Dispensing Of Antibiotics Research Articles

Requests for new oral antibiotic prescriptions in children within 2 days: a Norwegian population-based study.

BackgroundChildren commonly refuse to take antibiotics, which may induce parents to request new antibiotic prescriptions with different pharmaceutical characteristics.ObjectivesTo investigate prescription changes for children 0–12 years receiving oral liquid or solid antibiotic formulations and to explore the relationships between prescription changes and characteristics related to the child, prescriber and antibiotic.MethodsA population-based registry study based on data from the Norwegian Prescription Database (NorPD) from 2004 to 2016. Antibiotic prescription changes were defined as the dispensing of subsequent antibiotics with different pharmaceutical characteristics to the same child within 2 days after initial prescriptions. Data were analysed using multivariable logistic regression and generalized estimating equations.ResultsRequests for new prescriptions followed 3.0% of 2 691 483 initial antibiotic prescriptions for children. Young children who received solid formulations (10.9%) and certain poor-tasting antibiotics (8.6%) had the highest proportions of new prescriptions. Penicillin V was most commonly changed, while macrolides/lincosamides dominated subsequent prescriptions. In order of magnitude, the characteristics associated with requests for new prescriptions were the children’s ages, poor taste and concentration of liquids, size and shape of solids, prescribers born in recent decades, and girl patients. Reimbursed prescriptions and scored solids were associated with fewer requests.ConclusionsWhile only 3% of the antibiotic prescriptions were changed, the preference of broad-spectrum over narrow-spectrum antibiotics for young children in this study mirrors international prescription patterns. Avoiding the costs of children’s refusal and consequent changes may thus be a motivation for choosing more preferred antibiotics.

Amoxicillin Quality and Selling Practices in Urban Pharmacies and Drug Stores of Blantyre, Malawi.

This study evaluated a newly developed paper analytical device (PAD) for screening amoxicillin samples in Blantyre urban townships. Covert shoppers attempted to buy amoxicillin from a geographically stratified selection of private pharmacies (N = 22 out of 26) and drug stores (N = 23 out of 103) in the township area. According to the PAD results, all 42 samples obtained by the shoppers contained amoxicillin and none contained suspicious filler materials. Next, the products were assayed using high-performance liquid chromatography. Consistent with the PAD results, all samples contained the correct amount of amoxicillin with no unexpected ingredients. However, one sample was purchased as amoxicillin and contained that ingredient, but was packaged in capsules that are normally used to package ampicillin. Almost every sample failed a simple packaging analysis. Nine in 10 samples were missing their original packaging and/or inserts (52.4% repackaged capsules and 35.7% repackaged blister packs). Only 33.3% of the packages had expiry dates, 16.7% had batch numbers, and 47.6% had the manufacturer's name. Dispensing practices were likewise unsatisfactory. Ninety-five percentage of the sellers sold the amoxicillin without a prescription, even though this medicine is regulated as prescription-only in Malawi. Although the chemical analysis showed that amoxicillin quality was good, our market survey revealed poor adherence to prescription-only medicine dispensing of antibiotics, which threatens antimicrobial stewardship efforts. Furthermore, the wide prevalence of repackaging deprives medicines of important information needed during patient's use, regulatory investigations, and pharmacovigilance reporting.

Treatment practices of households and antibiotic dispensing in medicine outlets in developing countries: The case of Ghana.

Antibiotic resistance, associated with inappropriate drug use, is a global public health threat. The pharmaceutical sectors in developing countries are poorly regulated leading to antibiotic sales and use without a prescription. The study documents the treatment of acute illnesses in households and the antibiotic dispensing practices of medicine sales outlets in Eastern region, Ghana. Twice-weekly illness recall visits were made to 12 households in three rural communities over eight consecutive weeks. Detailed fieldnotes were taken and analysed using a thematic approach. Quantitative counts of health events and treatment were also conducted. Dispensing practices were systematically observed and documented in three rural and three urban medicine outlets for analysis. Fever, abdominal, and respiratory symptoms were the most common causes of ill-health in the 12 households. Most (65%) medicine-use events involved self-treatment with pharmaceuticals; 40% of medicine-use events involved antibiotics, often without a prescription. Although the number of antibiotic transactions without prescription in rural medicine outlets (n = 139, 27.4%) was statistically significantly more than in urban pharmacies (n = 140, 13.5%); z = 6.7, p < .0001), the volume of antibiotics sold in pharmacies was higher. Penicillins were the most commonly dispensed antibiotics constituting 30% of antibiotic sales in urban medicine outlets and 46% in rural ones. The lack of controls in the dispensing of antibiotics, community knowledge and use of antibiotics in ways inconsistent with biomedical recommendations, poverty and perceived barriers to formal healthcare were factors that influenced the inappropriate use of antibiotics. Self-medication, including antibiotic self-prescription, constitutes an integral part of healthcare in the study settings and the qualitative data provides a contextual understanding of over-the-counter antibiotic acquisition and use. Inappropriate antibiotic use is apparent in the study settings. Stricter regulation of the pharmaceutical sector, training of dispensers and evidence-based treatment guidelines, and public education are potential interventions.

Antibiotic distribution channels in Thailand: results of key-informant interviews, reviews of drug regulations and database searches.

ObjectiveTo analyse how antibiotics are imported, manufactured, distributed and regulated in Thailand.MethodsWe gathered information, on antibiotic distribution in Thailand, in in-depth interviews – with 43 key informants from farms, health facilities, pharmaceutical and animal feed industries, private pharmacies and regulators– and in database and literature searches.FindingsIn 2016–2017, licensed antibiotic distribution in Thailand involves over 700 importers and about 24 000 distributors – e.g. retail pharmacies and wholesalers. Thailand imports antibiotics and active pharmaceutical ingredients. There is no system for monitoring the distribution of active ingredients, some of which are used directly on farms, without being processed. Most antibiotics can be bought from pharmacies, for home or farm use, without a prescription. Although the 1987 Drug Act classified most antibiotics as “dangerous drugs”, it only classified a few of them as prescription-only medicines and placed no restrictions on the quantities of antibiotics that could be sold to any individual. Pharmacists working in pharmacies are covered by some of the Act’s regulations, but the quality of their dispensing and prescribing appears to be largely reliant on their competences.ConclusionIn Thailand, most antibiotics are easily and widely available from retail pharmacies, without a prescription. If the inappropriate use of active pharmaceutical ingredients and antibiotics is to be reduced, we need to reclassify and restrict access to certain antibiotics and to develop systems to audit the dispensing of antibiotics in the retail sector and track the movements of active ingredients.

Community pharmacists perspectives about reasons behind antibiotics dispensing without prescription: a qualitative study

Background: Dispensing of antibiotics without prescription is a widespread practice particularly in developing countries. This may lead to bacterial resistance, extra cost and possible adverse drug events. Objective: To explore views, experiences and perceptions of community pharmacists about the reasons behind antibiotics dispensing without prescription. Methods: This was a qualitative enquiry conducted among community pharmacists working in Riyadh city, Saudi Arabia. Interviews were conducted with the pharmacists using a semi structured interview guide. All interviews were audio-recorded, transcribed verbatim and then coded and analysed independently by two researchers. Results: A total of 16 community pharmacists were interviewed. The majority of the pharmacists have dispensed antibiotics without prescription during their practice (14 out of 16). Indications for dispensing antibiotics included fever, sore throat, tonsillitis, urinary tract infections, common cold and cough. Factors contributing to the dispensing of antibiotics without prescriptions included, increasing demand by the public, financial considerations, promotion by pharmaceutical companies, the pharmacy management and time pressures. However, pharmacists mentioned that they did not dispense antibiotics without prescriptions for severe cases and patients with unknown or incomplete medical history. Conclusion: Pharmacists reported several encouraging factors to dispense antibiotics without prescription. A combination of public education, professional training and enforcing regulations are likely to be important in ensuring patient safety and appropriate dispensing and use of antibiotics.

Previous antibiotic exposure and antibiotic resistance of commensal Staphylococcus aureus in Spanish primary care

Introduction: Commensal flora of healthy people is becoming an important reservoir of resistant bacteria.Objectives: To evaluate the relationship of previous antibiotic-dispensed and resistance pattern of strains of Staphylococcus aureus in primary care patients.Methods: A cross-sectional study was carried out in seven primary care centres in Catalonia, Spain, from October 2010 to May 2011, as part of the APRES (The appropriateness of prescribing antibiotics in primary care in Europe concerning antibiotic resistance) study. Outpatients aged 4 or more who did not present an infectious disease and had not taken antibiotic or had not been hospitalised in the previous 3 months were invited to participate. Nasal swabs were collected for S. aureus culture, and antimicrobial susceptibility testing was carried out. Antibiotics dispensed boxes in the previous 4 years were extracted from Information System for Research in Primary Care.Results: A total of 4,001 nasal swabs were collected, and 3,969 were tested for identification, 765 S. aureus were tested for resistance. Resistance rates to penicillin, azithromycin and methicillin were 87.1%, 11.6% and 1.3%, respectively, and a total of 10 MRSA strains were isolated (1.3%). Penicillin-resistant staphylococci were statistically significantly associated with the previous number of packages of penicillin dispensed (OR, 1.18; 95% CI, 1.04–1.35).Conclusion: Although no causal inference is possible, an association was observed between previous antibiotic dispensation and isolation of resistant organisms in community-dwelling individuals, mainly between packages of penicillin and penicillin-resistant staphylococci.

Doctors Adjacent to Private Pharmacies: The New Ambulatory Care Provider for Mexican Health Care Seekers

BackgroundIn 2010 Mexican health authorities enacted an antibiotic sale, prescription, and dispensation bill that increased the presence of a new kind of ambulatory care provider, the doctors adjacent to private pharmacies (DAPPs). ObjectivesTo analyze how DAPPs’ presence in the Mexican ambulatory care market has modified health care seekers’ behavior following a two-stage health care provider selection decision process. MethodsThe first stage focuses on individuals’ propensity to captivity to the health care system structure before 2010. The second stage analyzes individuals’ medical provider selection in a health system including DAPPs. This two-stage process analysis allowed us not only to show the determinants of each part in the decision process but also to understand the overall picture of DAPPs’ impact in both the Mexican health care system and health care seekers, taking into account conditions such as the origins, evolution, and context of this new provider. We used data from individuals (N = 97,549) participating in the Mexican National Survey of Health and Nutrition in 2012. ResultsWe found that DAPPs have become not only a widely accepted but also a preferred option among the Mexican ambulatory care providers that follow no specific income-level population user group (in spite of its original low-income population target). Our results showed DAPPs as an urban and rapidly expanded phenomenon, presumably keeping the growing pace of new communities and adapting to demographic changes. ConclusionsIndividuals opt for DAPPs when they look for health care: in a nearby provider, for either the most recent or common ailments, and in an urban setting; regardless of most socioeconomic background. The relevance of location and accessibility variables in our study provides evidence of the role taken by this provider in the Mexican health care system.

Dispensing pattern for acute non‐infectious diarrhoea in children at community pharmacies in Thailand

AbstractBackgroundIn cases of non‐infectious diarrhoea in children, the WHO and the Thai Antibiotic Smart Use (ASU) project recommend that no antibiotics should be given and drinking water should be replaced with oral rehydration salt (ORS) solution until the diarrhoea is finished.AimTo survey the dispensing pattern for non‐infectious diarrhoea treatment in children in Thailand.MethodsSimulated clients visited 91 Class I community pharmacies in five districts in Khon Kaen province and asked for advice to treat non‐infectious diarrhoea in a 14‐month‐old child. The patient history questions asked by the dispensers, the medications dispensed and non‐pharmacological advice given were recorded by the simulated clients immediately after leaving the pharmacy.ResultsIn this study, ORS solution was correctly dispensed to the simulated clients in only 7.7% of pharmacies with 68.1% incorrectly dispensing antibiotics. More than half of the dispensers (57.1%) did not give any advice regarding non‐pharmacological treatment.ConclusionThe results of this study indicate the need to implement a program to emphasise the importance of providing ORS and discourage the dispensing of antibiotics in this circumstance.

Perspectives of pharmacy staff on dispensing subtherapeutic doses of antibiotics: a theory informed qualitative study.

Background Injudicious dispensing of antibiotics in subtherapeutic doses is common in many developing countries. In Egypt, as in many developing countries, a few pills of common cold products are offered under the name cold group (CG). A cold group may contain one or more pills of antibiotics. A pharmacy client may obtain subtherapeutic doses of antibiotics upon direct request or as part of a CG. Objective To examine factors associated with the unwarranted dispensing of subtherapeutic doses of antibiotics in community pharmacies as part of a CG or upon direct request from patients among community pharmacy staff. Setting Community pharmacy staff in Alexandria, Egypt. Methods Semi-structured interviews were conducted with a purposeful sample of community pharmacy staff. An interview guide was developed based on the theory of planned behavior. Constructs related to attitudes, subjective norm, perceived behavioral control and perceived moral obligation were explored. Directed content analysis was conducted using interview data which were recorded and transcribed verbatim. Main outcome measures Community pharmacy staff's views on factors associated with the unwarranted dispensing of subtherapeutic doses of antibiotics. Results Nine Pharmacists and six pharmacy assistants were purposively sampled to assure variance in age, gender, time in practice and socioeconomic status of patients served by their corresponding pharmacies. Factors contributing to dispensing antibiotics injudiciously included incorrect beliefs about potential benefit of antibiotics, profit, client pressure, ease of obtaining antibiotics from other pharmacies, inadequate enforcement of the law, pharmacist absenteeism, and assuming that the 'nonmalfeasance' principle is not violated. Reasons for lying to clients about the actual content of CGs included protecting the patient from harm resulting from antibiotic resistance and avoiding a possible argument. Conclusions Examining constructs related to pharmacy staff's attitude, subjective norm, perceived behavioral control as well as perceived moral obligation provided insight into community pharmacy staff's behavior related to dispensing subtherapeutic doses of antibiotics. Multi-tiered interventions are urgently needed to tackle different factors contributing to this dangerous practice.

Infections in non‐splenectomized persistent or chronic primary immune thrombocytopenia adults: risk factors and vaccination effect

Introduction Risk factors for infection and protective effect of vaccines in immune thrombocytopenia (ITP) patients in the era of rituximab therapy are unknown. Objectives To assess the risk factors for serious and non-serious infections (respectively, SIs and NSIs) in non-splenectomized adults treated for persistent or chronic primary ITP, including the effect of pneumococcal and influenza vaccines. Patients/Methods The population was the 2009-2012 FAITH cohort (n = 1805), which is the cohort of all incident (newly diagnosed) primary ITP adults treated > 3 months in France built into the national health insurance database (SNIIRAM). SIs were hospitalizations with any infection as the primary diagnosis code. NSIs were identified using out-of-hospital antibiotic dispensing. Cox models were performed. Results Incidence rates were 6.3/100 patient-years (95% confidence interval [CI], 5.4-7.4) for SIs (lower respiratory tract in 42.8% of the cases) and 100.5/100 patient-years (95% CI, 95.0-106.3) for NSIs. In multivariate analyses, increasing age and chronic pulmonary disease were associated with both SI and NSI occurrence. The hazard ratios (HRs) for corticosteroids and rituximab were, respectively, 3.83 (95% CI, 2.76-5.31) and 2.60 (95% CI, 1.67-4.03) for SIs and 2.46 (95% CI, 2.19-2.76) and 1.49 (95% CI, 1.28-1.74) for NSIs. Pneumococcal vaccine showed a protective effect for both SIs and NSIs (0.38 [95% CI, 0.20-0.73] and 0.52 [95% CI, 0.43-0.65], respectively), as did influenza vaccine (0.42 [95% CI, 0.27-0.64] and 0.49 [95% CI, 0.41-0.59], respectively). Conclusions Chronic pulmonary disease, corticosteroids and rituximab are the main risk factors for infections, whereas pneumococcal and influenza vaccines are protective against SIs and NSIs.

Post-antibiotic management of immunocompromised children with febrile neutropenia.

39 Background: Febrile neutropenia in immunocompromised children is a medical emergency and requires prompt administration of antibiotics and supportive care management to prevent death from sepsis. We have previously shown that improvement in time to antibiotic administration from a baseline of 108 minutes was decreased to 64 minutes in 67 children in six St. Jude affiliate clinics. The improvement was achieved by designing a unique order set and process for prompt dispensing of antibiotics at each affiliate site. However, the clinical assessment of patients after antibiotic administration to provide early intervention for treatment of septic shock did not improve. Management of fluid status, oxygen therapy, and blood pressure support are critical for optimal outcome. The time from antibiotic administration to clinical assessment remained above the expected time of 15 minutes at an average of 60 minutes. To improve the post-antibiotic management, additional guidelines were established and monitored for compliance. Methods: Clinical guidelines were written. The guidelines included: patient assessed by nurse and vital signs checked within 15 minutes of arrival, patient assessed by a clinician within 30 minutes of arrival, antibiotic administrated within 60 minutes of arrival, nurse completed post-antibiotic assessment and vital signs rechecked within 15 minutes of administration, and clinician completed post antibiotic assessment within 30 minutes of administration. Results: After establishing guidelines, each site developed a process for implementation using a similar approach of automated order sets, time reminders, and staff education of the initial management of septic shock. Chart reviews were done at one year after implementation and all were in compliance. Conclusions: Clinical guidelines, automated order sets, and continued awareness and education in the management of immunocompromised children with febrile neutropenia improved compliance with this quality project. Continued monitoring is needed to ensure the results are sustained.

What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India

ObjectivesThere are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings....

Antibiotic Use in Children – A Cross-National Analysis of 6 Countries

To describe the rates of pediatric antibiotic use across 6 countries on 3 continents. Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries. A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population. We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.

Non-prescription sale and dispensing of antibiotics in community pharmacies in Zambia

ABSTRACTBackground: In Zambia, antibiotics are categorized as prescription-only medicines. Antibiotics dispensed without a prescription pose a public health threat, which is a concern. Consequently, the aim is to ascertain the extent of non-prescription sales and dispensing of antibiotics in community pharmacies in Zambia.Methods: The practice of non-prescription sale and dispensing were assessed in 73 randomly selected community retail pharmacies, using a structured interviewer-administered questionnaire with simulated case scenarios.Results: Majority (97%) stated that clients frequently requested non-prescribed antibiotics. Interviewees usually asked clients’ indications (94%), counselled on dosing (96%) and suggested changes to antibiotic choices (97%). All (100%) dispensed non-prescribed antibiotics. Commonly dispensed antibiotics included amoxicillin (52%), cotrimoxazole (25%) and metronidazole (23%). Non-prescription sale and dispensing of antibiotics was significantly associated with interviewees’ professional qualification in four out of five simulations.Conclusion: Non-prescription sale and dispensing of antibiotics is widespread in Zambia. Concerted public and professional interventions are needed coupled with stronger regulatory enforcement to reduce this.

Appropriateness of diagnosis of streptococcal pharyngitis among Thai community pharmacists according to the Centor criteria.

Background Inappropriate use of antibiotic treatment for pharyngitis by community pharmacists is prevalent in developing countries. Little is known about how the pharmacists identify patients with bacterial pharyngitis. Objective To ascertain the appropriateness of diagnosis of streptococcal pharyngitis among Thai community pharmacists according to the Centor criteria and to identify factors related to antibiotic dispensing. Setting 1040 Thai community pharmacists. Method A cross-sectional survey of community pharmacists was conducted in November 2012 to March 2013. The self-administered questionnaires were mailed to 57% of community pharmacists in the south of Thailand (n=1040). The survey included questions on diagnosis of streptococcal pharyngitis, knowledge on pharyngitis, and attitudes and control beliefs regarding antibiotic dispensing. Main outcome measure The appropriateness of diagnosis of streptococcal pharyngitis according to the original and modified Centor criteria and determinants of antibiotic dispensing including demographic characteristics of pharmacists, knowledge on pharyngitis, and attitudes and control beliefs on antibiotic dispensing. Results Approximately 68% completed the questionnaires (n=703). Compared to the pharmacists who reported not dispensing antibiotics in the hypothetical case with common cold, those reported dispensing antibiotics were more likely to consider the following conditions-presence of cough, mild sore throat and patients with age >60years as cues for diagnosis of streptococcal pharyngitis (p<0.05). The use of fewer scores of the clinical prediction rules for diagnosis was observed in antibiotic dispensers, compared to who did not do so (p<0.005). Antibiotic dispensing was positively associated with period of dispensing experience (>5years) [odds ratio (OR) 1.52; 95% confidence interval (CI) 1.03-2.23], belief that antibiotics could shorten duration of pharyngitis (OR 1.48; 95% CI 1.11-1.99), belief that antibiotics could prevent the complications (OR 1.44; 95% CI 1.09-1.91) and belief that dispensing antibiotics could satisfy the patients (OR 1.31; 95% CI 1.01-1.71). Nonetheless, antibiotic dispensing was negatively associated with knowledge about pharyngitis (OR 0.83; 95% CI 0.75-0.93). Conclusion Pharmacists who are knowledgeable on the Centor criteria are more likely to appropriately diagnose streptococcal pharyngitis and less likely to dispense antibiotics in such case.

Virulent Characteristics of Multidrug Resistant E. coli from Zaria, Nigeria

Most multidrug resistant (MDR) Escherichia coli isolates (resistant to more than 3 classes of antibiotics) exhibit co-virulent characteristics that contribute to mortality and morbidity as a result of resistance to commonly prescribed antibiotics in the clinics. This study evaluated phenotypically some virulent characteristics in E. coli that contribute to the expressed MDR properties of E. coli using standard microbiological methods. Eighty seven E. coli isolates were confirmed as E. coli from urinary tract infection and diarrhoea patients in selected hospitals in Zaria Nigeria using Microgene identification kit, out of which 58.6% (51) were observed to be MDR. Significant number of the MDR isolates (70.6% (36)) were extended spectrum beta-lactamase producers, 45.1% (23) were resistant to cefoxitin and produce ampC. While further analysis on the isolates showed that 23.5% (12) were biofilm producers, 47.1% (24) were heteroresistant to cefoxitin while 5.9% (3) produced carbapenemase. This study showed that most MDR E. coli from UTI and diarrhoea could exhibit more than one virulent characteristics. Hence, isolates with MDR should be subjected to various tests in other to validate the mechanisms of resistance. This will encourage better treatment options and good periodic surveillance in prescription and dispensing of antibiotics in clinical settings.

Attitudes and perceptions of community pharmacists to antibiotic dispensing and microbial resistance. A study in aseer region, Kingdom of Saudi Arabia

Purpose: The aim of this study was to study and explore the attitudes, perceptions, and dispensing habits of community pharmacist about antibiotic usage and microbial resistance. Material/Methods: It is a descriptive study conducted during April 2015 - July 2015in community pharmacies located in multiple places of Southern region of Saudi Arabia. 120 pharmacists were selected randomly and were invited to participate in the study by structured interview answering the question in the questionnaire. Results: The results of the present study included from both the chain pharmacies (n=84) and single pharmacies (n=36). Most of them had a Bachelor of Pharmacy (80.8%) and few had Pharm.D. (19.2%) degree. Attitudes related to the problem of resistance were attributed external responsibility, to patients, to physicians, to other pharmacies. Some attitudes were identified that could lead to antibiotic dispensing without a prescription. These were commercial interest and pressure from the patient. Conclusions: To conclude the present study, the community pharmacist had positive attitude towards improving antibiotic use and bacterial resistance. However, we are of opinion that strong regulation coupled with education intervention both to the pharmacist and public would be the way forward to tackle this issue of fight against antimicrobial resistance

Serious and Non-Serious Infections in Non-Splenectomized Adults Treated for Persistent or Chronic Primary Immune Thrombocytopenia: Effect of Treatments and Protection of Vaccines. Results of the French Nationwide Faith Study

Background: No study has specifically assessed the risk factors of infection in immune thrombocytopenia (ITP) patients in the era of rituximab therapy. Similarly, the protective effect of pneumococcal and influenza vaccines is unknown in real-life settings. Aim: The objective of this study was to assess the risk factors of serious infection (SI) and non-serious infection (NSI) in non-splenectomized adults treated for persistent or chronic primary ITP, including baseline characteristics, ITP treatments as well as pneumococcal and influenza vaccines. Methods: The population was the 2009-2012 FAITH cohort, which is the cohort of all incident primary ITP adults persistently treated in France built in the national health insurance database (SNIIRAM). The FAITH study is registered ENCePP n°4574. SIs were hospitalizations with infection as primary diagnosis code (predictive positive value: 97%). NSIs were identified using out-hospital antibiotic dispensing. Cox models were performed to assess separately the risk of SIs and of NSIs. The index date was the date of first ITP treatment exposure (date of entry in the FAITH cohort). Follow-up was censored at a first infection, splenectomy, death or end of follow-up (December, 31 2012). The following covariates were included: age, gender, mucosal bleeding at ITP onset, diabetes mellitus, chronic pulmonary, heart and kidney diseases. Exposure to ITP treatments was considered as time-varying covariates. Exposure to rituximab was defined as the 6 months period following dispensing and exposure to vaccine occurring in that period was considered as null. Results: The cohort included 1805 patients. Mean age was 57.6 ± 21.3 years and 58.9% were females. With a mean follow-up of 18.5 ± 6.8 months, 681 patients were exposed to rituximab, 1035 to IVIg, 90 to other immunosuppressants (azathioprine, mycophenolate); 161 (9.1%) patients experienced SIs (39.7% respiratory) and 1227 (68.0%) NSIs. The respective incidences were 6.3/100 patients-years and 8.4/100 patients-months. In multivariate analyses, increasing age and chronic pulmonary disease were associated with both SI and NSI occurrence. Mucosal bleeding at ITP onset, male gender and chronic kidney disease were also associated with SI occurrence. The hazard ratios (HRs) for corticosteroids were 3.83, 95% confidence interval - 95% CI [2.76-5.31] (p&lt;0.0001) for SI and 2.46, 95% CI [2.19-2.76] for NSI (p&lt;0.0001). HRs were respectively 2.60, 95% CI [1.67-4.03] (p&lt;0.0001) and 1.49, 95% CI [1.28-1.74] (p&lt;0.0001) for rituximab. Pneumococcal vaccine showed a protective effect for both SIs and NSIs (respectively, 0.38, 95% CI [0.20-0.73], p=0.003 and 0.52, 95% CI [0.43-0.65], p&lt;0.0001), as well as influenza vaccine (respectively, 0.42, 95% CI [0.27-0.64], p&lt;0.0001 and 0.49, 95% CI [0.41-0.59], p&lt;0.0001). IVIg was also associated with a higher risk of infection, probably due to channeling bias. Conclusions: SIs are mainly respiratory infections in this population. Chronic pulmonary disease, corticosteroids and rituximab are the main risk factors for infections, while pneumococcal and influenza vaccines are protective against SIs and NSIs. Disclosures No relevant conflicts of interest to declare.

What motivates antibiotic dispensing in accredited drug dispensing outlets in Tanzania? A qualitative study.

BackgroundTanzania introduced the accredited drug dispensing outlet (ADDO) program more than a decade ago. Previous evaluations have generally shown that ADDOs meet defined standards of practice better than non-accredited outlets. However, ADDOs still face challenges with overuse of antibiotics for acute respiratory infections (ARI) and simple diarrhea, which contributes to the emergence of drug resistance. This study aimed to explore the attitudes of ADDO owners and dispensers toward antibiotic dispensing and to learn how accreditation has influenced their dispensing behavior.MethodsThe study used a qualitative approach. We conducted in-depth interviews with ADDO owners and dispensers in Ruvuma and Tanga regions where the government implemented the ADDO program under centralized and decentralized approaches, respectively; a secondary aim was to compare differences between the two regions.ResultsFindings indicate that the ADDO program has brought about positive changes in knowledge of dispensing practices. Respondents were able to correctly explain treatment guidelines for ARI and diarrhea. Almost all dispensers and owners indicated that unnecessary use of antibiotics contributed to antimicrobial resistance. Despite this knowledge, translating it to appropriate dispensing practice is still low. Dispensers’ behavior is driven by customer demand, habit (“mazoea”), following inappropriate health facility prescriptions, and the need to make a profit. Although the majority of dispensers reported that they had intervened in situations where customers asked for antibiotics unnecessarily, they tended to give in to clients’ requests. Small variations were noted between the two study regions; for example, some dispensers in Ruvuma reported sending clients with incorrect prescriptions back to the health facility, a practice that may reflect regional differences in ADDO implementation and in Integrated Management of Childhood Illness training. Dispensers in rural settings reported more challenges in managing ARI and diarrhea than their urban counterparts did.ConclusionTo reduce inappropriate antibiotic use, integrated interventions must include communities, health facilities, and ADDOs. Periodic refresher training with an emphasis on communication skills is crucial in helping dispensers deal with customers who demand antibiotics. Responsible authorities should ensure that ADDOs always have the necessary tools and resources available.

Analysis of Primary Care Medicines Expenditure In Relation To Measures of Deprivation In Wales Uk

e144 Volume 37 Number 8S (with antibiotic leftovers or by acquiring antibiotics directly in the pharmacy without a prescription), are behaviours directly related with this misuse, revealing the necessity of interventions directed to health professionals. The aim of this study is to improve the consumption of antibiotics through an educational intervention directed to community pharmacists and primary care physicians. Material and Methods: A cluster randomized trial in the region center of Portugal. Of the 8 clusters, 4 clusters received an educational intervention and the other four clusters did not received any intervention and were included in the control group. Educational intervention consisted of group sessions with physicians and group sessions with pharmacists. In the sessions groups it was presented information about the problem of microbial resistances and each sessions was focused in the identified attitudes that influence the behaviour of physician during antibiotic prescription or the behaviour of pharmacist during the dispensation of antibiotics in pharmacies. At the end of each group session, were distributed flyers and poster about the importance of the adequate use of antibiotics to be divulgated to the patients. The data of antibiotics consumption was compared between the intervention group and the control group. Results: The intervention was well received for the pharmacists and for the physicians included in the study. Comparing the consumption of antibiotics between the two groups, it was observed a decrease in the total consumption of antibiotics in the intervention group during 12 months of the follow-up period after the intervention was made. Conclusions: It was possible decrease the consumption of antibiotics through an educational intervention directed to community pharmacists and primary care physicians.