Ramadan is not associated with increased infection risk in Pakistani and Bangladeshi populations: Findings from controlled interrupted time series analysis of UK primary care data

Background The effect of fasting on immunity is unclear. Prolonged fasting is thought to increase the risk of infection due to dehydration. This study describes antibiotic prescribing patterns before, during, and after Ramadan in a primary care setting within the Pakistani and Bangladeshi populations in the UK, most of whom are Muslims, compared to those who do not observe Ramadan. Method Retrospective controlled interrupted time series analysis of electronic health record data from primary care practices. The study consists of two groups: Pakistanis/Bangladeshis and white populations. For each group, we constructed a series of aggregated, daily prescription data from 2007 to 2017 for the 30 days preceding, during, and after Ramadan, respectively. Findings Controlling for the rate in the white population, there was no evidence of increased antibiotic prescription in the Pakistani/Bangladeshi population during Ramadan, as compared to before Ramadan (IRR: 0.994; 95% CI: 0.988–1.001, p = 0.082) or after Ramadan (IRR: 1.006; 95% CI: 0.999–1.013, p = 0.082). Interpretation In this large, population-based study, we did not find any evidence to suggest that fasting was associated with an increased susceptibility to infection.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England

Background Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians’ decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients. Setting We test our prediction on general practitioners’ antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population. Methods We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs’ prescribing. Results We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure. Conclusions Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians’ work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45 Highlights Many physicians are working under increasing pressure. We test the importance of pressure on physicians’ prescribing of antibiotics. The prescribed rate of broad-spectrum antibiotics increases with pressure. Policy makers should be aware of the societal costs of pressured physicians. [Formula: see text]

Appropriateness of Antibiotic Prescribing in Patients Discharged From a Community Hospital Emergency Department

IMPORTANCE: Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. PURPOSE: The purpose of this study was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. ENDPOINTS: The primary objective was to determine the overall percent of appropriate antibiotic prescriptions for patients discharged from the ED. Secondary objectives included the following: identify reasons for inappropriateness categorized by antibiotic selection, dose, duration, and allergies; identify the most common antibiotics prescribed inappropriately as well as the most common disease states that led to inappropriate prescribing of antibiotics; and analyze prescribing trends based on provider type and time of day the prescription was written. STUDY DESIGN AND METHODS: Patients eligible for inclusion were adults age 18 and older who presented to the ED during four chosen weeks in 2019 and who were discharged with oral antibiotics. Extracted electronic health record data was reviewed to identify the discharge diagnosis for each patient that meets the inclusion criteria. Pertinent information gathered from the patients’ medical records along with a validated antimicrobial assessment tool were utilized to determine the level of appropriateness of the prescribed antibiotic regimens. RESULTS: A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. Overall, medical residents prescribed the highest percent of appropriate regimens, and the time of day that had the highest percent of appropriate prescriptions was third shift (11 p.m. to 7 a.m.). CONCLUSION AND RELEVANCE: Almost half of all the nonoptimal antibiotic regimens had an excessive duration. Targeted local education efforts and future clinical decision support can facilitate appropriate prescribing of discharge antibiotics from the ED, ultimately improving antimicrobial stewardship within the community.

Molecular surveillance reveals widespread colonisation by carbapenemase and extended spectrum beta-lactamase producing organisms in neonatal units in Kenya and Nigeria

Objectives Neonatal sepsis, a major cause of death amongst infants in sub-Saharan Africa, is often gut derived. Impairments in immunity and the gut barrier in sick neonates allow colonisation by opportunistic pathogens such as Enterobacteriaceae to progress to blood stream infection. Colonisation by Enterobacteriaceae producing extended spectrum beta-lactamase (ESBL) or carbapenemase enzymes is particularly problematic and can lead to antimicrobial-resistant (AMR) or untreatable infections. We sought to explore the rates of colonisation by ESBL or carbapenemase producers and their genotypes in two neonatal units (NNUs) in West and East Africa. Methods Stool and rectal swab samples were taken at multiple timepoints from newborns admitted to the NNUs at the University College Hospital, Ibadan, Nigeria and the Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, western Kenya. Samples were tested for ESBL and carbapenemase genes using a previously validated qPCR assay with high resolution melt analysis. Kaplan-Meier survival analysis was used to examine colonisation rates at both sites. Results A total of 119 stool and rectal swab samples were taken from 42 infants admitted to the two NNUs. Six (14.3%) infants were extremely preterm (gestation <28 weeks), 19 (45.2%) were born by Caesarean section and 3 (8.6%) mothers were HIV positive. Median (IQR) duration of admission was 12.5 (5-26) days and 12 (28.6%) infants died. Overall, colonisation with ESBL (37 infants, 89%) was more common than with carbapenemase producers (26, 62.4%; P = 0.093). Median survival time before colonisation with ESBL organisms was 7 days and with carbapenemase producers 16 days (P=0.035). The majority of ESBL genes detected belonged to the CTX-M-1 (36/38; 95%), and CTX-M-9 (2/36; 5%) groups. The most prevalent carbapenemase was blaNDM (27/29, 93%). Single blaVIM (1/32, 3%) and blaOXA-48 genes (1/32, 3%) were also detected. Conclusions Gut colonisation of neonates by AMR organisms was common and occurred rapidly in NNUs in Kenya and Nigeria. Active surveillance of colonisation will improve the understanding of AMR in these settings and guide infection control and antibiotic prescribing practice to improve clinical outcomes.

Using machine learning to examine drivers of inappropriate outpatient antibiotic prescribing in acute respiratory illnesses

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

COVID-19 and Antibiotic Prescribing in Pediatric Primary Care

BACKGROUND AND OBJECTIVES: With the onset of the coronavirus disease 2019 (COVID-19) pandemic, pediatric ambulatory encounter volume and antibiotic prescribing both decreased; however, the durability of these reductions in pediatric primary care in the United States has not been assessed. METHODS: We conducted a retrospective observational study to assess the impact of the COVID-19 pandemic and associated public health measures on antibiotic prescribing in 27 pediatric primary care practices. Encounters from January 1, 2018, through June 30, 2021, were included. The primary outcome was monthly antibiotic prescriptions per 1000 patients. Interrupted time series analysis was performed. RESULTS: There were 69 327 total antibiotic prescriptions from April through December in 2019 and 18 935 antibiotic prescriptions during the same months in 2020, a 72.7% reduction. The reduction in prescriptions at visits for respiratory tract infection (RTI) accounted for 87.3% of this decrease. Using interrupted time series analysis, overall antibiotic prescriptions decreased from 31.6 to 6.4 prescriptions per 1000 patients in April 2020 (difference of −25.2 prescriptions per 1000 patients; 95% CI: −32.9 to −17.5). This was followed by a nonsignificant monthly increase in antibiotic prescriptions, with prescribing beginning to rebound from April to June 2021. Encounter volume also immediately decreased, and while overall encounter volume quickly started to recover, RTI encounter volume returned more slowly. CONCLUSIONS: Reductions in antibiotic prescribing in pediatric primary care during the COVID-19 pandemic were sustained, only beginning to rise in 2021, primarily driven by reductions in RTI encounters. Reductions in viral RTI transmission likely played a substantial role in reduced RTI visits and antibiotic prescriptions.

The Overlooked Issue of Outpatient Combination Antibiotic Prescribing in Low- and Middle-Income Countries: An Example from Syria

This study aimed to determine and describe the prevalence of combination antibiotics dispensed in outpatients with health insurance in Syria. Data on all dispensed medicines between June 2018 and May 2019 for 81,314 adults were obtained, and medicines belonging to the J01 group of the World Health Organization (WHO) anatomical therapeutic classification (ATC) were included in the analysis. Prescriptions were stratified according to the number of antibiotics, age, and sex. Antibiotic utilization was expressed as the number of prescriptions per 1000 persons per year. Out of 59,404 prescriptions for antibiotics, 14.98% contained antibiotic combinations, distributed to 22.49% of the patients. The prevalence of dispensing antibiotic combinations was higher in female patients (23.00%), and the youngest (18–30 years, 26.19%) and oldest age groups (>70 years, 25.19%). The antibiotics most commonly combined were co-amoxiclav, second- and third-generation cephalosporins, and macrolides. Over 60% of the combinations contained ceftriaxone alone or in combination with sulbactam. The present study shows an alarmingly widespread prescription of antibiotic combinations, posing a risk to global health by promoting resistance development.

Changing antibiotic prescribing practices in outpatient primary care settings in China: Study protocol for a health information system-based cluster-randomised crossover controlled trial

Background The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours. Methods We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods. Discussion This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area. Trial registration ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

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

Background The 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. Methods Pharmacy 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. Results The 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. Conclusions Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.