Determinants of Clinician and Patient to Prescription of Antimicrobials: Case of Mulanje, Southern Malawi

Background: Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. Methods: In-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. Results: Participants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance.Conclusion: Inappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

Antimicrobial Prescription Practices for Outpatients with Cystitis: A Multicenter, Medical Record-Based Study

To promote antimicrobial stewardship (AMS) and appropriate antibiotic use, we studied antimicrobial prescription rates for uncomplicated cystitis, a common outpatient disease requiring antibiotic treatment in Japan. This multicenter retrospective study was performed from January 1, 2018, to December 31, 2020, targeting outpatients aged ≥20 years whose medical records revealed International Classification of Diseases (ICD-10) codes suggesting uncomplicated cystitis (N300). We divided eligible cases into two age groups (20–49 years and ≥50 years) and defined broad-spectrum antimicrobials as fluoroquinolones, third-generation cephalosporins, and faropenem. Primary and secondary outcomes were defined as the prescription rates of broad-spectrum antimicrobials for the disease and the association of antimicrobial types with recurrence. The data of 1,445 patients were collected and that of 902 patients were analyzed. The overall proportion of broad-spectrum antimicrobial prescriptions was 69.1%. The broad-spectrum agents were prescribed frequently in the older group, male patients, and internal medicine. Recurrence was observed in 37 (4.1%) cases, and age, sex, or antimicrobial types were not associated with the recurrence. Hence, approximately two-thirds of antimicrobials prescribed for uncomplicated cystitis were broad-spectrum agents. Administration of broad-spectrum antimicrobials was not associated with the prevention of the recurrence of cystitis.

Pattern and Appropriateness of Antimicrobial Prescriptions for Upper Respiratory Tract and Dental Infections in Male Prisoners in Italy

Background: This study explored the antimicrobial prescribing pattern for upper respiratory tract and dental infections in prisoners in Italy, with specific attention paid to the appropriateness of indication and its potential determinants. Methods: This investigation was conducted through the consultation of clinical records of adult male inmates in a prison in the south of Italy. Results: Prescription of antimicrobials for upper respiratory tract infections ranged from 41.9% in influenza diagnoses to 88% in pharyngitis diagnoses, with high prevalence also for bronchitis (73.5%) and common cold (57.7%), and those for dental infections ranged from 82% in pulp necrosis and symptomatic apical periodontitis/pulp necrosis and localized acute apical abscess diagnoses, to 85.7% in symptomatic irreversible pulpitis with or without symptomatic apical periodontitis diagnoses. The most frequently prescribed antimicrobial was amoxicillin and clavulanic acid (33.8%), followed by amoxicillin (26.5%), macrolides (19.8%) and third-generation cephalosporins (7.9%). The overall antimicrobial overprescription was 69.4%, whereas an antimicrobial prescription was provided in all 52 cases in which it was indicated. The inappropriate antimicrobial prescriptions were significantly less likely for bronchitis, influenza and symptomatic irreversible pulpitis with or without symptomatic apical periodontitis compared to common cold/pharyngitis/rhinosinusitis, and when the antimicrobial prescription was provided by medical specialists compared to prison physicians, whereas antimicrobial overprescriptions without indications were significantly more frequent in patients with underlying chronic clinical conditions. Conclusions: A concerning widespread practice of inappropriate antimicrobial prescriptions in prisoners was found. Diagnoses-specific monitoring of antimicrobial use and prison-focused antimicrobial stewardship policies are strongly needed.

Antimicrobial prescription practices for outpatients with acute respiratory tract infections: A retrospective, multicenter, medical record-based study

Antimicrobial stewardship for outpatients with acute respiratory tract infections (ARTIs) should be urgently promoted in this era of antimicrobial resistance. Previous large-sample studies were based on administrative data and had limited reliability. We aimed to identify current antimicrobial prescription practices for ARTIs by directly basing on medical records. This multicenter retrospective study was performed from January to December in 2018, at five medical institutes in Japan. We targeted outpatients aged ≥18 years whose medical records revealed International Classification of Diseases (ICD-10) codes suggesting ARTIs. We divided the eligible cases into three age groups (18–64 years, 65–74 years, and ≥75 years). We defined broad-spectrum antimicrobials as third-generation cephalosporins, macrolides, fluoroquinolones, and faropenem. Primary and secondary outcomes were defined as the proportion of antimicrobial prescriptions for the common cold and other respiratory tract infections, respectively. Totally, data of 3,940 patients were collected. Of 2,914 patients with the common cold, 369 (12.7%) were prescribed antimicrobials. Overall, compared to patients aged ≥75 years (8.5%), those aged 18–64 years (16.6%) and those aged 65–74 years (12.1%) were frequently prescribed antimicrobials for the common cold (odds ratio [95% confidential interval]; 2.15 [1.64–2.82] and 1.49 [1.06–2.09], respectively). However, when limited to cases with a valid diagnosis of the common cold by incorporating clinical data, no statistical difference was observed among the age groups. Broad-spectrum antimicrobials accounted for 90.2% of the antimicrobials used for the common cold. Of 1,026 patients with other respiratory infections, 1,018 (99.2%) were bronchitis, of which antimicrobials were prescribed in 49.9% of the cases. Broad-spectrum antimicrobials were the main agents prescribed, accounting for nearly 90% of prescriptions in all age groups. Our data suggested a favorable practice of antimicrobial prescription for outpatients with ARTIs in terms of prescribing proportions, or quantitative aspect. However, the prescriptions were biased towards broad-spectrum antimicrobials, highlighting the need for further antimicrobial stewardship in the outpatient setting from a qualitative perspective.

Determinants of Clinician and Patient to prescription of antimicrobials: case of Mulanje, Southern Malawi

BackgroundAntimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. MethodsIn-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. ResultsParticipants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance. ConclusionInappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

Trends in healthcare visits and antimicrobial prescriptions for acute infectious diarrhea in individuals aged 65 years or younger in Japan from 2013 to 2018 based on administrative claims database: a retrospective observational study

Background The inappropriate use of antimicrobials for acute infectious diarrhea is widespread and leads to the problem of antimicrobial resistance. To improve the use of antimicrobials, it is first necessary to understand the actual situation of diarrheal disease and to identify potential targets for intervention. This study aimed to investigate the recent epidemiological characteristics of and antimicrobial prescriptions for acute infectious diarrhea in Japan. Methods This was a retrospective observational study of outpatients aged 0–65 years, separated into children (age 0–17 years) and adults (age 18–65 years), diagnosed with acute infectious diarrhea, using the administrative claims database of the Japan Medical Data Center from 2013 to 2018. We evaluated the number of eligible visits/number of database registrants (defined as the visit rate). The analysis of the antimicrobial prescription rate was restricted to otherwise healthy individuals diagnosed with acute infectious diarrhea alone by excluding patients with multiple disease diagnoses and with medical backgrounds of chronic bowel diseases or immunocompromised conditions. We further classified them by diagnosis of bacterial or nonbacterial acute infectious diarrhea. Results The total number of eligible visits for acute infectious diarrhea was 2,600,065. The visit rate, calculated based on the number of eligible visits by database registrants, was higher in children (boys, 0.264; girls, 0.229) than in adults (men, 0.070; women, 0.079), with peaks in early summer and winter. The peaks for visits in adults lagged those of children. In total, 482,484 visits were analyzed to determine the antimicrobial prescription rate; 456,655 (94.6%) were diagnosed with nonbacterial acute infectious diarrhea. Compared with children (boys, 0.305; girls, 0.304), the antimicrobial prescription rate was higher in adults, and there were differences between sexes in adults (men, 0.465; women, 0.408). Fosfomycin and fluoroquinolone were most frequently used for nonbacterial acute infectious diarrhea in children (44.1%) and adults (50.3%), respectively. Conclusions These results revealed overprescription of antimicrobials for acute infectious diarrhea in this administrative claims database in Japan and contribute to the development of antimicrobial stewardship strategies and the identification of targets for efficiently reducing inappropriate antimicrobial use.

Impact of a hospital-wide computerised approach to optimise the quality of antimicrobial prescriptions in patients with severe obesity: a quasi-experimental study

Background Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity. Methods This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m2) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption. Results Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p < 0.001; intercept, 11.3% [95% CI 8.2 to 14.5], p < 0.001), which led to a reduction of 35% over an eight-year period (from pre-intervention level of 19.1%). Intervention 1 resulted in a downward trend in antimicrobial consumption, followed by an increasing trend after intervention 2. In these patients, the most frequent interventions made by pharmacists targeted posology (46%). Conclusions Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

A Multicultural Demographic Study to Analyze Antibiotic Prescription Practices and the Need for Continuing Education in Dentistry

Objectives. The objective of the study was to understand and analyze the prescription patterns of dentists across various demographic locations for managing oral infections and pain with antibiotics and explore the evidence-based practices by clinicians as well as the need for further education. Materials and methods. This cross-sectional study was carried out using an online questionnaire framed to explore the knowledge, attitude, and practices among dentists with varying levels of experience and qualifications, regarding antimicrobial prescription. The questions were validated from previous published studies that explored the knowledge, attitude, and practice (KAP) with respect to antimicrobial prescription. In total, N = 300 of dentists from four different countries responded to the online questionnaire out of which 53% were specialists while 47% were general dentists. After data collection, descriptive analysis was carried out along with a one-sided hypothesis test to depict the power of the sample. Results. It was seen from the results of the study that the first-choice antibiotics for 67.8% of dentists were found to be the β-lactam group while sulfonamides and tetracyclines at 20% were the second most prescribed group. Another important finding was that 45.6% of dentists ignored hypersensitivity testing before prescription of antibiotics even though 83.3% of the total dentists interviewed were aware of the increase in antibiotic resistance. Conclusion. In conclusion, the dentists are partially aware of the guidelines but need further training and education on antimicrobial prescription that enables evidence-based decision-making for better practices and outcomes.

Trends In Healthcare Visits And Antimicrobial Prescriptions For Acute Infectious Diarrhea In Individuals Aged 65 Years Or Younger In Japan From 2013 to 2018 Based On Administrative Claims Database: A Retrospective Observational Study

Background: The inappropriate use of antimicrobials for acute infectious diarrhea is widespread and leads to the problem of antimicrobial resistance. To improve the use of antimicrobials, it is first necessary to understand the actual situation of diarrheal disease and to identify potential targets for intervention. This study aimed to investigate the recent epidemiological characteristics of and antimicrobial prescriptions for acute infectious diarrhea in Japan.Methods: This was a retrospective observational study of outpatients aged 0–65 years, separated into children (age 0–17 years) and adults (age 18–65 years), diagnosed with acute infectious diarrhea, using the administrative claims database of the Japan Medical Data Center from 2013 to 2018. We evaluated the number of eligible visits/number of database registrants (defined as the visit rate). The analysis of the antimicrobial prescription rate was restricted to otherwise healthy individuals diagnosed with acute infectious diarrhea alone by excluding patients with multiple disease diagnoses and with medical backgrounds of chronic bowel diseases or immunocompromised conditions. We further classified them by diagnosis of bacterial or nonbacterial acute infectious diarrhea.Results: The total number of eligible visits for acute infectious diarrhea was 2,600,065. The visit rate, calculated based on the number of eligible visits by database registrants, was higher in children (boys, 0.264; girls, 0.229) than in adults (men, 0.070; women, 0.079), with peaks in early summer and winter. The peaks for visits in adults lagged those of children. In total, 482,484 visits were analyzed to determine the antimicrobial prescription rate; 456,655 (94.6%) were diagnosed with nonbacterial acute infectious diarrhea. Compared with children (boys, 0.305; girls, 0.304), the antimicrobial prescription rate was higher in adults, and there were differences between sexes in adults (men, 0.465; women, 0.408). Fosfomycin and fluoroquinolone were most frequently used for nonbacterial acute infectious diarrhea in children (44.1%) and adults (50.3%), respectively.Conclusions: These results revealed overprescription of antimicrobials for acute infectious diarrhea in this administrative claims database in Japan and contribute to the development of antimicrobial stewardship strategies and the identification of targets for efficiently reducing inappropriate antimicrobial use.