Quality Of Antibiotic Prescribing Research Articles

Pricing, Procurement and Reimbursement Policies for Incentivizing Market Entry of Novel Antibiotics and Diagnostics: Learnings from 10 Countries Globally.

Fostering market entry of novel antibiotics and enhanced use of diagnostics to improve the quality of antibiotic prescribing are avenues to tackle antimicrobial resistance (AMR), which is a major public health threat. Pricing, procurement and reimbursement policies may work as AMR 'pull incentives' to support these objectives. This paper studies pull incentives in pricing, procurement and reimbursement policies (e.g., additions to, modifications of, and exemptions from standard policies) for novel antibiotics, diagnostics and health products with a similar profile in 10 study countries. It also explores whether incentives for non-AMR health products could be transferred to AMR health products. This research included a review of policies in 10 G20 countries based on literature and unpublished documents, and the production of country fact sheets that were validated by country experts. Initial research was conducted in 2020 and updated in 2023. Identified pull incentives in pricing policies include free pricing, higher prices at launch and price increases over time, managed-entry agreements, and waiving or reducing mandatory discounts. Incentives in procurement comprise value-based procurement, pooled procurement and models that delink prices from volumes (subscription-based schemes), whereas incentives in reimbursement include lower evidence requirements for inclusion in the reimbursement scheme, accelerated reimbursement processes, separate budgets that offer add-on funding, and adapted prescribing conditions. While a few pull incentives have been piloted or implemented for antibiotics in recent years, these mechanisms have been mainly used to incentivize launch of certain non-AMR health products, such as orphan medicines. Given similarities in their product characteristics, transferability of some of these pull incentives appears to be possible; however, it would be essential to conduct impact assessments of these incentives. Trade-offs between incentives to foster market entry and thus potentially improve access and the financial sustainability for payers need to be addressed.

Point prevalence surveys of antibiotic prescribing in children at a tertiary hospital in a resource constraint, low-income sub-Saharan African country—the impact of an antimicrobial stewardship program

BackgroundResistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital.MethodA point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis (http://www.global-pps.com).ResultsA total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%.ConclusionThe indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department.

Quality of antibiotic prescribing for outpatient cystitis in adult females

Background: Urinary tract infections (UTI) are responsible for a significant portion of female, outpatient antibiotic prescriptions. Especially true in uncomplicated cases, where symptoms remain the cornerstone of diagnosis, ensuring the optimal choice of agent, dose, and duration may mitigate future bacterial resistance and lower the likelihood of adverse events and/or recurrence. This study is the first in Canada to examine the quality of antibiotic prescribing to females in the outpatient setting, for uncomplicated UTI–by agent, dose, and duration. Methods: All adult female residents of British Columbia with a physician record for cystitis from January 1, 2014, to December 31, 2018, were identified. Patients with a history of urologic abnormalities, spinal cord injury, catheter use, kidney transplant, as well as pregnant females, were excluded. Primary outcomes included the proportion of total episodes prescribed and the proportion of appropriate antibiotic use, examined using Poisson regression. Results: A total of 182,162 episodes of cystitis were examined, with 70% receiving an antibiotic prescription. The rate of cystitis-associated prescribing was 697 prescriptions per 1,000 population. Overall, 35% of prescriptions were appropriate by guideline adherence or clinical justification. Nitrofurantoin and trimethoprim-sulfamethoxazole, accounted for 71% of total antibiotic use. Seven days was the most commonly dispensed duration of therapy, followed by 5, then 10. Conclusions: Shortening length of therapy in line with clinical guidelines and encouraging the use of first line agents present clear, actionable targets for provincial stewardship efforts.

Patterns and Quality of Antibiotic Prescribing: Results from a Multicentre Point Prevalence Survey in Government Hospitals in Perak, Malaysia

A point prevalence survey (PPS) is used to collect data on antimicrobial prescribing and assess a set of quality indicators associated with antimicrobial use. This study aimed to describe patterns and quality indicators of antibiotic prescribing among government hospitals in Perak, Malaysia. Data was retrospectively reviewed data from a PPS conducted from 1st to 14th December 2021 in 5 specialist and 10 non-specialist hospitals. All hospitalised patients on the day of the survey formed the study population. Those who had received at least one active systemic antibiotic by 8.00 a.m. or surgical prophylaxis within 24 h of the survey day were eligible for PPS. Data on pattern and quality indicators of prescribing (documentation of indication, guideline compliance and appropriateness of surgical prophylaxis) were analysed with descriptive evaluation. Of 2,386 hospitalised patients, 40% were prescribed antibiotics, mainly from the ‘Access’ category (52.3%). Antibiotic prevalence was highest in the intensive care unit (ICU) (90.8%). The predominant antibiotic class was beta-lactam/ beta-lactamase inhibitor (32.6%), corresponding to community-acquired pneumonia (CAP) (19.8%) being the most common diagnosis. Intravenous administration was ordered in 79.4%, while empirical therapy constituted 84.5%. Documentation of indication within 24 h and guideline compliance were 88.2% and 69.8%, respectively. Inappropriate choice of antibiotics and improper dose/frequency were identified as important non-compliance issues. Of the surgical prophylaxis prescriptions, 35.6% were administered for more than 24 h. The findings have helped identify critical areas for antimicrobial stewardship interventions. Efforts are needed to reinforce compliance, documentation and improve surgical prophylaxis prescribing practices.

Development of antibiotic metrics for hospitalists via multi-institutional modified Delphi survey.

Closing the gap between evidence-supported antibiotic use and real-world prescribing among clinicians is vital for curbing excessive antibiotic use, which fosters antimicrobial resistance and exposes patients to antimicrobial side effects. Providing prescribing information via scorecard improves clinician adherence to quality metrics. We aimed to delineate actionable, relevant antimicrobial prescribing metrics extractable from the electronic health record in an automated way. We used a modified Delphi consensus-building approach. Our study entailed two iterations of an electronic surveydisseminated to hospital medicine physicians at 10 academic medical centers nationwide. Main outcomes comprised consensus metrics describing the quality of antibiotic prescribing to hospital medicine physicians. Twenty-eight participants from 10 United States institutions completed the first survey version containing 38 measures. Sixteen respondents completed the second survey, which contained 37 metrics. Sixteen metrics, which were modified based on qualitative survey feedback, met criteria for inclusion in the final scorecard. Metrics considered most relevant by hospitalists focused on the appropriate de-escalation of antimicrobial therapy, selection of guideline-concordant antibiotics, and appropriate duration of treatment for common infectious syndromes. Next steps involve prioritization and implementation of these metrics based on quality gaps at our institution, focus groups exploring impressions of clinicians who receive a scorecard,and analysis of antibiotic prescribing patterns before and after metric implementation. Other institutions may be able to implement metrics from this scorecard based on their own quality gaps to provide hospitalists with automated feedback related to antibiotic prescribing.

Antibiotics Prescribing Pattern and Quality of Prescribing in Croatian Dental Practices-5-Year National Study.

Antibiotic resistance is one of the biggest threats to global health today. The aim of this study was to analyze antibiotic prescribing patterns and quality of prescribing in Croatian dental practices over a 5-year period. This is a retrospective observational study based on the analysis of the electronic prescriptions (medicines in ATC groups J01 and P01) from dental practices in Croatia prescribed from 1 January 2015 to 31 December 2019. Prescriptions were retrieved from the Croatian Health Insurance Fund (HZZO). The analyses included the number of prescriptions, type and quantity of prescribed drugs, indication, and the patient's and prescriber's characteristics. The consumption increased from 1.98 DID in 2015, to 2.10 DID in 2019. The most prescribed antibiotic was Amoxicillin with clavulanic acid followed by Amoxicillin, Clindamycin, Metronidazole and Cefalexin. The analyses showed that 29.79% of antibiotics were not prescribed in accordance with the contemporary guidelines for the proper use of antibiotics. Additionally, 22% of antibiotics were prescribed in inconclusive indications. The research showed an increase in antibiotic consumption over five years along with unnecessary prescribing of antibiotics in cases with no indications for its use. The development of national guidelines for antibiotic use is necessary.

Randomised multicentre effectiveness trial of rapid syndromic testing by panel assay in children presenting to European emergency departments with acute respiratory infections—trial protocol for the ADEQUATE Paediatric trial

IntroductionSyndromic panel assays, that is, using one test to simultaneously target multiple pathogens with overlapping signs and symptoms, have been integrated into routine paediatric care over the past decade, mainly...

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.

Le rôle du service d'infectiologie dans la gestion des anti-infectieux : étude prospective des avis réalisés par le service des maladies infectieuses du CHU Mohammed VI de Marrakech

IntroductionThe aim of this study was to evaluate the role of the infectious diseases department in optimizing the use of antibiotics in the hospital. MethodWe carried out a prospective study of all medical advice performed by the Infectious Diseases Department of the Marrakech University Hospital, over a six-month period. ResultsThe number of medical advices was 153. Surgical departments accounted for 56 % of all requests for advice, compared with 44% for medical departments. The diagnosis of infection was retained in 76% of cases. Infections were nosocomial in 29% of cases and community-acquired in 46%. Among documented infections, multi-resistant bacteria were isolated from 11% of patients, Pseudomonas aeruginosa was the most common microorganisme. Escherichia coli and Klebsiella pneumoniae were the most frequently implicated bacteria in multi-resistant infections. The actions suggested by the referring physician were to start antibiotic therapy in 30% of cases, stop antibiotic therapy in 16% of cases, modify the antibiotic therapy in 23% of cases, and adjust the dose in 11% of cases. The same treatment was maintained in 11% of cases. ConclusionThe study shows that the infectious diseases team's advice allows optimizing or improving the quality of antibiotic prescribing.

Diagnosis-linked antibiotic prescribing quality indicators: demonstrating feasibility using practice-based routine primary care data, reliability, validity and their potential in antimicrobial stewardship.

Quality indicators (QIs) can be used to obtain valuable insights into prescribing quality. Five quantitative and nine diagnosis-linked QIs, aiming to provide general practitioners (GP) with feedback on their antibiotic prescribing quantity and quality, were previously developed and evaluated in a controlled study. To confirm, in a larger non-controlled study, the feasibility of using routinely collected and extracted electronic patient records to calculate the diagnosis-linked QI outcomes for antibiotic prescribing, and their reliability and validity. Retrospective study involving 299 Dutch general practices using routine care data (2018-2020). QIs describe total antibiotic and subgroup prescribing, prescribing percentages and first-choice prescribing for several clinical diagnoses. Practice variation in QI outcomes, inter-QI outcome correlations and sensitivity of QI outcomes to pandemic-induced change were determined. QI outcomes were successfully obtained for 278/299 practices. With respect to reliability, outcomes for 2018 and 2019 were comparable, between-practice variation in outcomes was similar to the controlled pilot, and inter-QI outcome correlations were as expected, for example: high prescribing of second choice antibiotics with low first-choice prescribing for clinical diagnoses. Validity was confirmed by their sensitivity to pandemic-induced change: total antibiotic prescribing decreased from 282 prescriptions/1000 registered patients in 2018 to 216 in 2020, with a decrease in prescribing percentages for upper and lower respiratory infections, from 26% to 18.5%, and from 28% to 16%. This study confirmed the fit-for-purpose (feasibility, reliability and validity) of the antibiotic prescribing QIs (including clinical diagnosis-linked ones) using routinely registered primary health care data as a source. This feedback can therefore be used in antibiotic stewardship programmes to improve GPs' prescribing routines.

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes.This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

Antibiotics Prescriptions in the Otolaryngology Department of the Departmental and Teaching Hospital of Borgou-Alibori in 2020

Aims: The aim of this study was to assess the quality of antibiotic prescriptions in the ENT department of the Departmental and Teaching Hospital of Borgou-Alibori (DTH-BA).
 Study design: This was a prospective descriptive study.
 Place and Duration of Study: Departmental and Teaching Hospital of Borgou-Alibori (DTH-BA), from June 15 to September 15, 2020.
 Methodology: All patients admitted to the department during the study period who had received a on for an antibiotic and had given informed consent were recruited exhaustively. A team of experts consisting of an infectious diseases physician and an ENT physician was responsible for analyzing and assessing the quality of antibiotic prescriptions.
 Results: Of the 455 consultations recorded over the period, 141 patients were included, 132 of them treated on an outpatient basis and nine hospitalized. The most frequently diagnosed conditions were acute otitis media (AOM) in 36 patients (25%), chronic otitis media (COM) in 24 patients (16.7%) and sinusitis in 14 patients (9.7%). The most commonly prescribed antibiotics were penicillins (84 patients or 59.6%), followed by macrolides (30 patients or 21.3%) and cephalosporins (21 patients or 14.9%). Antibiotic therapy was justified in 54.6% of cases, and dosage and duration were correct in 73.9% and 37.7% respectively.
 Conclusion: This study suggests that ENT doctors should be given more training in the basics and procedures for the proper use of antibiotics.

Antibiotic use in pediatric acute care hospitals: an analysis of antibiotic consumption data from Germany, 2013–2020

BackgroundAntimicrobial stewardship (AMS) programs are effective tools for improving antibiotic prescription quality. Their implementation requires the regular surveillance of antibiotic consumption at the patient and institutional level. Our study captured and analyzed antibiotic consumption density (ACD) for hospitalized pediatric patients.MethodWe collected antibacterial drug consumption data for 2020 from hospital pharmacies at 113 pediatric departments of acute care hospitals in Germany. ACD was calculated as defined daily dose (DDD, WHO/ATC Index 2019) per 100 patient days (pd). In addition, we analyzed the trends in antibiotic use during 2013–2020.ResultsIn 2020, median ACD across all participating hospitals was 26.7 DDD/100 pd, (range: 10.1–79.2 DDD/100 pd). It was higher at university vs. non-university hospitals (38.6 vs. 25.2 DDD/100 pd, p < 0.0001). The highest use densities were seen on oncology wards and intensive care units at university hospitals (67.3 vs. 38.4 DDD/100 pd). During 2013–2020, overall ACD declined (− 10%) and cephalosporin prescriptions also decreased (− 36%). In 2020, cephalosporins nevertheless remained the most commonly dispensed class of antibiotics. Interhospital variability in cephalosporin/penicillin ratio was substantial. Antibiotics belonging to WHO AWaRe “Watch” and “Reserve” categories, including broad-spectrum penicillins (+ 31%), linezolid (+ 121%), and glycopeptides (+ 43%), increased over time.ConclusionSignificant heterogeneity in ACD and prescription of different antibiotic classes as well as high prescription rates for cephalosporins and an increased use of reserve antibiotics indicate improvable antibiotic prescribing quality. AMS programs should urgently prioritize these issues to reduce antimicrobial resistance.

Improving antibiotic prescribing quality in out-of-hours primary care: a mixed-methods study using participatory action research

Abstract Background During out-of-hours (OOH) primary care, GPs overprescribe antibiotics for respiratory tract infections (RTIs). Many interventions have been shown to improve antibiotic prescribing quality, but their implementation in practice remains difficult. Participatory action research (PAR) aims to explore, implement and evaluate change in practice with an active involvement of local stakeholders, while generating knowledge through experience. Objectives To evaluate whether PAR improves antibiotic prescribing quality for RTIs during OOH primary care and simultaneously identify the pivotal lessons learned. Methods A mixed-methods study with a PAR approach in three OOH GP cooperatives (GPCs). Each GPC co-created a multifaceted intervention focusing on improving antibiotic use for RTIs through plan-do-study-act cycles. We quantified antibiotic prescribing quality indicators and formulated the lessons learned from a qualitative process analysis. Results Interventions were chosen with the GPs and adapted to be context-relevant. The willingness to work on quality and engagement of local stakeholders led to ownership of the project, but was time-consuming. In one GPC, antibiotic prescribing significantly decreased for tonsillitis, bronchitis, otitis media and acute upper RTI. In all three GPCs, use of guideline-recommended antibiotics for otitis media significantly increased. Conclusions Implementing multifaceted interventions through PAR can lower total and increase guideline-recommended antibiotic prescribing for RTIs in OOH primary care. Co-creating interventions with GPs to suit local needs is feasible, but reaching all GPs targeted is challenging.

Antibiotic point prevalence survey and antimicrobial resistance in hospitalized patients across Peruvian reference hospitals

BackgroundPeru reports higher levels than other countries in Latin America of resistance to antimicrobials among Gram-positive and Gram-negative bacteria, however data on antibiotic use in Peru are scarce. This study aims to estimate the prevalence and quality of antibiotic prescription in hospitalized patients and to determine the antibiotic susceptibility rates of bacteria causing key bacterial infections. MethodsWe carried out a point prevalence survey of antibiotic prescription at ten public hospitals in nine regions of Peru. Data was collected from patients hospitalized during a 3-week period, with details about antibiotic use, patient information, and antimicrobial susceptibility. Results1620 patient charts were reviewed; in 924 cases antibiotics were prescribed (57.0 %, range 45.9–78.9 %). Most of the antibiotics (74.2 %) were prescribed as empirical treatment, only 4.4 % as targeted treatment. For 9.5 % of cases the reason for antibiotic use was unknown. Cephalosporins were the most prescribed (30.0 %), followed by carbapenems (11.3 %). Ninety-four blood cultures were positive for bacterial growth, 48.8 % of the Staphylococcus aureus were methicillin-resistant, among Escherichia coli and Klebsiella pneumoniae, 51.7 % and 72.7 % were resistant to third-generation cephalosporins (3GC), 3.4 % and 18.2 % were resistant to carbapenems, respectively. Among bacteria isolated from urine cultures (n = 639), 43.9 % of E. coli and 49.2 % of K. pneumoniae were resistant to 3GC, and 0.9 % of E. coli and 3.2 % of K. pneumoniae were resistant to meropenem. ConclusionsThe overall proportion of hospitalized patients receiving antibiotics in hospitals from different regions in Peru was high, with only a small proportion receiving targeted treatment. Cephalosporins and carbapenems were the most frequently prescribed antibiotics, reflecting high resistance rates against 3GC and carbapenems in Enterobacterales isolated from blood and urine.

Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care

BackgroundAntibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration.MethodsA retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex.Result(s)A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics.Conclusion(s)This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.

Enhancing Medical Students' Confidence and Knowledge in Antibiotic Prescription and Administration through Virtual Education: A Quasi-Experimental Study.

Antibiotic resistance is a worldwide health concern that necessitates antibiotic stewardship. Medical students significantly impact future healthcare practices; thus, their trust in antibiotic prescription and administration is crucial. This research aims to assess medical students' levels of confidence and knowledge in these areas before and after exposure to virtual antibiotic stewardship education. A one-group pretest-posttest design was conducted with medical students from King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. Participants were enrolled in the WHO-online antibiotic stewardship course. The group's baseline confidence and background knowledge were reported to be lower than what was offered after introducing the virtual course. The McNemar-Bowker test showed a significant difference in students' confidence in pre-course and post-course scores (Z = 20, p < 0.002); the matched paired t-test revealed a significant difference in students' knowledge scores (M = 7.66 verses M = 5.36, Z = 3.54, p = 0.001). In the sample, 70% of the students were unfamiliar with antibiotic stewardship; thus, the analysis revealed a significant difference in their familiarity before and after enrolling in the online course (30 vs. 100, p < 0.001). Medical students experience low confidence in the safe practice of the antibiotic stewardship program. The WHO-online antibiotic stewardship course is considered a valuable resource that can be used in a formative medical curriculum. Thus, educators and the academic curriculum must promote practical strategies to minimize antibiotic stewardship literacy and increase antibiotic prescribing and administration quality. Introducing antibiotic stewardship across the medical curriculum and establishing educational courses are some strategies that can be undertaken to ensure that future doctors are well-educated in the principles and practices of the appropriate use of antibiotic stewardship.

The impact of the COVID-19 pandemic on the treatment of common infections in primary care and the change to antibiotic prescribing in England

BackgroundThere is concern that the COVID-19 pandemic altered the management of common infections in primary care. This study aimed to evaluate infection-coded consultation rates and antibiotic use during the pandemic and how any change may have affected clinical outcomes.MethodsWith the approval of NHS England, a retrospective cohort study using the OpenSAFELY platform analysed routinely collected electronic health data from GP practices in England between January 2019 and December 2021. Infection coded consultations and antibiotic prescriptions were used estimate multiple measures over calendar months, including age-sex adjusted prescribing rates, prescribing by infection and antibiotic type, infection consultation rates, coding quality and rate of same-day antibiotic prescribing for COVID-19 infections. Interrupted time series (ITS) estimated the effect of COVID-19 pandemic on infection-coded consultation rates. The impact of the pandemic on non- COVID-19 infection-related hospitalisations was also estimated.ResultsRecords from 24 million patients were included. The rate of infection-related consultations fell for all infections (mean reduction of 39% in 2020 compared to 2019 mean rate), except for UTI which remained stable. Modelling infection-related consultation rates highlighted this with an incidence rate ratio of 0.44 (95% CI 0.36–0.53) for incident consultations and 0.43 (95% CI 0.33–0.54) for prevalent consultations. Lower respiratory tract infections (LRTI) saw the largest reduction of 0.11 (95% CI 0.07–0.17). Antibiotic prescribing rates fell with a mean reduction of 118.4 items per 1000 patients in 2020, returning to pre-pandemic rates by summer 2021. Prescribing for LRTI decreased 20% and URTI increased 15.9%. Over 60% of antibiotics were issued without an associated same-day infection code, which increased during the pandemic. Infection-related hospitalisations reduced (by 62%), with the largest reduction observed for pneumonia infections (72.9%). Same-day antibiotic prescribing for COVID-19 infection increased from 1 to 10.5% between the second and third national lockdowns and rose again during 2022.ConclusionsChanges to consultations and hospital admissions may be driven by reduced transmission of non-COVID-19 infections due to reduced social mixing and lockdowns. Inconsistencies in coding practice emphasises the need for improvement to inform new antibiotic stewardship policies and prevent resistance to novel infections.

Comments by Microbiologists for Interpreting Antimicrobial Susceptibility Testing and Improving the Appropriateness of Antibiotic Therapy in Community-Acquired Urinary Tract Infections: A Randomized Double-Blind Digital Case-Vignette Controlled Superiority Trial.

In primary care, urinary tract infections (UTIs) account for the majority of antibiotic prescriptions. Comments from microbiologists on interpreting the antimicrobial susceptibility testing (AST) profile for urinalysis were made to improve the prescription of antibiotics. We aimed to explore the added value of these comments on the quality of antibiotic prescribing by a superior double-blind digital randomized case-vignette trial among French general practitioners (GPs). One case vignette with (intervention) or without (control) a 'comment' after AST was randomly assigned to GPs. Among 815 participating GPs, 64.7% were women, at an average age of 37 years. Most (90.1%) used a computerized decision support system for prescribing antibiotics. Empirical antibiotic therapy was appropriate in 71.9% (95% CI, 68.8-75.0) of the cases, without differences between arms. The overall appropriateness of targeted antibiotic therapy (primary outcome) was not significantly increased when providing 'comments': 83.4% vs. 79.9% (OR = 1.26, 95% CI, 0.86-1.85). With the multivariate analysis, the appropriateness was improved by 2-folds (OR = 2.38, 95% CI, 1.02-6.16) among physicians working in healthcare facilities. Among digital-affine young general practitioners, the adjunction of a 'comment' by a microbiologist to interpret urinalysis in community-acquired UTIs did not improve the overall level of appropriateness of the targeted antibiotic.

448 Prescribing of oral antibacterial drugs in primary care out-of-hours services: a scoping review

Abstract Introduction The rapid spread of antimicrobial resistance (AMR), which causes a serious threat to both human health and the global economy, is primarily linked to the overuse and misuse of antibacterial drugs. The AMR crisis is significantly impacted by the use of antibacterial drugs in primary care (1). Within these settings, oral antibacterial drugs are considered one of the most frequently prescribed group of medicines. It has been claimed that within primary care, the proportion of antibacterial drug prescribing is higher outside the regular working hours (out-of-hours (OOH) services) compared to in-hours (IH) services (2). Aim To identify the existing body of literature around oral antibacterial drug prescribing within primary care OOH services. Methods The scoping review was guided by the Joanna Briggs Institute manual and reported in accordance with the PRISMA-ScR. Seven electronic databases (Medline, Embase, Emcare, CINAHL, Scopus, Web of Science, and Cochrane Library) were systematically searched, and the results were screened against pre-defined eligibility criteria. Original and secondary analysis studies that addressed oral antibacterial prescribing in OOH primary care and were published in English were included. Titles and abstracts were independently screened by three reviewers. A pre-piloted extraction form was used to extract relevant data. A narrative synthesis approach was used to summarise the results. Results The initial search yielded 834 records. Upon screening, 28 publications fulfilled the eligibility criteria. Included studies originated from nine high-income countries, with the most frequent being the United Kingdom (six studies, 21.4%) followed by Belgium (five studies, 17.9%). Literature on antibacterial prescribing in OOH services was mostly from quantitative studies (23 studies, 82.14%), with only a few employing a qualitative design (five studies, 17.86%). Different themes and sub-themes were identified across these studies. The majority discussed antibacterial prescribing data in terms of the commonly prescribed medications and/or associated conditions. Eleven studies provided a comparison between IH and OOH settings. Seven studies reported the trends of prescribing over time; of these, three explored prescribing trends before and during COVID-19. The impact of ­intervention implementation on prescribing was investigated in two studies, an educational intervention in one study and the use of an interactive booklet in the other study. Four studies assessed the quality/appropriateness of prescribing either by adherence to guidelines or antibiotic prescribing quality indicators. Limited studies explored prescribing predictors and patients’ expectations and satisfaction with OOH services. In contrast, qualitative studies focussed more on exploring prescribers’ experiences, perspectives, behaviours, and the challenges they face during consultations within OOH settings which may influence their decision-making process. Of these, one study explored why patients consult OOH services and how they communicate their problems. Conclusion This review shows the key areas around oral antibacterial prescribing in primary care OOH services. While there is a satisfactory number of published articles covering various areas within OOH, the use of different approaches to OOH across countries may confound the comparison of practice. A strength of this work is using three reviewers to screen identified records independently. Further research is needed to provide a better understanding of current practice in these settings and how it may be contributing to AMR.