of a comprehensive antibiotic stewardship programme in China’s primary care hospitals to reduce inappropriate prescribing of antibiotics for acute respiratory infections among all ages.MethodsWe will use a parallel-group, cluster-randomised, controlled, superiority trial with blinded outcome evaluation but unblinded treatment (providers and patients). We will randomise 34 primary care hospitals from two counties within Guangdong province into the intervention and control arm (1:1 overall ratio) stratified by county (8:9 within-county ratio). In the control arm, antibiotic prescribing and management will continue through usual care. In the intervention arm, we will implement an antibiotic stewardship programme targeting family physicians and patients/caregivers. The family physician components include: (1) training using new operational guidelines, (2) improved management and peer-review of antibiotic prescribing, (3) improved electronic medical records and smart phone app facilitation. The patient/caregiver component involves patient education via family physicians, leaflets and videos. The primary outcome is the proportion of prescriptions for acute respiratory infections (excluding pneumonia) that contain any antibiotic(s). Secondary outcomes will address how frequently specific classes of antibiotics are prescribed, how frequently key non-antibiotic alternatives are prescribed and the costs of consultations. We will conduct a qualitative process evaluation to explore operational questions regarding acceptability, cultural appropriateness and burden of technology use, as well as a cost-effectiveness analysis and a long-term benefit evaluation. The duration of the intervention will be 12 months, with another 24 months’ post-trial long-term follow-up.DiscussionOur study is one of the first trials to evaluate the effect of an antibiotic stewardship programme in primary care settings in a low- or middle-income country (LMIC). All interventional activities will be designed to be embedded into routine primary care with strong local ownership. Through the trial we intend to impact on clinical practice and national policy in antibiotic prescription for primary care facilities in rural China and other LMICs.Trial registrationISRCTN, ID: ISRCTN96892547. Registered on 18 August 2019.

Инфекции дыхательных путей в педиатрической практике: сложные ответы на простые вопросы

Despite modern highly-effective treatment and preventive tools available to physicians, respiratory tract infections (RTIs) are still the most common reason for referral to pediatricians. A myriad of papers are published every year, however, there is a growing concern over this issue. This paper responds to seemingly simple questions that, however, are often challenging and controversial for physicians and pediatricians. These questions are the use of antibiotics for acute RTIs to prevent bacterial complications, the impact of antibiotic resistance of respiratory pathogens (Streptococcus pyogenes, Streptococcus pneumoniae, and Haemophilus influenzae) on antibacterial treatment choice, current position of macro-lides in the treatment for RTIs and ENT infections, the prescription of aminopenicillins and inhibitor-protected aminopenicillins in specific clinical situations, dosage regimens of amoxicillin and amoxicillin/clavulanic acid in pediatrics, the position of peroral third-generation cephalosporins in the treatment for RTIs, and optimal antibacterial treatment duration in children. Pediatricians often face these issues in routine clinical practice.Keywords: pediatrics, respiratory tract infections, acute respiratory disorders, antibiotics, antibiotic resistance.For citation: Andreeva I.V., Stetsyuk O.U., Egorova O.A. Respiratory tract infections in pediatrics: difficult answers to simple questions. Russian Journal of Woman and Child Health. 2020;3(2):105–111. DOI: 10.32364/2618-8430-2020-3-2-105-111.

Delayed prescribing of antibiotics for acute respiratory infections by GP registrars: a qualitative study.

Antibiotic prescribing for acute self-limiting respiratory tract infections (ARTIs) in Australia is higher than international benchmarks. Antibiotics have little or no efficacy in these conditions, and unnecessary use contributes to antibiotic resistance. Delayed prescribing has been shown to reduce antibiotic use. GP registrars are at a career-stage when long-term prescribing patterns are being established. To explore experiences, perceptions and attitudes of GP registrars and supervisors to delayed antibiotic prescribing for ARTIs. A qualitative study of Australian GP registrars and supervisors using a thematic analysis approach. GP registrars and supervisors were recruited across three Australian states/territories, using maximum variation sampling. Telephone interviews explored participants' experience and perceptions of delayed prescribing of antibiotics in ARTIs. Data collection and analysis were concurrent and iterative. A total of 12 registrars and 10 supervisors were interviewed. Key themes included the use of delayed prescribing as a safety-net in cases of diagnostic uncertainty or when clinical review was logistically difficult. Delayed prescribing was viewed as a method of educating and empowering patients, and building trust and the doctor-patient relationship. Conversely, it was also seen as a loss of control over management decisions. Supervisors, more so than registrars, appreciated the psychosocial complexity of ARTI consultations and the importance of delayed antibiotic prescribing in this context. Better awareness and understanding by GP registrars of the evidence for delayed antibiotic prescription may be a means of reducing antibiotic prescribing. Understanding both registrar and supervisor usage, uncertainties and attitudes should inform educational approaches on this topic.

FebriDx®: A Rapid Diagnostic Test for Differentiating Bacterial and Viral Aetiologies in Acute Respiratory Infections.

FebriDx® is a rapid, point-of-care diagnostic test that is designed to aid in the differentiation of bacterial and viral acute respiratory infections (ARIs), thus helping to guide decisions regarding the prescription of antibiotics in the outpatient setting. FebriDx carries a CE mark for use in the EU and is also approved in several other countries, including Canada, Saudi Arabia and Singapore. It is indicated for use in patients > 2 years old with symptoms consistent with a community-acquired ARI. The test involves the use of an immunoassay on a fingerstick blood sample to provide simultaneous, qualitative measurement of elevated levels of C-reactive protein (CRP) and myxovirus resistance protein A (MxA). In two prospective, multicentre studies in patients with acute upper respiratory tract infections, FebriDx was shown to be both sensitive and specific in identifying patients with a clinically significant infection and in differentiating between infections of bacterial and viral aetiology. The test is simple, requires no additional equipment and produces actionable results in ~ 10 min. As was demonstrated in a small, retrospective analysis, FebriDx results can help guide (improve) antibiotic prescribing decisions. Reducing the unnecessary or inappropriate prescription of antibiotics for ARIs of probable viral aetiology is important for antibiotic stewardship and can also reduce the unnecessary exposure of patients to the risk of antibiotic-related adverse events. FebriDx thus represents a useful diagnostic tool in the outpatient setting.

An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study

BackgroundAntibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs).MethodsThe entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use.ResultsPost-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample.ConclusionsOverall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt.

Antibiotic Prescribing Practices: Is There a Difference Between Patients Seen by Telemedicine Versus Those Seen In-Person?

Background: Direct-to-consumer telemedicine is becoming part of mainstream medicine, but questions exist regarding the quality of care provided. We assessed antibiotic stewardship, one measure of quality, by comparing antibiotic prescription rates for acute respiratory infections (ARIs) between patients seen by telemedicine and patients seen in-person in two urban emergency departments (EDs). Methods: In two urban EDs where low-acuity patients in the ED have the option of being seen by telemedicine rather than in-person, we analyzed telemedicine and in-person visits of patients ≥18 years who received ARI diagnoses between July 2016 and September 2017. The identified ARI telemedicine visits were matched to in-person visits by diagnosis, treatment hospital, and Emergency Severity Index level. We compared antibiotic prescribing rates for telemedicine and in-person visits. Results: We identified 260 telemedicine visits and compared with 260 matched in-person visits. Antibiotics for ARIs were prescribed for 29% of telemedicine visits and 28% of in-person visits (odds ratio [OR] 1.038; 95% confidence interval [CI] 0.71-1.52; p = 0.846). This finding did not materially change after adjustment for age and gender (adjusted OR 1.034; 95% CI 0.70-1.53; p = 0.86). Conclusions: Antibiotic prescribing rates for ARIs were similar for patients seen by telemedicine and patients seen in-person at two urban EDs. If differences in antibiotic stewardship between telemedicine and in-person encounters are found, contextual factors unrelated to the video-based evaluation should be investigated.

Overprescription of Antibiotics for Acute Respiratory Infections

Overprescription of Antibiotics for Acute Respiratory Infections

Narrow-spectrum, compared with broad-spectrum, antibiotics equally effective with less adverse events

Gerber JS, Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman R, et al. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA 2017;318:2325-36. Question Among children with acute respiratory infections (acute otitis media, group A streptococcal pharyngitis, and acute sinusitis), what is the efficacy and safety profile of broad-spectrum, compared with narrow-spectrum, antibiotics? Design Retrospective and prospective cohorts. Stratified and propensity score-matched analyses. Setting Thirty-one pediatric practices in Pennsylvania and New Jersey. Participants Children 6 months to 12 years, with acute otitis media, group A streptococcal pharyngitis, and acute sinusitis. Intervention Broad- versus narrow-spectrum antibiotics. Outcomes Effectiveness and adverse events. Main Results Broad-spectrum antibiotics were not associated with less treatment failure, risk difference 0.3% (95% CI, −0.4% to 0.9%), and were associated with more clinician-reported and patient-reported adverse events, risk difference 1.1% (95% CI, 0.4% to 1.8%) and 12.2% (95% CI, 7.3% to 17.2%), respectively. Conclusions Narrow-, compared with broad-spectrum antibiotics were equally effective and demonstrated a lower rate of adverse events. Commentary This cohort study supports guidelines recommending narrow-spectrum amoxicillin or penicillin for treatment of acute otitis media, acute sinusitis, and group A streptococcal pharyngitis in children. Although broad-spectrum antibiotics, such as amoxicillin-clavulanate, are commonly prescribed based on conflicting guidelines for these conditions, they were not associated with improved outcomes compared to narrow-spectrum therapy. This large retrospective cohort demonstrated convincingly that broad-spectrum antibiotics do not lower overall rates of treatment failure, even when adjusting for differences in provider prescribing practices or illness severity using clinician-stratified and propensity-score matched analyses. The unique inclusion of patient-reported outcomes in a prospective cohort detected a 10-fold higher rate of adverse events compared with the retrospective cohort, which suggests most antibiotic adverse events are unreported and/or unrecognized by clinicians. Also, in this group, broad-spectrum antibiotics were associated with an increased risk of adverse events with no improvement in quality of life. While observational cohorts undoubtedly include children with viral infections that may obfuscate differences in antibiotic efficacy, this study reflects real clinical practice where the empiric choice of broad rather than narrow-spectrum antibiotics for acute respiratory infections in children may lead to more harm than benefit.