High Antibiotic Prescribing Rates Research Articles

Antibiotic prescribing and bacterial infection in COVID-19 inpatients in Southeast Asia: a systematic review and meta-analysis.

The prescribing of antibiotics to treat COVID-19 patients has been observed to occur frequently, often without clear justification. This trend raises concerns that it may have exacerbated antimicrobial resistance (AMR). Despite longstanding concerns over AMR in Southeast Asian countries, data on this issue are notably lacking. To explore the impact of COVID-19 on antibiotic prescribing, bacterial infection prevalence and common resistant pathogens in COVID-19 inpatients. We searched PubMed, EMBASE, Web of Science and ThaiJO (a Thai academic database) to identify studies conducted in ASEAN member countries and published between December 2019 and March 2023. Screening and data extraction were done by two independent reviewers, with results synthesized using random-effects meta-analyses and descriptive statistical analyses. This review was registered with PROSPERO (CRD42023454337). Of the 29 studies (19 750 confirmed COVID-19 cases) included for final analysis, the antibiotic prescribing rate was 62.0% (95%CI: 46.0%-76.0%) with a prescribing rate of 58.0% (21.0%-91.0%) in mild/moderate cases versus 91.0% (82.0%-98.0%) in severe/critical cases. Notably, 80.5% of antibiotics prescribed fall under the WHO AWaRe 'Watch' list, followed by 'Access' at 18.4% and 'Reserve' at 1.0%. The reported bacterial infection prevalence was 16.0% (7.0%-29.0%), with Acinetobacter baumannii being the most common resistant bacterium at 7.7%. Singapore was notable for its lower antibiotic prescribing rate of 17.0% and a lower bacterial infection rate of 10.0%. High antibiotic prescribing rates, disproportionate to bacterial infections and varying practices for COVID-19 inpatients across countries highlight the urgent need for this region to collaborate to tackle and mitigate AMR.

Antibiotic Prescribing Practices for Upper Respiratory Tract Infection Among Clinical Officers at Kiambu County

Background Antibiotics are the most prescribed medications worldwide. Global consumption rose by 65% in 76 low and middle-income countries between the years 2000 and 2015. According to the World Health Organization, improper administration of antibiotics occurs in over 60% of people with upper respiratory tract infections. Inadvertent antibiotic use has been identified as a contributor to antimicrobial resistance. Outpatient antibiotic use accounts for around 80-90% of all antibiotic use in patients. Clinical officers are non-physician healthcare workers who have received less training, have a more restricted scope of practice than physicians. Clinical officers are key service providers in this country especially at the primary healthcare level. Objective The study assessed the factors that influence antibiotic prescribing for upper respiratory tract infections by clinical officers. Method A prospective study was carried out at 20 public hospitals in Kiambu County, on 36 clinical officers and 600 patient prescriptions. The parameters measured were patient factors, prescriber factors, institutional factors and how they affected the antibiotic prescribing practices by either being rational or irrational. Rational prescribing was identified as prescribing the right drug, at the right frequency, in the right duration, right dose for the right indication. Prescriptions were considered irrational if they did not satisfy any of the rational indices. Data was collected via a questionnaire from the clinical officers while WHO prescription checklist was used to collect data from patient encounters. Data was analyzed using Statistical Package for Social Sciences version 22.0 (SPSS v22.0) with P-value, Confidence Interval and Odds Ratio. Results A total of 600 patient encounters were recorded and 79.8% of the 479 encounters had an antibiotic prescription for URTI, 91% of the antibiotics prescribed were the right dose, 98% had the right frequency, 75% had the right duration, and only 23% had the right indication. Patients above 65 years were more likely to receive an antibiotic prescription OR 3.98 CI 0.91,17.41 P=0.17 compared to children under 12 years old. Males were more likely to receive an antibiotic, but this was not significant OR 1.06 CI 0.70, 1.59 P=0.79. A total of 28 (4.6%) patients had fever, and all received antibiotics. A total of 36 clinical officers were sampled and only 5 (13.8%) were found to have rational prescriptions (P=0.63), prescriber age (P=0.92), prescriber level of education (P=0.99) and prescriber work experience (P=0.22) were not associated with antibiotic prescription. As per institutional factors, availability of antibiotics (P=0.026) and availability of prescription guidelines (P=0.012) were associated with rational prescription of antibiotics. Conclusion The study indicated that there was a high antibiotic prescription rate deviating from the WHO standard. It demonstrated that most antibiotic prescriptions were irrational.

Prevalence of Antibiotic Prescription in Primary Healthcare Settings in the Municipality of Prishtina, Kosovo

Background: Antibiotics remain among the most prescribed drugs in primary healthcare, contributing to increased antibiotic resistance in the community and prevailing as an emerging global health concern. We aimed to quantify the prevalence and quality of antibiotic prescription in primary healthcare settings in the Municipality of Prishtina to identify targets for quality improvement.Methods and Results: This study represents a population-based, retrospective cohort, including data from eight randomly selected family medical centers in the Municipality of Prishtina. Each 150th patient on medical records was assessed for demographic data, diagnosis (ICD-10), antibiotic prescription, antibiotic class, and antibiotic form. In total, the study included 1614 cases reviewed. The antibiotic prescription rate was 16%. The health condition for which most of the cases received antibiotics was J18 - Pneumonia, unspecified organism (67%), followed by J03 - Acute tonsillitis (54%), J42 - Unspecified chronic bronchitis (46%), and N39 - Other disorders of the urinary system (43%) Broad-spectrum antibiotics, such as co-amoxiclav (17.7%), amoxicillin (16.5%), and ceftriaxone (12.6%), featured among the most routinely prescribed antibiotics. The antibiotic prescription rate was the highest for cases in the 3-5 age group, of whom 27% received an antibiotic prescription. In 73% of cases, oral antibiotics were prescribed, 69% of which belong to the WHO AWaRe (Access, Watch, Reserve) essential medicines list. Only 18% of antibiotics were prescribed with their generic names. Conclusion: The prevalence of antibiotic prescription in primary healthcare settings in Prishtina is moderately low. These data cannot be extrapolated to other municipalities in Kosovo or other countries due to different organizational levels. High antibiotic prescription rates for young age groups, prescription of broad-spectrum antibiotics, and high rates of parenteral antibiotics were identified as targets for quality improvement.

Antibiotic Use in Korean Children Diagnosed With Acute Bronchiolitis: Analysis of the National Health Insurance Reimbursement Data.

Acute bronchiolitis, the most common lower respiratory tract infection in infants, is mostly caused by respiratory viruses. However, antibiotics are prescribed to about 25% of children with acute bronchiolitis. This inappropriate use of antibiotics for viral infections induces antibiotic resistance. This study aimed to determine the antibiotic prescription rate and the factors associated with antibiotic use in children with acute bronchiolitis in Korea, where antibiotic use and resistance rates are high. Healthcare data of children aged < 24 months who were diagnosed with acute bronchiolitis between 2016 and 2019 were acquired from the National Health Insurance system reimbursement claims data. Antibiotic prescription rates and associated factors were evaluated. A total of 3,638,424 visits were analyzed. The antibiotic prescription rate was 51.8%, which decreased over time (P < 0.001). In the multivariate analysis, toddlers (vs. infants), non-capital areas (vs. capital areas), primary clinics and non-tertiary hospitals (vs. tertiary hospitals), inpatients (vs. outpatients), and non-pediatricians (vs. pediatricians) showed a significant association with antibiotic prescription (P < 0.001). Fourteen cities and provinces in the non-capital area exhibited a wide range of antibiotic prescription rates ranging from 41.2% to 65.4%, and five (35.7%) of them showed lower antibiotic prescription rates than that of the capital area. In Korea, the high antibiotic prescription rates for acute bronchiolitis varied by patient age, region, medical facility type, clinical setting, and physician specialty. These factors should be considered when establishing strategies to promote appropriate antibiotic use.

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications.

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia. A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool. Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List. There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.

UTI Friday: The Review of Antibiotic Prophylaxis for Recurrent Urinary Tract Infection (rUTI) in Primary Care

Abstract Introduction There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines [NG15, NG112] state that patients on antibiotic prophylaxis for rUTI should be reviewed within 6 months and consideration given to discontinue the antibiotic. Self-care measures should be promoted instead. Aim This project aims to assess current practice in relation to rUTI management in Primary Care and identify opportunities for improved antimicrobial stewardship. Methods An audit was developed to review rUTI management and it was used in three GP practices (patient population 35,134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. A search for all repeat prescriptions issued between 1st July 2017 and 30th June 2018, for any strength of antibiotic, was run and 179 patients were identified as being on antibiotic prophylaxis for rUTI. The results of the audit were fed back to the practice and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract, remaining until 2022 due to the COVID pandemic. Ethical approval not required. Results Primary care initiated prophylaxis accounted for 69% of the total number of patients identified (n=123). Of those taking prophylaxis for &amp;gt;6 months (n=160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for &amp;gt;3 years accounted for 39% of the total (n=70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend Locality (patient population 152,041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed and of those reviewed 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2,223 fewer antibiotic prescriptions per year. Discussion/Conclusion Initial results suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. The impact of this in terms of antimicrobial resistance is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019-2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.

P16 UTI Friday: a review of antibiotic prophylaxis in the management of recurrent UTI in primary care

Abstract Background An appropriate and evidence-based strategy for treating patients with recurrent urinary tract infection (rUTI) is to use low-dose antibiotics as prophylaxis. All antibiotics used for rUTI prophylaxis are associated with problems of resistance and adverse effects. Antimicrobial resistance (AMR) refers to a natural phenomenon in which micro-organisms become resistant to antibiotics that were originally effective in killing them. There is an established link between antibiotic use and the emergence of resistant organisms. Current NICE guidelines (NG15, NG112) state that patients on antibiotic prophylaxis for rUTI should have a clinical review within 6 months to assess success from the prophylactic regimen. At this review, consideration should be given to discontinuing the antibiotic and the promotion of self-care measures in its place. This project aims to assess current practice in relation to rUTI management in primary care and identify opportunities for improved antimicrobial stewardship. Methods An audit was developed to review rUTI management, and it was used in three GP practices (patient population 35 134) within the Bridgend Locality of Cwm Taf Morgannwg University Health Board. If regular antibiotic prophylaxis is required, nitrofurantoin 50 mg/100 mg nocte or trimethoprim 100 mg nocte should be considered first line, unless associated with resistance, allergy or co-morbidities. Cefalexin 125 mg nocte is the second choice. A search for all repeat prescriptions issued for any strength of these drugs, from 1 July 2017 to 30 June 2018, was run in the GP practice systems, and 179 patients were identified as being on antibiotic prophylaxis for rUTI (∼0.5% of the practice populations). The results of the audit were fed back to the practice, and a co-designed action plan agreed to review the identified patients. The outcome of this activity was the proof of concept for national roll-out and lead to the audit being included in a ‘basket’ of Quality Improvement Projects as part of the Welsh General Medical Services (GMS) 2019/20 contract. Due to the COVID pandemic, it remained live until September 2022. Results Primary care–initiated prophylaxis accounted for 69% of the total number of patients identified (n = 123). Of those taking prophylaxis for &amp;gt;6 months (n = 160), 24% had a prophylactic review within the previous 6 months as per NICE guidance. Patients taking prophylaxis for &amp;gt;3 years accounted for 39% of the total (n = 70). Whilst taking antibiotic prophylaxis, 98 patients (54.7%) had at least one documented acute UTI in the previous 12 months. For an acute UTI, 35 patients (19.6%) were prescribed the same antibiotic as they were taking prophylactically. When an MSU showed resistance to the prophylactic antibiotic, prophylaxis was changed 17.5% of the time, n = 57. Therefore, 82.5% were continued on a potentially ineffective antibiotic. Results from the Welsh GMS contract for the Bridgend locality (patient population 152 041) identified 431 patients on antibiotic prophylaxis for rUTI. Of these, 334 (77.5%) were reviewed, and of those reviewed, 171 (51%) were stopped (confirmed on re-audit after 6 months). This equates to a 40% locality reduction in antibiotic prophylaxis for rUTI, which is estimated to be in the region of 2223 fewer antibiotic prescriptions per year. Conclusions Initial results from the UTI Friday audit suggest that there can be marked improvement in antibiotic use for rUTI management. Through a multi-disciplinary approach, this project has demonstrated how pharmacists can support GPs in the review and management of patients with rUTI. Using audit feedback, co-designed action plans have been implemented. The impact of this on resistance seen in urinary isolates is not yet known but, with increased guideline awareness/compliance, a positive step has been made towards improving rUTI management and meeting the antimicrobial stewardship targets set by the UK Antimicrobial Resistance National Action Plan 2019–2024. In order to tackle high rates of antibiotic prescribing in primary care, innovative approaches to quality improvement and prescriber feedback will be essential and should be further developed.

A multi-institutional exploration of emergency medicine physicians’ attitudes and behaviours on antibiotic use during the COVID-19 pandemic: a mixed-methods study

BackgroundThe COVID-19 pandemic has changed the epidemiology of upper respiratory tract infections (URTI) and the disease profile of patients attending the emergency department (ED). Hence, we sought to explore the changes in ED physicians’ attitudes and behaviours in four EDs in Singapore.MethodsWe employed a sequential mixed-methods approach (quantitative survey followed by in-depth interviews). Principal component analysis was performed to derive latent factors, followed by multivariable logistic regression to explore the independent factors associated with high antibiotic prescribing. Interviews were analysed using the deductive-inductive-deductive framework. We derive five meta-inferences by integrating the quantitative and qualitative findings with an explanatory bidirectional framework.ResultsWe obtained 560 (65.9%) valid responses from the survey and interviewed 50 physicians from various work experiences. ED physicians were twice as likely to report high antibiotic prescribing rates pre-COVID-19 pandemic than during the pandemic (AOR = 2.12, 95% CI 1.32 to 3.41, p = 0.002). Five meta-inferences were made by integrating the data: (1) Less pressure to prescribe antibiotics due to reduced patient demand and more patient education opportunities; (2) A higher proportion of ED physicians self-reported lower antibiotic prescribing rates during the COVID-19 pandemic but their perception of the overall outlook on antibiotic prescribing rates varied; (3) Physicians who were high antibiotic prescribers during the COVID-19 pandemic made less effort for prudent antibiotic prescribing as they were less concerned about antimicrobial resistance; (4) the COVID-19 pandemic did not change the factors that lowered the threshold for antibiotic prescribing; (5) the COVID-19 pandemic did not change the perception that the public's knowledge of antibiotics is poor.ConclusionsSelf-reported antibiotic prescribing rates decreased in the ED during the COVID-19 pandemic due to less pressure to prescribe antibiotics. The lessons and experiences learnt from the COVID-19 pandemic can be incorporated into public and medical education in the war against antimicrobial resistance going forward. Antibiotic use should also be monitored post-pandemic to assess if the changes are sustained.

Inappropriate antibiotic prescribing in primary healthcare facilities in China: a nationwide survey, 2017–2019

ObjectivesWe aimed to generate comprehensive estimates of the appropriateness of outpatient antibiotic prescriptions at primary healthcare facilities (PHFs) in China. MethodsBetween 2017 and 2019, we collected outpatient-visit prescriptions from 269 Chinese PHFs in 31 cities located in 6 provinces. Conditions that resulted in antibiotic use were classified into appropriate, potentially appropriate, and inappropriate using a well-established classification approach. We then assessed the magnitude, appropriateness, and costs of antibiotic prescribing, overall and by antibiotic classification group, diagnostic categories, and patient characteristics. ResultsOf all eligible 209 662 antibiotic prescriptions, 147 758 (70.5%) were inappropriate, which accounted for 66.8% (558.0/835.3 thousand US dollars) of costs for antibiotics. Upper respiratory tract infections, acute bronchitis, and non-infectious gastroenteritis were responsible for 68.9% (101 744/147 758) of inappropriately antibiotic prescriptions. High inappropriate antibiotic prescribing rates were observed among children aged 0–5 years (78.5% (21 049/26 799)) and patients living in economically undeveloped areas (77.5% (38 430/49 587)). A total of 256 474 individual antibiotics were prescribed, of which 82.2% (210 885/256 474) were broad-spectrum antibiotics, with second-generation cephalosporins (15.1% (38 705/256 474)) and third-generation cephalosporins (14.6% (37 491/256 474)) being the most commonly prescribed subgroups. DiscussionOur findings highlight the excessive and inappropriate use of antibiotics in Chinese PHFs pending multidimensional efforts.

Pattern of hospital antibiotic use in term neonates using WHO Access, Watch and Reserve Classification (AWaRe).

Pakistan has high neonatal mortality rate and antibiotic utilization data in hospitalized term neonates from Pakistan is lacking. The study aimed to determine the pattern of hospital antibiotic use in term neonates using World Health Organization (WHO) Access, Watch, and Reserve classification (AWaRe). This cross-sectional chart review study was conducted at the neonatal unit of Pediatric Medicine Department of University Hospital over a period of one year from 1st January 2020 to 31st December 2020. Hospitalized full term newborns up to 28-days of life, of either gender were consecutively included in the study. Data on demographic characteristics, admission diagnoses and antibiotic prescribed (class, agent and duration) were extracted from clinical charts. Descriptive statistics in the form of mean ± SD and frequency and percentages were calculated. A total of 2276 term neonates consisting of 69% (n=1570) males were included in the study. Antibiotic prescription rate was 92.8%. Most common reason for admission was birth asphyxia (36.1%) followed by sepsis (33%). Most commonly prescribed antibiotic Ampicillin (84%) belonged to Access group of WHO - AWaRe classification. More than 97% of prescriptions were two or more antimicrobial combinations belonging to Watch group. Ampicillin and Cefoperazone was the most commonly prescribed (42.8%) two drug combination. Meropenem and vancomycin was prescribed to 20% of the neonates - mostly for sepsis and pneumonia. Mortality rate was 7.7% in current study. High antibiotic prescription rate particularly from Watch-group is demonstrated in this study. There is high need of antimicrobial stewardship program in neonatal units.

The Impact of Point-of-Care Polymerase Chain Reaction Testing on Prescribing Practices in Primary Care for Management of Strep A: A Retrospective Before-After Study.

BackgroundRapid antigen detection tests (RADTs) are the standard of care (SOC) for testing in patients with suspected group A β-hemolytic Streptococcus (Strep A) infection. Due to lower sensitivity, guidelines recommend confirmatory microbiological culture following negative RADT results. This process is time-consuming, and adherence is often poor, resulting in high rates of inappropriate antibiotic prescribing. We sought to evaluate the impact of switching from RADTs to point-of-care (POC) polymerase chain reaction (PCR) testing on use of antibiotics in primary care, when used as part of an antibiotic stewardship initiative.MethodsIn this retrospective before–after study, electronic medical records of any patients presenting with suspected acute pharyngitis (June 2018–May 2019) across 15 outpatient primary care clinics were evaluated. Strep A was detected using the cobas Strep A assay (cobas Liat system).ResultsAnalysis of 10 081 eligible patient records showed that POC PCR testing resulted in a 44.1% reduction in antibiotic prescribing for patients with a negative POC PCR test result (10.1% PCR vs 18.0% RADT; P < .0001). Rates of antibiotic prescription varied across clinical sites, ranging between 10.7% and 33.8% and 12.4% and 34.4% during the use of PCR tests and RADTs, respectively. POC PCR had no impact on prescription rates in patients with positive POC test results compared to RADTs (76.2% vs 76.5%, respectively). More than 99% of antibiotics were prescribed during the initial primary care encounter.ConclusionsAs part of a broader antibiotic stewardship initiative, implementation of POC PCR as SOC in outpatients with acute pharyngitis symptoms reduced the volume of inappropriate antibiotic prescriptions.

Clinical insights into appropriate choice of antimicrobials for acute respiratory tract infections

Australia has relatively high rates of antibiotic prescribing in the community. The aim of this study was to identify clinical insights regarding antibiotic prescribing choices for the management of common upper respiratory tract infections through analysis of anonymised primary care electronic medical records (EMRs). EMR data relating to 1926 antimicrobial prescriptions for tonsillitis, pharyngitis and acute rhinosinusitis in adults and acute otitis media (AOM) in children were extracted from 11 general practices in Victoria and analysed for consistency with Australian Therapeutic Guidelines recommendations. The analysis suggests that underdosing of amoxicillin for AOM in children, prescription of phenoxymethylpenicillin at doses not consistent with Therapeutic Guidelines recommendations for tonsillitis and pharyngitis in adults,and potential overprescription of antibiotics for patients with acute rhinosinusitis are not infrequent ingeneral practice. Anonymised EMR data provide an opportunity to analyse antibiotic prescribing practices at scale and provide insights relevant to clinical practice.

Co-infections and antimicrobial use among hospitalized COVID-19 patients in Punjab, Pakistan: findings from a multicenter, point prevalence survey

ABSTRACT There are reports of high rates of antibiotic prescribing among hospitalized patients with COVID-19 around the world. To date, however, there are few reports of prescribing in relation to COVID-19 in Pakistan. Herein, we describe a point prevalence survey of antibiotic prescribing amongst patients hospitalized with suspected or proven COVID-19 in Pakistan. A Point Prevalence Survey (PPS) was undertaken in seven tertiary care health facilities in Punjab Provence, Pakistan. Baseline information about antimicrobial use according to the World Health Organization (WHO) standardized methodology was collected on a single day between 5th and 30 April 2021. A total of 617 patients’ records were reviewed and 578 (97.3%) were documented to be receiving an antibiotic on the day of the survey. The majority (84.9%) were COVID-19 PCR positive, 61.1% were male and 34.9% were age 36 to 44 years. One quarter presented with severe disease, and cardiovascular disease was the major comorbidity in 13%. Secondary bacterial infection or co-infection (bacterial infection concurrent with COVID-19) was identified in only 1.4%. On the day of the survey, a mean of 1.7 antibiotics was prescribed per patient and 85.4% antibiotics were recorded as being prescribed for ‘prophylaxis’. The most frequently prescribed antibiotics were azithromycin (35.6%), ceftriaxone (32.9%) and meropenem (7.6%). The majority (96.3%) of the antibiotics were empirical and all were from WHO Watch or Reserve categories. Overall, a very high consumption of antibiotics in patients hospitalized with suspected or proven COVID-19 was observed in Pakistan and this is concerning in view of already high rates of antimicrobial resistance in the region. Antimicrobial stewardship programs need to urgently address unnecessary prescribing in the context of COVID-19 infection.

Antibiotic Use and Associated Risk Factors for Antibiotic Prescribing in COVID-19 Hospitalized Patients

Background: Literature suggests that antibiotic prescribing in COVID-19 patients is high. Currently, there are insufficient data on what drives antibiotic prescribing practices throughout the COVID-19 pandemic. Objective: This study sought to determine antibiotic use rates and identify risk factors for antibiotic prescribing in hospitalized patients. It was the first study to assess risk factors for receiving more than 1 course of antibiotics. Methods: This was a retrospective, multi-center, observational study. Patients admitted from March 1, 2020, to May 31, 2020, and treated for COVID-19 were included. The primary endpoint was the rate of antibiotic use during hospitalization. Secondary endpoints included risk factors associated with antibiotic use, risk factors associated with receiving more than 1 antibiotic course, and rate of microbiologically confirmed infections. Results: A total of 208 encounters (198 patients) were included in the final analysis. Eighty-three percent of patients received at least 1 course of antibiotics, despite low rates of microbiologically confirmed infection (12%). Almost one-third of patients (30%) received more than 1 course of antibiotics. Risk factors identified for both antibiotic prescribing and receiving more than 1 course of antibiotics included increased hospital length of stay (median 12 days), intensive care unit admission, and the necessity for mechanical ventilation. Conclusion and Relevance: There were high rates of antibiotic prescribing with low rates of microbiologically confirmed bacterial co-infection. Many patients received more than 1 course of antibiotics during hospitalization. This study highlights the importance and demand for appropriate antibiotic stewardship practices in COVID-19 patients.

Antibiotic prescribing to Kentucky Medicaid children, 2012‐2017: Prescribing is higher in rural areas

Antibiotic resistance is a major public health threat. Antibiotic use is the main driver of resistance, with children and the state of Kentucky having particularly high rates of outpatient antibiotic prescribing. The purpose of this study was to describe patient and provider characteristics associated with pediatric antibiotic use in Kentucky Medicaid children. We used Medicaid prescription claims data from 2012 to 2017 to describe patterns of pediatric antibiotic receipt in Kentucky. Patient and provider variables were analyzed to identify variations in prescribing. Children who were female, less than 2 years old, White, and living in a rural area had consistently higher rates of antibiotic prescriptions. There was significant geographic variability in prescribing, with children in Eastern Kentucky receiving more than 3 courses of antibiotics a year. Most antibiotic prescriptions for children were written by general practitioners and nurse practitioners rather than pediatricians. These findings support the need for extensive antibiotic stewardship efforts inclusive of rural outpatient practices.

Impact of a clinical decision rule on antibiotic prescription for children with suspected lower respiratory tract infections presenting to European emergency departments: a simulation study based on routine data.

Discriminating viral from bacterial lower respiratory tract infections (LRTIs) in children is challenging thus commonly resulting in antibiotic overuse. The Feverkidstool, a validated clinical decision rule including clinical symptoms and C-reactive protein, safely reduced antibiotic use in children at low/intermediate risk for bacterial LRTIs in a multicentre trial at emergency departments (EDs) in the Netherlands. Using routine data from an observational study, we simulated the impact of the Feverkidstool on antibiotic prescriptions compared with observed antibiotic prescriptions in children with suspected LRTIs at 12 EDs in eight European countries. We selected febrile children aged 1 month to 5 years with respiratory symptoms and excluded upper respiratory tract infections. Using the Feverkidstool, we calculated individual risks for bacterial LRTI retrospectively. We simulated antibiotic prescription rates under different scenarios: (1) applying effect estimates on antibiotic prescription from the trial; and (2) varying both usage (50%-100%) and compliance (70%-100%) with the Feverkidstool's advice to withhold antibiotics in children at low/intermediate risk for bacterial LRTI (≤10%). Of 4938 children, 4209 (85.2%) were at low/intermediate risk for bacterial LRTI. Applying effect estimates from the trial, the Feverkidstool reduced antibiotic prescription from 33.5% to 24.1% [pooled risk difference: 9.4% (95% CI: 5.7%-13.1%)]. Simulating 50%-100% usage with 90% compliance resulted in risk differences ranging from 8.3% to 15.8%. Our simulations suggest that antibiotic prescriptions would be reduced in EDs with high baseline antibiotic prescription rates or predominantly (>85%) low/intermediate-risk children. Implementation of the Feverkidstool could reduce antibiotic prescriptions in children with suspected LRTIs in European EDs.

Incidence and management of acute otitis media in adults: a primary care-based cohort study.

Although primarily considered a childhood disease, acute otitis media (AOM) also occurs in adults. Data on the burden of this condition in adults are, however, scarce. To explore the primary care incidence and current management of AOM in adults. All patients aged 15 and older included in the routine health care database of the Julius General Practitioners' Network were followed from 2015 to 2018 (contributing to a total of 1 261 575 person-years). We extracted data on AOM episodes, AOM-related consultations, comorbidities, and antibiotic and analgesic prescriptions. Five thousand three hundred and fifty-eight patients experienced one or more AOM episodes (total number of AOM episodes: 6667; mean 1.2 per patient). The overall AOM incidence was 5.3/1000 person-years and was fairly stable over the study period. Incidence was particularly high in atopic patients (7.3/1000 person-years) and declined with age (from 7.1 in patients 15-39 years of age to 2.7/1000 person-years in those aged 64 years and older). Oral antibiotics, predominantly amoxicillin, were prescribed in 46%, and topical antibiotics in 21% of all episodes. Over the past years, the incidence of AOM in adults in primary care has been stable. Oral antibiotic prescription rates resemble those in children with AOM, whereas a remarkably high topical antibiotic prescription rate was observed. Future prognostic research should inform on the need and feasibility of prospective studies into the best management strategy in this condition.

In vitro Inhibition of Clinical Isolates of Otitis Media Pathogens by the Probiotic Streptococcus salivarius BLIS K12.

Otitis media is a common childhood infection, frequently requiring antibiotics. With high rates of antibiotic prescribing and increasing antibiotic resistance, new strategies in otitis media prevention and treatment are needed. The aim of this study was to assess the in vitro inhibitory activity Streptococcus salivarius BLIS K12 against otitis media pathogens. Efficacy of the bacteriocin activity of S. salivarius BLIS K12 against the otitis media isolates was assessed using the deferred antagonism test. Overall, 48% of pathogenic isolates exhibited some growth inhibition by S. salivarius BLIS K12. S. salivarius BLIS K12 can inhibit the in vitro growth of the most common pathogens.

Recent Practice Patterns and Variations in Children Hospitalized for Asthma Exacerbation in Japan

Background: High antibiotic prescribing rates for adults with an asthma exacerbation have been reported in developed countries, but few studies have assessed the variation of antibiotic and adjunctive treatment in the routine care of children. Objective: We evaluated the trends in health resource utilization for children hospitalized for asthma exacerbation, ascertained the variations of practices across hospitals and geographic location, and classified these different patterns at hospital levels. Methods: Using data on Japanese children hospitalized for asthma exacerbation with no indication of bacterial infection during 2010–2018, we conducted a retrospective observational study to assess the trends in initial treatment patterns and their variations. Mixed-effect generalized linear models were used to investigate the treatment trends. Hierarchical cluster analyses were performed to classify the treatment variations across hospitals. Results: Overall, 54,981 children were eligible for the study. Proportions of antibiotic use decreased from 47.2% in 2010 to 26.9% in 2018. Similarly, utilization of antitussives, antihistamines, and methylxanthine showed decreasing trends over the period, whereas the use of mucolytics and ambroxol increased. These treatment variations were more considerable in hospital levels than in 47 prefecture levels. Hierarchical cluster analyses classified these patterns into 6 groups, mostly based on mediator release inhibitor, ambroxol, and antitussives. Conclusions: Wide variations in antibiotics and adjunctive treatments were observed across hospital levels. Our findings support the improvement in reducing inappropriate antibiotic use and highlight the need for comparative effectiveness research of the adjunctive treatments among children hospitalized for asthma.

Guideline Adherence in Antibiotic Prescribing to Patients with Respiratory Diseases in Primary Care: Prevalence and Practice Variation.

Respiratory tract infections (RTIs) account for a large part of antibiotic prescriptions in primary care. However, guidelines advise restrictive antibiotic prescribing for RTIs. Only in certain circumstances, depending on, e.g., comorbidity, are antibiotics indicated. Most studies on guideline adherence do not account for this. We aimed to assess guideline adherence for antibiotic prescribing for RTIs as well as its variation between general practices (GPs), accounting for patient characteristics. We used data from electronic health records of GPs in the Netherlands. We selected patients who consulted their GP for acute cough, rhinitis, rhinosinusitis or sore throat in 2014. For each disease episode we assessed whether, according to the GP guideline, there was an indication for antibiotics, using the patient’s sociodemographic characteristics, comorbidity and co-medication. We assessed antibiotic prescribing for episodes with no or an unsure indication according to the guidelines. We analysed 248,896 episodes. Diagnoses with high rates of antibiotic prescribing when there was no indication include acute tonsillitis (57%), strep throat (56%), acute bronchitis (51%) and acute sinusitis (48%). Prescribing rates vary greatly between diagnoses and practices. Reduction of inappropriate antibiotic prescribing remains a key target to tackle antimicrobial resistance. Insight into reasons for guideline non-adherence may guide successful implementation of the variety of interventions already available for GPs and patients.