Inappropriate Antimicrobial Use Research Articles

Knowledge, Attitudes, Practices, and Risk Perception of Antimicrobial Use and Antimicrobial Resistance Among Dairy Farm Owners/Workers in Addis Ababa, Ethiopia.

Antimicrobial resistance (AMR) is one of the most significant global health threats to the public, animals, and the ecosystem. Inappropriate use of antibiotics in food animals is considered a major driver of AMR in humans. This study was conducted to assess the knowledge, attitude, practices, and risk perception (KAPP) of dairy farm owners/workers in Addis Ababa about antibiotic use and resistance. A face-to-face interview using a structured questionnaire was conducted with 281 respondents in four selected subcities of Addis Ababa. The responses provided by each participant were recoded into a binary scale based on the mean score of each domain. Pearson chi-square was used to check the association between the KAPP and sociodemographic characteristics of the respondents and logistic regression analysis was done to explore the factors associated with KAPP. Overall, more than half of the surveyed dairy farm owners/workers had good knowledge (57.7%) and appropriate practice (53.0%), while less than half of the respondents showed desirable attitudes (47.7%) and positive risk perceptions (42.7%). The findings revealed a strong association between the respondents' KAPP and education and between knowledge and risk perception and farming experience. This study found that continuous education of dairy farm owners/workers regarding antimicrobial usage and antimicrobial resistance in dairy farms will increase their awareness and perception of risk as well as motivate them to adopt desirable attitudes and appropriate practices, and consequently limit inappropriate use of antimicrobials leading to mitigating emergence of AMR.

Decision support systems for antibiotic prescription in hospitals: a survey with hospital managers on factors for implementation.

Inappropriate antimicrobial use, such as antibiotic intake in viral infections, incorrect dosing and incorrect dosing cycles, has been shown to be an important determinant of the emergence of antimicrobial resistance. Artificial intelligence-based decision support systems represent a potential solution for improving antimicrobial prescribing and containing antimicrobial resistance by supporting clinical decision-making thus optimizing antibiotic use and improving patient outcomes. The aim of this research was to examine implementation factors of artificial intelligence-based decision support systems for antibiotic prescription in hospitals from the perspective of the hospital managers, who have decision-making authority for the organization. An online survey was conducted between December 2022 and May 2023 with managers of German hospitals on factors for decision support system implementation. Survey responses were analyzed from 118 respondents through descriptive statistics. Survey participants reported openness towards the use of artificial intelligence-based decision support systems for antibiotic prescription in hospitals but little self-perceived knowledge in this field. Artificial intelligence-based decision support systems appear to be a promising opportunity to improve quality of care and increase treatment safety. Along with the Human-Organization-Technology-fit model attitudes were presented. In particular, user-friendliness of the system and compatibility with existing technical structures are considered to be important for implementation. The uptake of decision support systems also depends on the ability of an organization to create a facilitating environment that helps to address the lack of user knowledge as well as trust in and skepticism towards these systems. This includes the training of user groups and support of the management level. Besides, it has been assessed to be important that potential users are open towards change and perceive an added value of the use of artificial intelligence-based decision support systems. The survey has revealed the perspective of hospital managers on different factors that may help to address implementation challenges for artificial intelligence-based decision support systems in antibiotic prescribing. By combining factors of user perceptions about the systems´ perceived benefits with external factors of system design requirements and contextual conditions, the findings highlight the need for a holistic implementation framework of artificial intelligence-based decision support systems.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature.

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.

Use of antimicrobials in the intensive care unit of a Loreto public hospital

Introduction. Inappropriate use of antimicrobials in the Intensive Care Unit (ICU) contributes to bacterial resistance. Objective. The purpose of the present study was to measure the use and type of antimicrobials in patients hospitalized in the Intensive Care Unit of the Loreto Regional Hospital (HRL). Methods. Descriptive study. We reviewed 120 medical records in ICU-HRL patients from January to June 2023. Results. Most patients used antimicrobials (74.2%), indicated for septic shock (42.7%), 1 to 3 antimicrobials (93.2%), with therapy of 1 to 3 days (45%). Of the total number of antimicrobials used, the greatest proportion were bactericides 89 (90.4%), from the cephalosporin family (33.1%) and carbapenemics (23.5%); the most commonly used drugs were ceftriaxone (26.5%) and meropenem (21.1%) by the intravenous route (90.4%). Conclusion. The highest proportion of hospitalized patients use antimicrobials of the cephalosporin and carbapenemics family.

Knowledge, Attitudes, and Practices of Rural Communities Regarding Antimicrobial Resistance and Climate Change in Adadle District, Somali Region, Ethiopia: A Mixed-Methods Study.

There is an urgent need for interventions in addressing the rapid and disproportionate impact of antimicrobial resistance (AMR) and climate change (CC) on low- and middle-income countries. Within this context, it is important to understand indigenous knowledge in rural communities, which are highly affected. This study examined knowledge, attitude, and practices (KAP) regarding AMR and CC in the Adadle district, Somali region, Ethiopia, utilizing mixed methods, including 362 surveys and 12 focus group discussions among rural communities. Findings showed that 39% and 63% of participants were familiar with AMR and CC, respectively. Of those surveyed, 57% attributed AMR to inappropriate antimicrobial use in animals and humans, while CC was often associated with Allah/God. Multivariable analysis indicated that males exhibited superior knowledge and a positive attitude towards AMR and CC. Additionally, individuals aged 26-35 and 36-45 years showed heightened awareness of AMR and CC, respectively. Moreover, participants who were government employees, pastoralists, and business owners showed better knowledge on CC compared to family caretaker. Religious education and households with more than six members were linked to lower AMR knowledge. This study underlines a greater awareness of CC than AMR and highlights gender-based disparities, recommending integrated educational AMR programs targeting different demographics through a One Health lens, actively involving females, and incorporating local beliefs and practices.

Not surprising: a rebound in antibacterial consumption in Europe, with Cyprus and Greece on the podium.

Recent European-wide data place Cyprus and Greece in the highest positions of total antimicrobial consumption. While this level of consumption might be partly attributed to the high rates of infections due to MDR bacteria in these countries, several other reasons should be sought to help apply local measures, to decrease inappropriate and excess antimicrobial use. The present viewpoint aims to provide a roadmap for interventions, by briefly discussing the various factors that underlie antimicrobial use and prescribing practices in Greece and Cyprus.

Global approaches to tackling antimicrobial resistance: a comprehensive analysis of water, sanitation and hygiene policies

BackgroundUnsafe water, sanitation and hygiene (WASH) contributes to a high burden of disease and exacerbates factors that promote the development of antimicrobial resistance (AMR). Enforceable policies are foundational to curbing...

Agreement of methods to assess antimicrobial susceptibility using Escherichia coli isolates as target models.

Antimicrobial susceptibility tests (AST) conducted in vitro offer a range of methods to assess the antimicrobial resistance (AMR) of microorganisms. Escherichia coli, a widely distributed bacterium, is closely linked to the issue of AMR. In this way, the present study aimed to assess the agreement among different in vitro AST methods, including disk diffusion in agar, broth dilution, and agar dilution method. A total of 100 E. coli isolates were analyzed for their resistance levels against six antibiotics: amoxicillin, ceftiofur, ciprofloxacin, chloramphenicol, tetracycline, and sulfamethoxazole+trimethoprim, using the aforementioned AST methods. Standard breakpoint values were employed to classify isolates as resistant, intermediate, or susceptible, and comparisons among the AST methods were conducted by McNemar's test (P<.05). The obtained data demonstrated equivalence among the AST methods, highlighting the reliability of these standardized classical methodologies. This standardization aids in preventing the inappropriate use of antimicrobials and the dissemination of antimicrobial-resistant microorganisms.

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal.

Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common. To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal. The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes. A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices. Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review.

A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal. This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes. A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community. Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors. DOI: 10.17605/OSF.IO/FV326.

Prioritizing Equity in Antimicrobial Stewardship Efforts (EASE): a framework for infectious diseases clinicians.

Health equity gaps persist across minoritized groups due to systems of oppression affecting health-related social needs such as access to transportation, education and literacy, or food and housing security. Consequently, disparities in the prevalence of multidrug-resistant infections, infectious disease outcomes, and inappropriate antimicrobial use have been reported across minoritized populations. The Joint Commission and Centers for Medicare and Medicaid Services (CMS) have formally acknowledged the importance of integrating health equity-focused initiatives into existing hospital quality improvement (QI) programs. Here, we review documented disparities in antimicrobial stewardship and offer a framework, derived from components of existing health equity and QI tools, to guide clinicians in prioritizing equity in antimicrobial stewardship efforts (EASE).

Reaching high-hanging fruit in antimicrobial stewardship: a hospital-based intervention to withdraw inappropriately prescribed antimicrobials.

Antimicrobial stewardship programs (ASPs) are responsible for addressing unnecessary antimicrobial use. We describe our experience with a unique intervention to withdraw unnecessary antimicrobials. Design, Setting, Participants: descriptive case series of adult inpatients at a single academic medical center, December 2021 to December 2022; Intervention: hospital-wide policy allowing ASP to discontinue inappropriate antimicrobials in select cases not resolved by prospective audit and feedback; Measures: count, date, and generic names of antimicrobials prescribed; reason for antimicrobial withdrawal (prolonged duration, no evidence of infection, or other); withdrawals by inpatient service (surgical or medical); time from antimicrobial start date to withdrawal intervention; days of therapy (DOT) saved; "nudge effect" defined as the prescribing team self-discontinuing withdrawn antimicrobial within 24 hours of withdrawal notice; appeals to withdrawals; ordering of alternative antimicrobials following withdrawal; incident infections, readmission, in-hospital mortality within 30 days of withdrawal intervention. There were 54 antimicrobials withdrawn among 36 unique patients during the study period; piperacillin-tazobactam followed by vancomycin were the most frequently withdrawn agents; prolonged duration of therapy or prophylaxis followed by no evidence of infection were the most common reasons for withdrawal; withdrawals occurred most often on surgical services; an estimated 236 DOT (27.2 DOT per 100 patient-days) were saved; 32% of withdrawals were appealed; alternative antimicrobials were ordered following 20% of withdrawals; no incident infections, readmissions or in-hospital deaths were definitively attributed to withdrawal intervention. Our antimicrobial withdrawal intervention was a safe and effective addition to ASP activities to reduce inappropriate antimicrobial use and improve prescriber accountability.

Collecting Multi-country Retrospective Antimicrobial Consumption and Use Data: Challenges and Experience.

Excessive or inappropriate antimicrobial use contributes to antimicrobial resistance, emphasizing the need to monitor and document the types and quantities of antibiotics used. Thus, data on antimicrobial consumption (AMC) and antimicrobial usage (AMU) are key in informing and promoting judicious use. Our study, conducted during 2019-2023, as part of the CAPTURA project, aimed to understand the state of data availability and quality for AMC and AMU monitoring in Asia. In this article, we describe the challenges and opportunities faced and provide examples of AMU and AMC analysis. World Health Organization (WHO) and country-tailored methodologies and tools were applied to collect retrospective data from 2016 to 2019 in Bangladesh, Bhutan, Laos, Nepal, Pakistan, Papua New Guinea, Sri Lanka, and Timor-Leste. The primary indicator for national AMC was total level of consumption, expressed as total defined daily doses (DDD) per 1000 inhabitants per day for the year or period of data collected. For facility AMC and AMU, the primary indicator was total DDD per admissions per day for the year or period of data collected. Although many countries faced infrastructural challenges in data collection and storage, we managed to collect and analyze AMC data from 6 countries and AMU data from 5. The primary indicators, and additional findings, were visualized to facilitate dissemination and promote the development of action plans. Looking ahead, it is crucial that future initiatives empower each country to establish surveillance infrastructures tailored to their unique contexts, ensuring sustainable progress in the fight against antimicrobial resistance.

Antimicrobial use of patients with sexually transmitted infection symptoms prior to presentation at five health facilities in Southern Ghana

BackgroundUnregulated and inappropriate antimicrobial use are major contributors to the evolution of antimicrobial resistance worldwide. It is important to monitor and collect data on the use of antibiotics at health facilities and in the general population in order to support antimicrobial stewardship programs.MethodsAs part of a gonorrhea surveillance study that was conducted from June 2012 to Jan 2018, we administered a questionnaire to elicit information on the types of antimicrobials used by individuals to treat symptoms of a gonorrhea infection prior to presenting at five health facilities in Southern Ghana.ResultsAlmost one-third (383/1,349; 28%) of study participants admitted taking one or more antimicrobial types before hospital presentation, while 138/383 (36%) of those who took antimicrobials could not remember what they ingested. A greater percentage of individuals who reported prior antimicrobial use before presentation at a health facility tested positive for gonorrhea by NAAT (30%), in contrast to 24% for those without prior treatment (p = 0.004). Penicillin and its derivatives, as well as ciprofloxacin and doxycycline, were the most used, while a few individuals reported taking drugs such as kanamycin and rifampin. Males were more likely than females to take an antimicrobial prior to attending a health center.ConclusionIn order to curb excessive and inappropriate antimicrobial use, antibiotics used by patients before presenting at hospitals ought to be investigated by healthcare providers. It is recommended that health professionals receive continuing education on the consequences of unregulated antimicrobial use.

Antibiotic Prescribing Practice in a Paediatric Outpatient Clinic in Owerri, Imo State, Nigeria

Background: Antibiotics are amongst the most frequently prescribed drugs for children in outpatient clinics but irrational prescribing can cause medication errors, antibiotic resistance and treatment failure. Examples of irrational prescribing includes poly-pharmacy, over use of injections, inappropriate use of antimicrobials and failure to prescribe in accordance with treatment guidelines.&#x0D; This study sought to assess antibiotic prescribing practice in the children’s outpatient clinic of the Federal university teaching hospital Owerri, Imo state.&#x0D; Materials and Methods: This was a descriptive prospective study carried out in the Children’s Outpatient Clinic (CHOP) of the Federal university teaching hospital Owerri, Imo state Nigeria between April and June 2021. During the study period, medical record of patients who attended the CHOP and who had antibiotic(s) prescribed were collated. Prescribing practice was assessed using the World Health Organization prescribing indicators.&#x0D; Results: A total of 495 antibiotic prescriptions were made for 478 patients. This gave 1.04 as the average number of medicines prescribed per patient encounter. 1.6% of the antibiotics were prescribed as injections and 79.2% of the prescriptions were in generic names. While only 96.8% of the prescriptions were from the Nigerian essential drug list, the three most prescribed antibiotics Amoxicillin/Clavulanic acid, Cefuroxime and Amoxicillin are all listed in it.&#x0D; Conclusion: The antibiotic prescribing practice in the children’s outpatient clinic was rational with regards to average number of medications per patient encounter and percentage of encounters with injection prescribed. It was irrational in terms of percentage of antibiotics prescribed in generic names and percentage of antibiotics prescribed from the Nigerian essential drug list.

Impact of UG Training on Understanding the Severity of Antimicrobial Resistance.

Background: Antibiotic resistance is increasing at an alarming rate. Many reasons are there which need urgent attention toward this problem. Efforts in all directions are required to address this serious issue. The irrational prescribing habits of physicians lead to increasing morbidity, mortality, and treatment costs. One of the key components of the system is the prescriber and their practices. In the present study, efforts were made to know the understanding of the medical students about the severity of the problem and to find out the focus area that needs to be modified. Materials and methods: A cross-sectional, questionnaire-based survey was conducted among the second-year medical students of a teaching hospital after the ethical approval study was explained to the student and written consent was taken. The questionnaire was given before and after exposure to formal lectures on antimicrobial agents. The collected data was analyzed. Results: It was clear that inappropriate use of antimicrobials causes antimicrobial resistance (AMR) (87.3%) and can harm patients (82%). Interactive patient-oriented problem-solving modules on the internet (35%) and small group problem-based learning are preferred by (32%) students. Preparedness about antimicrobial use was seen only in 50% of the students in a few essential aspects. Learning during the medical course only does the purpose of sensitization, for the thorough knowledge repeated exposure is essential. Conclusion: Most of the students were partially aware of the AMR. The only concern was their casual attitude regarding antibiotic use. Further educational interventions are necessary to improve their understanding and perceptions of antibiotic resistance, as well as their attitude toward antibiotic use. How to cite this article: Deogaonkar A,Dawane J. Impact of UG Training on Understanding the Severity of Antimicrobial Resistance. J Assoc Physicians India 2023;71(11):14-18.

Consideration of factors associated with inequalities in interventions that support health-care professionals’ interaction with patients to reduce inappropriate antimicrobial use: a systematic review

BackgroundTackling the public health challenge of antimicrobial resistance (AMR) requires promotion of appropriate antimicrobial use by health-care professionals. The objective of this review was to identify interventions that facilitate appropriate antimicrobial behaviours when health-care professionals interact with patients and any considerations for factors associated with health inequalities. MethodsFor this systematic review, we searched electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) from Jan 31, 2023, to Feb 8, 2023. We included search terms such as antimicrobial use/prescribing, health-care professionals, and AMR programmes. We included any relevant primary study published from year 2010 and in English. We conducted forward and backward citation searching from included studies on March 27, 2023. We extracted information on the interventions following the Template for Intervention Description and Replication (TIDieR) guideline and examined reports on how the interventions might impact on inequalities. We performed quality assessment using the Mixed Methods Appraisal Tool (MMAT). We conducted descriptive synthesis. The protocol is registered with PROSPERO (CRD42023395642). FindingsAfter screening 4979 records, we included 59 studies. Most studies were randomised trials (n=25) and qualitative/mixed methods studies (n=16). Included studies covered 16 countries, particularly the UK (n=16) and the USA (n=13). Most studies (n=34) fulfilled at least 80% of the relevant quality criteria, but 12 studies fulfilled less than 50%. Many interventions were established strategies (eg, TARGET: Treat Antibiotics Responsibly, Guidance, Education and Tools). Patient interaction elements of the interventions often involved using education materials (eg, digital/paper leaflets, and videos) and point-of-care testing. While many studies (n=49) included participants from disadvantaged groups, only three examined how outcomes differ between groups. In those studies, antimicrobial prescription was not associated with age, sex, and level of learning disability. Some other studies reported issues with language barriers and potential digital exclusion, especially for older people. InterpretationWe might have missed some relevant studies due to publication year and language restrictions. Notwithstanding, this review showed that the potential impact of factors associated with health inequalities are not routinely considered during the implementation and evaluation of interventions to improve health-care professionals’ interaction with patients. Future work should routinely consider this to help mitigate potential inequalities. FundingUK Health Security Agency.

Divergent veterinarian and cat owner perspectives are barriers to reducing the use of cefovecin in cats.

To understand veterinarian and cat owner perspectives on antimicrobial use in cats, reasons for prescribing cefovecin, and barriers to improving antimicrobial stewardship, including veterinarian and cat owner perspectives of giving oral medication to cats. 21 New York veterinarians and 600 cat owners across the US. Cat owners were surveyed about their preferences for and experiences in giving oral medications to cats and their experiences with antimicrobials specifically. Veterinarians were interviewed about antimicrobial use decisions in cats, benefits and drawbacks of cefovecin, and their perspectives on antimicrobial resistance. Many veterinarians reported feeling pressure to prescribe antimicrobials, while 41% of cat owners reported requesting antimicrobials. Although veterinarians are aware of the downsides of prescribing cefovecin, many prescribed cefovecin in situations where an antimicrobial was not needed or cefovecin may not have been the best choice. Veterinarians thought that 20% of cat owners could not give oral medications, but < 10% of cat owners had a cat that was impossible to medicate. The disconnect between veterinarians' assessment of and cat owners' reported abilities in administering oral medication may contribute to cefovecin use. Demonstrating for cat owners how to give oral medication may help improve compliance and reduce the use of parenteral long-acting formulations. Structural and educational interventions are needed to address other contributors to inappropriate antimicrobial use. This research provides the specific considerations about barriers and motivations for cat owners and veterinarians that are required to guide strategic, tailored interventions for both audiences to advance stewardship.

Improving healthcare professionals’ interactions with patients to tackle antimicrobial resistance

Abstract Background Antimicrobial resistance (AMR) is one of the most important public health threats. It is important for healthcare professionals (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to mitigate inappropriate antimicrobial use. This review identified existing interventions which aim to improve HCPs’ interaction with patients and examined factors that enables or hinders appropriate behaviours. Methods We searched MEDLINE, EMBASE, Science Citation Index, Social Sciences Citation Index, Google Scholar, internet and conducted forward and backward citation searching from eligible studies. We included studies of any design, published in English language from year 2010 to 2023. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation - Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results We included 59 studies of diverse designs examining a range of interventions from 16 countries. Many interventions involved multiple components beyond HCPs’ interaction with patients, e.g., Treat Antibiotics Responsibly, Guidance, Education and Tools (TARGET). Patient interaction components mostly involved use of posters, leaflets, videos, interactive decision support tools and C reactive protein point-of-care testing. The interventions were often found to be useful. Barriers and facilitators identified related to capability (e.g., knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions, forgetfulness); opportunity (e.g., time constraint, intervention accessibility) and motivation (e.g., patient's desire for antibiotics, fear of litigation). Conclusions There are many useful interventions to improve HCPs and patients’ interactions for appropriate behaviours in antibiotic use. The barriers and facilitators identified in this review should be considered by intervention designers/adopters and policy makers to improve implementation and effectiveness. Key messages • Factors hindering appropriate antimicrobial use are complex. • This review can inform the development and implementation of strategies to improve healthcare professional’ interaction with the users.

Bacteriophages PECP14, PECP20, and their endolysins as effective biocontrol agents for Escherichia coli O157:H7 and other foodborne pathogens

Escherichia coli O157:H7 is a notorious foodborne pathogen known to cause severe illnesses such as hemolytic colitis and hemolytic uremic syndrome, with fresh produce consumption being implicated in recent outbreaks. The inappropriate use of antimicrobials to combat pathogens has led to the emergence and rapid dissemination of antimicrobial-resistant microorganisms including pathogenic E. coli, presenting a significant risk to humans. Here, we isolated two E. coli O157:H7 infecting bacteriophages, PECP14 and PECP20, from irrigation water and city sewage, respectively, as alternatives to antimicrobials. Both phages were stable for at least 16 h in a broad range of pH (pH 3–11) and temperature (4–40 °C) conditions and have a double-stranded DNA chromosome. PECP14 and PECP20, classified under the Epseptimavirus and Mosigvirus genera, respectively, exhibit specificity in targeting different host receptors, BtuB protein and lipopolysaccharide. Interestingly, these phages demonstrate the ability to infect not only E. coli O157:H7 but also other foodborne enteric pathogens like Shigella sonnei and S. flexneri. Upon mixing phages with their respective host bacteria, rapid adsorption (at least 68 % adsorption within 10 min) and substantial bacterial lysis were observed. The efficacy of phage treatment was further validated through the reduction of E. coli O157:H7 on radish sprouts. Moreover, purified endolysins, LysPECP14 and LysPECP20, derived from each phage exhibited remarkable bacteriolytic activity against E. coli O157:H7 cells pretreated with EDTA. In particular, the activity of LysPECP20 was also noticeable against Listeria monocytogenes and Bacillus cereus, suggesting its potential for broader antimicrobial applications in food industry. The combined results showed that the phages PECP14, PECP20, and their endolysins could be used for biological control of E. coli O157:H7 in various circumstances, from production, harvesting, and storage stages to processing and distribution steps of agricultural products.