Unnecessary Antibiotic Prescribing Research Articles

Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care

BackgroundThe desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians’ diagnostic uncertainty combined with parents’ concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care.MethodsPharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R.ResultsThe past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials.ConclusionsPaediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.

Utilization of quality tools to prevent unnecessary prescriptions of Antibiotics in hospitals

Utilization of quality tools to prevent unnecessary prescriptions of Antibiotics in hospitals

The prevalence of empiric antibiotic use in an emergency department on children with suspected urinary tract infections: A retrospective study in Saudi Arabia

Objectives: The prescription of antibiotics for suspected urinary tract infection (UTI) is common practice and may result in unnecessary antibiotic exposure. Our goal was to review the diagnosis and management of UTI in an emergency department and to determine the goals of antimicrobial stewardship. Methods: This is a single-centre, retrospective study that was conducted among children aged between 12 months and 18 years old who had been discharged from the emergency department with a diagnosis of UTI in the period between January and August 2022. Clinical information, laboratory findings, urine collection methods and urine culture results as well as details of prescribed antibiotics were gathered. The relation between urinalysis characteristics and confirmed UTI was assessed as a secondary outcome of the study. Results: In this study, we were able to collect data for 183 children with a mean age of 4.2 (1.1-7.5) years and 82.5% of them were girls. Almost all children with UTI were discharged to home with prescribed antibiotics (98%) for a median duration of seven days ranging between 7-10 days. Among those who used antibiotics, 46.4% of the patients had negative urine cultures, resulting in 525 unnecessary antibiotic prescriptions. Presence of nitrite in the urine was the strongest and highly specific predictor of UTI (odds ratio of 20.22, P< 0.001). Conclusions: Current practice in the management of suspected pediatric urinary tract infections in the selected emergency department resulted in significant and unnecessary exposure to antibiotics. We set goals to reduce unnecessary antibiotic exposure, including improving the accuracy of UTI diagnosis, establishing a process to discontinue antibiotic consumption for negative cultures, and standardizing the duration of antimicrobials. Keywords: urinary tract infections, pediatrics, children, antimicrobial monitoring, urinalysis, antibiotics, empiric use, E. coli, nitrite, urine culture.

Antibiotic prescribing across age groups in the Kaiser Permanente Northern California population in association with different diagnoses, and with influenza incidence, 2010-2018.

There is limited information on the volume of antibiotic prescribing that is influenza-associated, resulting from influenza infections and their complications (such as streptococcal pharyngitis and otitis media). Here, we estimated age/diagnosis-specific proportions of antibiotic prescriptions (fills) for the Kaiser Permanente Northern California population during 2010-2018 that were influenza-associated. The proportion of influenza-associated antibiotic prescribing among all antibiotic prescribing was higher in children aged 5-17 years compared to children aged under 5 years, ranging from 1.4% [95% CI (0.7-2.1)] in aged <1 year to 2.7% (1.9-3.4) in aged 15-17 years. For adults aged over 20 years, the proportion of influenza-associated antibiotic prescribing among all antibiotic prescribing was lower, ranging from 0.7% (0.5-1) for aged 25-29 years to 1.6% (1.2-1.9) for aged 60-64 years. Most of the influenza-associated antibiotic prescribing in children aged under 10 years was for ear infections, while for age groups over 25 years, 45-84% of influenza-associated antibiotic prescribing was for respiratory diagnoses without a bacterial indication. This suggests a modest benefit of increasing influenza vaccination coverage for reducing antibiotic prescribing, as well as the potential benefit of other measures to reduce unnecessary antibiotic prescribing for respiratory diagnoses with no bacterial indication in persons aged over 25 years, both of which may further contribute to the mitigation of antimicrobial resistance.

Predictors of Empiric Antibiotic Use in the Emergency Department in Children Without Urinary Tract Infections.

Urinary tract infections (UTIs) are a common diagnosis within the pediatric emergency department (ED). Because of the necessary delay in obtaining urine culture results, clinicians must decide whether to prescribe antibiotics for a suspected UTI before urine culture results. The primary objective of this study was to identify the proportion of children given empiric antibiotics who subsequently did not meet consensus definition of an UTI. The secondary objective was to identify factors associated with return visits to the ED after an index visit for UTI. We also attempted to identify predictors of prescription of empiric antibiotics for children who did not have a UTI. This was a retrospective chart review of all patients between the ages of 2 months and 18 years diagnosed with a UTI between July 2016 and June 2017 in the ED of a single urban quaternary care center. Patients were excluded for the following reasons: use of bag for urine collection, subsequent admission to the hospital, receipt of antibiotics within the previous 3 days, use of antibiotics for an indication other than a UTI, and urine culture obtained at an outside facility. Of 404 included patients, 389 (96.2%) were discharged on antibiotics and 243 (62.4%) did not have a UTI. On the multivariate analysis, age ≧ 36 months was associated with increased odds of receiving antibiotics and not having a UTI while both ≥1+ leukocyte esterase and ≥1+ nitrites on urinalysis were associated with decreased odds of receiving antibiotics and not meeting UTI criteria. Sixty-two patients revisited the ED within 30 days of the initial visit, 24 (38.7%) of which met criteria for UTI during the index visit. Prescription of antibiotics at the time of the index visit was associated with decreased odds of reutilization, whereas an extended-spectrum β-lactamase producing organism cultured from urine at the index visit was associated with increased odds of reutilization. A high number of patients discharged on empiric antibiotics did not meet criteria for a UTI. We did not identify clinically useful factors that predicted prescription of empiric antibiotics for children who do not have a UTI. We believe that unnecessary antibiotic prescriptions could be substantially decreased by decreasing empiric use of antibiotics coupled with reliable follow-up for positive urine cultures.

1006. Association of Development of Pneumonia and Virulence Gene Expression in Acinetobacter baumannii Isolated from Clinical Specimens

BackgroundNot all Acinetobacter baumannii isolated from respiratory specimens are true pathogens. Distinguishing between true pathogens and colonizers is important to initiate early treatment and to reduce the unnecessary prescription of antibiotics. To determine the microbiological factors contributing to the development of A. baumannii pneumonia, we investigated the association between the expression level of known A. baumannii virulence genes such as ompA and hisF and pneumonia. MethodsPatients in whose respiratory specimens A. baumannii was identified between January 2018 and January 2019 in a tertiary university hospital were recruited into this study. Relevant radiologic findings and more than 5 days of susceptible antibiotic prescription started within 3 days of bacterial isolation were considered as having pneumonia. The absence of radiologic findings of pneumonia until 7 days after the isolation of A. baumannii was defined as colonization. The expression of ompA and hisF was determined with quantitative reverse-transcription polymerase chain reaction. Host factors known to be associated with pneumonia and expression levels of virulent genes were compared between the groups. ResultsOverall, 246 patients in whose respiratory specimens A. baumannii was identified were recruited into this study. Among them, 17 and 24 patients were assigned to the pneumonia and colonizer groups, respectively. In the univariable analysis, ompA, ICU stay, and mechanical ventilation were significantly associated with pneumonia (p = 0.03, < 0.01, < 0.01 respectively). In the multivariable analysis, mechanical ventilation was significantly associated with pneumonia (OR = 9.75, p = 0.03). ompA expression was not significantly associated with pneumonia in the multivariable analysis (OR = 1.12, p = 0.75) (Table 1). ompA and hisF were significantly associated with the 30-day in-hospital mortality (p = 0.02, < 0.01).Table 1. Univariable and multivariable analysis of factors related to pneumonia ConclusionThe association between increased ompA expression in A. baumannii and the development of pneumonia was not statistically significant after adjusting for patient factors. However, the relatively high expression of ompA in pneumonia patients and their association with increased mortality suggests the need for larger-scale prospective studies to draw a conclusion.Disclosures All Authors: No reported disclosures

Insertion of a Clinical Pathway Pop-Up Window into a Computer-Based Prescription System: A Method to Promote Antibiotic Stewardship in Upper Respiratory Tract Infection.

Outpatient antibiotics are most frequently prescribed for upper respiratory tract infection (URI); however, most such prescriptions are inappropriate. We aimed to determine the effect of an electronic clinical pathway on the rates of overall and rational prescription of antibiotics in patients with URI. A pilot quasi-experimental study was conducted in a university hospital and two of its nearby primary care units (PCU) in northeast Thailand from June to September 2020. Clinical pathway pop-up windows were inserted into the hospital’s computer-based prescription system. Care providers were required to check the appropriate boxes before they were able to prescribe amoxicillin or co-amoxiclav. We examined a total of 675 visits to the outpatient department due to URI at three points in time: pre-intervention, immediately post-intervention, and 6 weeks post-intervention. Patients in the latter group tended to be younger and visits were more likely to be general practitioner-related and to the student PCU than in the other two groups. In addition, the rate of antibiotic prescription was significantly lower at 6 weeks after intervention than at either of the other time periods (32.0% vs 53.8% pre-intervention and 46.2% immediately post-intervention; p < 0.001), and the proportion of rational antibiotic prescriptions increased significantly after implementation. Antibiotic prescription rates were lower at the community primary care unit and higher when the physician was a resident or a family doctor. The deployment of an electronic clinical pathway reduced the rate of unnecessary antibiotic prescriptions. The effect was greater at 6 weeks post-implementation. However, discrepancy of patients’ baseline characteristics may have skewed the findings.

Evaluation of parental knowledge, attitudes and practices regarding antibiotic use in acute upper respiratory tract infections in children under 18\u2009years of age: a cross-sectional study in Turkey

BackgroundUpper respiratory tract infections (URTIs) are common in children. Antibiotics still continue to be prescribed although most URTIs are of viral origin. This is inappropriate use and this unnecessary administration contributes or may cause antibiotic resistance. The problem of unnecessary antibiotic use among children is a concern for antibiotic resistance in low- and middle-income developing countries. This study aims to evaluate the knowledge and attitudes of parents of children with upper respiratory tract infections regarding antibiotic use and their antibiotic administration practices in a tertiary care hospital in Turkey.MethodsOur study is a cross-sectional survey study. It was carried out between 14 December 2020 and 1 April 2021 for parents over 18 years of age with a child under 18 years’ old who applied to the general pediatrics outpatient clinics of Gazi University Faculty of Medicine Hospital Department of Pediatrics.ResultsFive hundred fifty-four parents responded to the questionnaire (93.2% rate of response). A total of 15.7% of parents stated to use antibiotics in any child with fever. 37% of parents believed that antibiotics could cure infections caused by viruses. 6.3% of parents declared that they put pressure on pediatricians to prescribe antibiotics. While 28% of the parents who thought that the use of inappropriate antibiotics would not change the effect and resistance of the treatment, 41% thought that new antibiotics could be developed continuously. 85.6% of the parents stated that they never gave their children non-prescription antibiotics when they had a high fever. 80.9% of them declared that they never used past antibiotics in the presence of a new infection.ConclusionAccording to the results of our study of parents’ lack of knowledge about antibiotics in Turkey, though generally it shows proper attitude and practices. It shows that some of the restrictions imposed by the National Action Plan are partially working. However, it is still necessary to continue to inform parents, pediatricians and pharmacists about the use of antibiotics, and to be more sensitive about the prescribing of antibiotics, and if necessary, sanctions should be imposed by the state in order to prevent unnecessary antibiotic prescriptions.

Effect of Antimicrobial Stewardship on Oral Quinolone Use and Resistance Patterns over 8 Years (2013–2020)

Since 2014, several global and national guidelines have been introduced to address the problem of antimicrobial resistance. We conducted a campaign in a tertiary hospital to promote appropriate quinolone use through educational lectures in 2018. The aim of this retrospective study was to evaluate the changes in the following: prescription characteristics, trend of oral quinolone use, and antibiotic susceptibility of bacteria from 2013 to 2020. Antimicrobial use was assessed as days of therapy per 1000 patient-days. We found a significant reduction in unnecessary antibiotic prescriptions between December 2013 and December 2020. Significant negative trends were detected in the use of quinolones over 8 years (outpatients, coefficient = −0.15655, p < 0.001; inpatients, coefficient = −0.004825, p = 0.0016). In particular, the monthly mean use of quinolones among outpatients significantly decreased by 11% from 2013 to 2014 (p < 0.05) and reduced further by 31% from 2017 to 2020 (p < 0.001). A significant positive trend was observed in the susceptibility of Pseudomonas aeruginosa to levofloxacin (p < 0.001). These results demonstrate that the use of oral quinolones was further reduced following educational intervention and the bacterial susceptibility improved with optimal quinolone usage compared to that in 2013.

Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review.

Antimicrobial resistance occurs due to the propensity of microbial pathogens to develop resistance to antibiotics over time. Antimicrobial stewardship programs (ASPs) have been developed in response to this growing crisis, to limit unnecessary antibiotic prescription through initiatives such as education-based seminars, prescribing guidelines, and rapid respiratory pathogen (RRP) testing. Paediatric patients who present to the emergency setting with respiratory symptoms are a particularly high-risk population susceptible to inappropriate antibiotic prescribing behaviours and are therefore an ideal cohort for focused ASPs. The purpose of this systematic review was to assess the efficacy and safety of ASPs in this clinical context. A systematic search of PubMed, Medline, EMBASE and the Cochrane Database of Systematic Reviews was conducted to review the current evidence. Thirteen studies were included in the review and these studies assessed a range of stewardship interventions and outcome measures. Overall, ASPs reduced the rates of antibiotic prescription, increased the prescription of narrow-spectrum antibiotics, and shortened the duration of antibiotic therapy. Multimodal interventions that were education-based and those that used RRP testing were found to be the most effective. Whilst we found strong evidence that ASPs are effective in reducing antibiotic prescribing, further studies are required to assess whether they translate to equivalent clinical outcomes.

CE: Pediatric Antibiotic Stewardship.

With the rise of antibiotic resistance, antimicrobial stewardship programs can now be found in the ambulatory setting, where nearly 95% of antibiotic prescriptions originate. Judicious use of antibiotics is of particular importance to the ambulatory pediatric provider, as the annual antibiotic prescription rate is highest among children ages two and younger and inappropriate early-life antibiotic use is associated with elevated childhood risk of several medical conditions. While most ambulatory antibiotic stewardship programs have focused on shaping clinician behaviors to prevent unnecessary antibiotic prescribing, duration of antibiotic therapy has been found to be a critical, yet underexamined, facet of antibiotic use. In the past, duration of antibiotic therapy was largely based on convention and expert opinion, with little scientific evidence supporting many of the recommendations. Research suggests that many common pediatric infections such as acute otitis media, community-acquired pneumonia, streptococcal pharyngitis, and urinary tract infections can be effectively and safely treated with reduced courses of antibiotic therapy. In addition to reducing the incidence of antibiotic resistance, a shorter duration of antibiotic therapy may help prevent many adverse effects associated with antibiotic treatment. Current studies on the duration of antibiotic therapy, especially in pediatrics, are limited as they often rely on data extrapolated from adult studies that fail to consider the effects of age-related growth and development on both pharmacokinetics and pharmacodynamics. Future investigation into this topic is also limited by researchers' reliance on subsidies from pharmaceutical companies; clinicians' fear of undertreating infection; and hesitancy to deviate from current standards of care, even when such standards are not evidence based. Despite these challenges, the dangers of inappropriate antibiotic use in the pediatric population warrant further evaluation.

Unnecessary antibiotic treatment of children hospitalised with respiratory syncytial virus (RSV) bronchiolitis: risk factors and prescription patterns

Respiratory syncytial virus (RSV) is a leading cause of respiratory tract infections, especially in young children. Antibiotics are often unnecessarily prescribed for the treatment of RSV. Such treatments affect antibiotic resistance in future bacterial infections of treated patients and the general population. This study aimed to understand risk factors for and patterns of unnecessary antibiotic prescription in children with RSV. In a single-centre, retrospective study in Israel, we obtained data for children aged ≤2 years (n=1016) hospitalised for RSV bronchiolitis during 2008-2018 and ascertained not to have bacterial co-infections. Antibiotic misuse was defined as prescription of antibiotics during hospitalisation of the study population. Demographic and clinical variables were assessed as predictors of unnecessary antibiotic treatment in a multivariable logistic regression model. The unnecessary antibiotic treatment rate of children infected with RSV and ascertained not to have a bacterial co-infection was estimated at 33.4% (95% CI 30.5-36.4%). An increased likelihood of antibiotic misuse was associated with drawing bacterial cultures and with variables indicative of a severe patient status such as lower oxygen saturation, higher body temperature, tachypnoea and prior recent emergency room visit. Older age and female sex were also associated with an increased likelihood of unnecessary antibiotic treatment. Unnecessary antibiotic treatment in RSV patients was very common and may be largely attributed to physicians' perception of patients' severity. Improving prescription guidelines, implementing antibiotic stewardship programmes and utilising decision support systems may help achieve a better balance between prescribing and withholding antibiotic treatment.

Frequency of respiratory pathogens other than SARS-CoV-2 detected during COVID-19 testing

The frequencies of 19 respiratory pathogens other than SARS-CoV-2 were assessed in 6,"?>235 Brazilian individuals tested for COVID-19. Overall, only 83 individuals who tested positive for SARS-CoV-2 had codetection of other pathogens. Individuals infected with Rhinovirus/Enterovirus, Human Coronavirus (HCoV)-HKU1, HCoV-NL63, HPIV-4, Influenza A (-H1N1 and other subtypes), Influenza B, Human Respiratory Syncytial Virus and Human Metapneumovirus were less likely to test positive for SARS-CoV-2. Infection with Streptococcys pyogenes, Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Bordetella pertussis were more frequent in individuals who tested negative for SARS-CoV-2, but without significancy. We found 150 individuals infected with ≥2 pathogens other than SARS-CoV-2, only 3 out of whom tested positive for COVID-19. The codetection frequency was low in individuals diagnosed with COVID-19. Other viral infections may provide a cross-reactive, protective immune response against SARS-CoV-2. Screening for bacterial respiratory infections upon COVID-19 testing is important to drive suitable therapeutic approaches and avoid unnecessary antibiotic prescription.

Treatment of Pharyngitis in Uninsured Patients: A Multicenter Study of Free Clinics.

IntroductionAppropriate antibiotic prescription practices for pharyngitis slow anti-microbial resistance. Unnecessary antibiotic prescribing and non-adherence to practice guidelines remain a clinical problem. The objective of this study was to examine the relationship between group A Streptococcus (GAS) throat culture testing and antibiotic prescriptions at 10 free clinics in the Tampa Bay Area serving the uninsured population.MethodsA retrospective cohort study was conducted using data from patient charts from January 2018 to December 2019. We obtained data regarding a chief complaint related to strep pharyngitis: sore throat, enlarged tonsils, pharyngeal erythema, and/or cervical lymphadenopathy. The frequency and relative proportions of throat swab administration and antibiotic prescription were also analyzed.ResultsOf the 12,005 patients serviced during the study period, 245 (2.0%) reported one or more of the chief complaints related to strep pharyngitis. Of the patients reporting pharyngitis, the mean age was 40.2 years, with 66% being female. Of the patients receiving antibiotics for pharyngitis symptoms, 93 (91.2%) did not receive a throat swab. Patients receiving a throat swab showed a significantly increased odds of antibiotic prescription (OR=3.4, 95% CI: 1.1-12.7). Patients reporting symptoms of pharyngitis commonly had other comorbidities, including smoking (14.7%) and diabetes (13.5%).ConclusionThe large proportion of patients receiving antibiotics for pharyngitis symptoms reveals the need for provider counseling on current recommendations of antibiotic prescription practices, which state that a throat swab with a rapid antigen detection test and/or culture should be performed for all patients where bacterial symptoms of rhinorrhea, cough, and/or oral ulcers are present. Another potential area of improvement indicated by this study may be providing additional supplies of throat swabs for these underserved clinics. Further research is needed to understand the root causes of providers' non-compliant prescribing patterns in the free clinics and to assess the role of the uninsured population in reducing anti-microbial resistance.

238 Antibiotic and Opioid Antitussive Prescribing Among Urgent Care and Emergency Department Visits for Respiratory Diagnoses

Urgent care (UC) centers frequently evaluate upper and lower respiratory complaints (eg, sore throat, cough), and patients increasingly prefer UCs to emergency departments (ED) due to their customer-centric approach. Recent studies have identified UCs as a source of unnecessary antibiotic prescribing for respiratory infections. Opioids may also be prescribed for relief of cough symptoms despite limited evidence of efficacy. No study has yet evaluated whether opioids are prescribed within UCs in a similar manner to antibiotics, and no guidelines have yet addressed opioid prescribing as an antitussive.

Accuracy of procalcitonin for diagnosing peripheral blood culture contamination among patients with positive blood culture for potential contaminants.

Blood culture contamination is still a frequently observed event and may lead to unnecessary antibiotic prescriptions and additional hazards and costs. However, in patients hospitalized in tertiary care, true bacteremias for pathogens that are classically considered as contaminants can be observed. We assessed the diagnostic accuracy of procalcitonin for differentiating blood culture contamination from bacteremia in patients with positive blood cultures for potential contaminants. We carried out a retrospective, cross-sectional, observational study on consecutive patients hospitalized between January 2016 and May 2019 at the University Hospital of Nancy and who had a positive peripheral blood culture for a pathogen classically considered as a potential contaminant. During the study period, 156 patients were screened, and 154 were retained in the analysis. Among the variables that were significantly associated with a diagnosis of blood culture contamination in univariate analyses, four were maintained in multivariate logistic regression analysis: a number of positive blood culture bottles ≤ 2 (OR 23.76; 95% CI 1.94-291.12; P = 0.01), procalcitonin < 0.1ng/mL (OR 14.88; 95% CI 1.62-136.47; P = 0.02), non-infection-related admission (OR 13.00; 95% CI 2.17-77.73; P = 0.005), and a percentage of positive blood culture bottles ≤ 25% (OR 12.15; 95% CI 2.02-73.15; P = 0.006). These data provide new evidence on the usefulness of plasma procalcitonin as a reliable diagnostic biomarker in the diagnostic algorithm of peripheral blood culture contamination among patients hospitalized in tertiary care. ClinicalTrials.gov #NCT04573894.

A Survey on Knowledge Attitude and Practices among Dental Faculty towards Antimicrobial Stewardship Program in Maharashtra

Background: Antibiotic resistance makes to the top ten threats to global health in 2019. It is important for dental faculty to make efforts to improve the quality of services provided; As a result the study of awareness of the dental faculty regarding antibiotic resistance and antibiotic stewardship program was undertaken.&#x0D; Objectives: Assessment of the knowledge, attitude and practices of the dental faculty towards Antibiotic stewardship program through a questionnaire study in Maharashtra.&#x0D; Methodology: The dental faculty in dental institutes located in Maharashtra will be the study participants. The questionnaire will be sent to all the faculty members as an online questionnaire survey.&#x0D; Expected Results: Evaluating the need of Implementation of antimicrobial stewardship program in institutions which will reduce the profuse use of unnecessary antibiotic prescription and improve the appropriateness of the antibiotic use by the dental health faculty working in a dental college without compromising the clinical patient outcome.&#x0D; Conclusion: The present study will assess the knowledge, attitude and practices of the dental faculty towards Antibiotic stewardship program.

Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan.

Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians’ preferred sources of information and evaluate physicians’ awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers’ views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.

Management of urinary tract infections and antibiotic susceptibility patterns of bacterial isolates.

Urinary tract infections (UTIs) are among the most common infections affecting individuals of different ages worldwide. Antimicrobial agents are usually the first-line treatment for UTIs, and the use of the prescribed antibiotic is escalating, resulting in increased rates of bacterial resistance and UTI recurrence. The current study aimed to identify the causative bacteria in Jordan, to explore their resistance pattern to antibiotics and to describe drug-related problems (DRPs) associated with UTI management. This prospective, descriptive study was conducted in two major health institutions in two cities in Jordan over a period of six months. The study population included inpatients and outpatients diagnosed with UTIs. Patients' data were collected directly from patients using data collection sheet and from patients' charts. A total of 273 patients were included, of whom 56.4% were women. Urine cultures were obtained from 81% of the patients. Escherichia coli was the most common causative pathogen (50.6%), followed by Klebsiella pneumonia (10.8%). Extended spectrum beta-lactamase (ESBL) producing E. coli was the most commonly detected organism across all types of UTIs. Ceftriaxone and imipenem/cilastatin were most commonly administered to hospitalised patients, whilst ciprofloxacin and co-triamzaxole were the most commonly prescribed in outpatient clinics. The susceptibility results for parenteral antibiotics showed high rates of resistance to cefazolin and ticarcillin. Additionally, high rates of resistance to fluoroquinolones were identified. Further, several DRPs were identified. High rates of resistance to commonly prescribed antibiotics were detected. DRPs (ie, inappropriate antibiotic dosage, unnecessary antibiotic prescribing, inappropriate duration of therapy and prescribing of ineffective antibiotics) were relatively common. The present study highlights the need for clinical pharmacists to manage the high level of drug related problems by providing updated information about proper drug selection, rational drug use and patient education and counselling.

Effect of Antibiotic-Prescribing Feedback to High-Volume Primary Care Physicians on Number of Antibiotic Prescriptions

Antibiotic overuse contributes to adverse drug effects, increased costs, and antimicrobial resistance. To evaluate peer-comparison audit and feedback to high-prescribing primary care physicians (PCPs) and assess the effect of targeted messaging on avoiding unnecessary antibiotic prescriptions and avoiding long-duration prescribing. In this 3-arm randomized clinical trial, administrative data collected from IQVIA's Xponent database were used to recruit the highest quartile of antibiotic-prescribing PCPs (n = 3500) in Ontario, Canada. Physicians were randomized 3:3:1 to receive a mailed letter sent in December 2018 addressing antibiotic treatment initiation (n = 1500), a letter addressing prescribing duration (n = 1500), or no letter (control; n = 500). Outliers at the 99th percentile at baseline for each arm were excluded from analysis. The primary outcome was total number of antibiotic prescriptions over 12 months postintervention. Secondary outcomes were number of prolonged-duration prescriptions (>7 days) and antibiotic drug costs (in Canadian dollars). Robust Poisson regression controlling for baseline prescriptions was used for analysis. Of the 3465 PCPs included in analysis, 2405 (69.4%) were male, and 2116 (61.1%) were 25 or more years from their medical graduation. At baseline, PCPs receiving the antibiotic initiation letter and duration letter prescribed an average of 988 and 1000 antibiotic prescriptions, respectively; at 12 months postintervention, these PCPs prescribed an average of 849 and 851 antibiotic prescriptions, respectively. For the primary outcome of total antibiotic prescriptions 12 months postintervention, there was no statistically significant difference in total antibiotic use between PCPs who received the initiation letter compared with controls (relative risk [RR], 0.96; 97.5% CI, 0.92-1.01; P = .06) and a small statistically significant difference for the duration letter compared with controls (RR, 0.95; 97.5% CI, 0.91-1.00; P = .01). For PCPs receiving the duration letter, this corresponds to an average of 42 fewer antibiotic prescriptions over 12 months. There was no statistically significant difference between the letter arms. For the initiation letter, compared with controls there was an RR of 0.98 (97.5% CI, 0.93-1.03; P = .42) and 0.97 (97.5% CI, 0.92-1.02; P = .19) for the outcomes of prolonged-duration prescriptions and antibiotic drug costs, respectively. At baseline, PCPs who received the duration letter prescribed an average of 332 prolonged-duration prescriptions with $14 470 in drug costs. There was an 8.1% relative reduction (RR, 0.92; 97.5% CI, 0.87-0.97; P < .001) in prolonged-duration prescriptions, and a 6.1% relative reduction in antibiotic drug costs (RR, 0.94; 97.5% CI, 0.89-0.99; P = .01). This corresponds to an average of 24 fewer prolonged-duration prescriptions and $771 in drug cost savings per PCP over 12 months. In this randomized clinical trial, a single mailed letter to the highest-prescribing PCPs in Ontario, Canada providing peer-comparison feedback, including messaging on limiting antibiotic-prescribing durations, led to statistically significant reductions in total and prolonged-duration antibiotic prescriptions, as well as drug costs. ClinicalTrials.gov Identifier: NCT03776383.