Article

Knowledge, Perceptions, and Attitudes Regarding Antibiotic Use for Lower Respiratory Tract Infections: Insights from Patients in Sri Lanka

Authors:
Article

Knowledge, Perceptions, and Attitudes Regarding Antibiotic Use for Lower Respiratory Tract Infections: Insights from Patients in Sri Lanka

If you want to read the PDF, try requesting it from the authors.

Abstract

Antibiotic resistance is an emerging global public health threat. One of the main drivers of this threat is the inappropriate use of antibiotics. In Sri Lanka, antibiotic consumption is increasing, but little is known locally about how patients perceive antibiotics. We conducted a qualitative study to gain a better understanding of the knowledge, perceptions, and attitudes of patients regarding antibiotics and antibiotic resistance. Semi-structured interviews involving 18 patients with lower respiratory tract infection (LRTI) admitted to a large, public tertiary care hospital in southern Sri Lanka were conducted. Interviews were analyzed to identify themes regarding the patients’ knowledge of LRTI etiology and treatment, perceptions and attitudes toward LRTI treatment, including antibiotics, and patient–physician communication. Most patients mentioned multiple care visits and the use of multiple pharmaceuticals prior to admission. Patients sought a quick resolution to their ailments and frequently visited several private physicians to obtain a satisfying answer. Self-medication was also common. Patients reused prescriptions for antibiotics, kept antibiotics for later use after prematurely stopping their course of treatment, and bought over-the-counter antibiotics. Patients’ knowledge of disease etiology and antibiotics was poor. Only a few patients were aware of antibiotic resistance. Despite the desire to receive more information regarding disease and treatment, patient–provider communication was limited and mainly confined to prescription instructions. This qualitative study performed in Sri Lanka suggests that inappropriate use of antibiotics is a multifactorial problem. To improve antibiotic use, a multifactorial approach that includes educating the public, increasing awareness among physicians, and implementing systems-level changes to restrict access to antibiotics is urgently needed.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

Article
Full-text available
Reducing the growth of antimicrobial resistance (AMR) through public understanding is a goal of the World Health Organization. It is especially important in countries where antibiotics are widely available for common ailments without prescription. This study assessed understanding of antibiotics and AMR alongside perception of antibiotic usage among the general public in two diverse Sri Lankan communities: ordinary urban and indigenous rural. A cross-sectional questionnaire survey was conducted, gaining 182 urban and 147 rural responses. The majority of urban respondents (69.2%) believed that they had very good or good knowledge about antibiotics compared to 40.1% of rural respondents. Belief about knowledge and actual knowledge (measured via a test question) were correlated (r = 0.49, p = 0.001) for rural respondents, but not for urban respondents. Several misconceptions about antibiotics were highlighted, including that Paracetamol, a painkiller, was thought to be an antibiotic by more than 50% of both urban and rural respondents. In addition, 18.5% of urban and 35.4% of rural participants would keep and re-use what they perceived as leftover antibiotics. It is urgent that we pay attention to educating the general public regarding the identified misconceptions of these powerful drugs and their appropriate use.
Article
Full-text available
Background Antibiotic resistance is a major public health concern. It has been associated with factors such as uncontrolled consumption, lack of knowledge, beliefs, and sociodemographic characteristics. Lebanon is characterized by high levels of antibiotic misuse, as almost half of the population self-medicates with antibiotics and over 30% of the antibiotics are dispensed without prescription. To-date, no studies determined adequately the association between knowledge, beliefs and antibiotic misuse in Lebanon. Objective To assess the association between level of knowledge and beliefs about antibiotics, and antibiotic misuse in Lebanon. Methods We conducted a cross-sectional study among 1,421 parents of schoolchildren using an anonymous self-administered Knowledge, Attitude and Practices questionnaire. The participants´ level of agreement with each item of knowledge and beliefs was measured using a Likert-type (0–10) scale. Misuse practices in the last month were detected through a series of questions aimed at determining the level of compliance with physicians´ instructions in terms of dosage and duration. Data were analyzed using logistic regression. Results 277 participants (16%) acknowledged using antibiotics in the previous month, 41% of whom showed at least one misuse behavior. Misconceptions and beliefs about antibiotics substantially increased the odds of their misuse. For instance, participants who believed that antibiotics were effective in treating viruses, cold, or sore throat infections were twice as likely to misuse antibiotics [Adjusted Interquartile Odds Ratio (aIqOR): 2.08 (95%CI: 1.32, 3.19), aIqOR: 1.81 (95%CI: 1.41, 2.29), aIqOR: 2.19 (95%CI: 1.61, 2.93), respectively]. Parents who usually keep antibiotics at home antibiotics for future use were more likely to misuse antibiotics [aIqOR: 2.44 (95%CI: 1.68, 3.46)]. Conclusions Our findings indicate that the low level of knowledge and the existence of erroneous beliefs about antibiotics are associated with increased odds of antibiotic misuse. Key elements including rationale prescription and control of dispensing should be addressed when designing educational campaigns against antibiotic misuse.
Article
Full-text available
Introduction The risk of emergence and spread of antibiotic resistance is high in Southeast Asian countries and various strategies are being used to raise awareness about appropriate antibiotic use and antibiotic resistance within communities. Public engagement in science has not been widely practised in Myanmar. We describe the use of a forum theatre to engage with the community about antibiotic use. Methods The engagement activities took place in a peri-urban township in Yangon, Myanmar. Five preliminary story gathering workshops with the community were carried out to develop scripts and songs for the forum theatre. After that, we organised forum theatre plays between September and October 2018. Following each play we provided four simple key messages based on WHO’s world antibiotic awareness week advocacy materials; 1) Antibiotics are medicines used to treat bacterial infections 2) Antibiotics are not useful for coughs and colds 3) Never use leftover antibiotics or share antibiotics with others 4) Prevent infections by regularly washing hands, preparing food hygienically, avoiding close contact with sick people, and keeping vaccinations up to date. We evaluated the engagement activities by conducting focus group discussions (FGD) with audience members. Results Ten forum theatre plays were performed on two topics; “Fever and antibiotics” and “Mixed medicines”, reaching 1175 community members. Four themes emerged from our thematic analysis: 1) Knowledge dissemination, 2) Enjoyment and fun, 3) Willingness to support and recommendations for future engagement activities and 4) Preference over traditional methods of health education. We found improvement of antibiotic related knowledge and enjoyment among audience who were also willing to support future engagement activities and preferred forum theatre approach over formal health talks. Conclusions We conclude that forum theatre is an effective innovative approach to engage and disseminate knowledge on appropriate use of antibiotics with the community in a participatory way.
Article
Full-text available
Globally, antimicrobial resistance (AMR) is a serious problem causing 700,000 deaths annually. By 2050, AMR is expected to cause approximately 10 million deaths globally each year if allowed to increase at the present rate. Many individuals have limited knowledge regarding appropriate antibiotic use and AMR. Most antibiotic use occurs in the outpatient setting, with approximately 30% of antibiotics prescribed deemed unnecessary. Antimicrobial stewardship (AMS) is a means to reduce inappropriate antibiotic use and AMR. While existing AMS efforts generally focus on the inpatient setting, a significant gap is present in the outpatient setting. A common theme across various national action plans to reduce AMR is the need for education and awareness. The importance of communicating information in a manner easily comprehended by the patient in addition to productive clinician–patient dialogue cannot be overestimated. Enhancing the public’s and patients’ AMS health literacy is an underrecognized approach to help address AMR. We describe Four Core Elements of Enhancing AMS Health Literacy in the Outpatient Setting, utilizing the Centers for Disease Control and Prevention’s framework: (1) leadership commitment, (2) intervention/action, (3) tracking/reporting, and (4) education/expertise. We call upon leaders in outpatient settings to embrace this approach to curb inappropriate antimicrobial use.
Article
Full-text available
Background Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners’ perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta. Methods This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach. Findings General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) “The Service Provider”–maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) “The Uncertainty Avoider”–reaching a compromise and providing treatment just in case, (C) “The Comforter”–providing the patient comfort and reassurance, (D) “The Conscientious Practitioner”–empowering and educating patients, and limiting antibiotic use, and (E) “The Holder of Professional Power”–retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon. Conclusions In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients’ and pharmacists’ views on delayed antibiotic prescription is required. Trial registration number NCT03218930
Article
Full-text available
Background: Antimicrobial resistance is a global public health concern, with extensive associated health and economic implications. Actions to slow and contain the development of resistance are imperative. Despite the fact that overuse and misuse of antibiotics are highlighted as major contributing factors to this resistance, no sufficiently validated measures aiming to investigate the drivers behind consumer behaviour amongst the general population are available. The objective of this study was to develop and investigate the psychometric properties of an original, novel and multiple-item questionnaire, informed by the Theory of Planned Behaviour, to measure factors contributing to self-reported antibiotic use within the community. Method: A three-phase process was employed, including literature review and item generation; expert panel review; and pre-test. Investigation of the questionnaire was subsequently conducted through a cross-sectional, anonymous survey. Orthogonal principal analysis with varimax rotation, cronbach alpha and linear mixed-effects modelling analyses were conducted. A 60 item questionnaire was produced encompassing demographics, social desirability, three constructs of the Theory of Planned Behaviour including: attitudes and beliefs; subjective norm; perceived behavioural control; behaviour; and a covariate - knowledge. Results: Three hundred seventy-three participants completed the survey. Eighty participants (21%) were excluded due to social desirability concerns, with data from the remaining 293 participants analysed. Results showed modest but acceptable levels of internal reliability, with high inter-item correlations within each construct. All four variables and the outcome variable of antibiotic use behaviour comprised four items with the exception of social norms, for which there were two items, producing a final 18 item questionnaire. Perceived behavioural control, social norms, the interaction between attitudes and beliefs and knowledge, and the presence of a healthcare worker in the family were all significant predictors of antibiotic use behaviour. All other predictors tested produced a nonsignificant relationship with the outcome variable of self-reported antibiotic use. Conclusion: This study successfully developed and validated a novel tool which assesses factors influencing community antibiotic use and misuse. The questionnaire can be used to guide appropriate intervention strategies to reduce antibiotic misuse in the general population. Future research is required to assess the extent to which this tool can guide community-based intervention strategies.
Article
Full-text available
Increased public awareness of antimicrobial resistance (AMR) is a key component of effective antimicrobial stewardship strategies. Educational theatre combined with an expert panel was used to engage the public about AMR through delivery of a play entitled "The drugs don't work". Audience knowledge and understanding of AMR were measured by pre- and post-play questionnaire. Delivery of the play and discussion with the expert panel significantly improved audience knowledge and understanding of AMR, including antibiotic misuse and prescribing. Educational theatre provides a positive learning experience and is an innovative method of public engagement to disseminate important public health messages.
Article
Full-text available
Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages. Electronic supplementary material The online version of this article (10.1007/s10096-018-03454-2) contains supplementary material, which is available to authorized users.
Article
Full-text available
A point-prevalence study of antimicrobial use among inpatients at 5 public hospitals in Sri Lanka revealed that 54.6% were receiving antimicrobials: 43.1% in medical wards, 68.0% in surgical wards, and 97.6% in intensive care wards. Amoxicillin-clavulanate was most commonly used for major indications. Among patients receiving antimicrobials, 31.0% received potentially inappropriate therapy.
Article
Full-text available
Tracking antibiotic consumption patterns over time and across countries could inform policies to optimize antibiotic prescribing and minimize antibiotic resistance, such as setting and enforcing per capita consumption targets or aiding investments in alternatives to antibiotics. In this study, we analyzed the trends and drivers of antibiotic consumption from 2000 to 2015 in 76 countries and projected total global antibiotic consumption through 2030. Between 2000 and 2015, antibiotic consumption, expressed in defined daily doses (DDD), increased 65% (21.1-34.8 billion DDDs), and the antibiotic consumption rate increased 39% (11.3-15.7 DDDs per 1,000 inhabitants per day). The increase was driven by low- and middle-income countries (LMICs), where rising consumption was correlated with gross domestic product per capita (GDPPC) growth (P= 0.004). In high-income countries (HICs), although overall consumption increased modestly, DDDs per 1,000 inhabitants per day fell 4%, and there was no correlation with GDPPC. Of particular concern was the rapid increase in the use of last-resort compounds, both in HICs and LMICs, such as glycylcyclines, oxazolidinones, carbapenems, and polymyxins. Projections of global antibiotic consumption in 2030, assuming no policy changes, were up to 200% higher than the 42 billion DDDs estimated in 2015. Although antibiotic consumption rates in most LMICs remain lower than in HICs despite higher bacterial disease burden, consumption in LMICs is rapidly converging to rates similar to HICs. Reducing global consumption is critical for reducing the threat of antibiotic resistance, but reduction efforts must balance access limitations in LMICs and take account of local and global resistance patterns.
Article
Full-text available
In tropical and subtropical settings, the epidemiology of viral acute respiratory tract infections varies widely between countries. We determined the etiology, seasonality, and clinical presentation of viral acute respiratory tract infections among outpatients in southern Sri Lanka. From March 2013 to January 2015, we enrolled outpatients presenting with influenza-like illness (ILI). Nasal/nasopharyngeal samples were tested in duplicate using antigen-based rapid influenza testing and multiplex polymerase chain reaction (PCR) for respiratory viruses. Monthly proportion positive was calculated for each virus. Bivariable and multivariable logistic regression were used to identify associations between sociodemographic/clinical information and viral detection. Of 571 subjects, most (470, 82.3%) were ≥ 5 years of age and 53.1% were male. Arespiratory virus was detected byPCRin 63.6% (N= 363).Commonviral etiologies included influenza (223, 39%), human enterovirus/rhinovirus (HEV/HRV, 14.5%), respiratory syncytial virus (RSV, 4.2%), and human metapneumovirus (hMPV, 3.9%). Both ILI and influenza showed clear seasonal variation, with peaks from March to June each year. RSV and hMPV activity peaked from May to July, whereas HEV/HRV was seen year-round. Patients with respiratory viruses detected were more likely to report pain with breathing (odds ratio [OR] = 2.60, P = 0.003), anorexia (OR = 2.29, P < 0.001), and fatigue (OR = 2.00, P = 0.002) compared with patients with no respiratory viruses detected. ILI showed clear seasonal variation in southern Sri Lanka, with most activity during March to June; peak activity was largely due to influenza. Targeted infection prevention activities such as influenza vaccination in January-February may have a large public health impact in this region. © 2017 by The American Society of Tropical Medicine and Hygiene.
Article
Full-text available
Background Acute respiratory tract infections (ARTIs) are a common reason for antibiotic overuse worldwide. We previously showed that over 80% of outpatients presenting to a tertiary care hospital in Sri Lanka with influenza-like illness received antibiotic prescriptions, although almost half were later confirmed to have influenza. The purpose of this qualitative study was to assess Sri Lankan patients’ and physicians’ attitudes towards ARTI diagnosis and treatment. Methods Semi-structured interviews were conducted with 50 outpatients with ARTIs and five physicians in the Outpatient Department (OPD) at a large, public tertiary care hospital in southern Sri Lanka. Interviews were audio-recorded, transcribed, and analyzed for themes related to ARTI diagnosis and treatment. ResultsPatients frequently sought ARTI care in the public sector due to the receipt of free care and the perception that government hospitals carried a sense of responsibility for patients’ health. Patients reported multiple medical visits for their illnesses of short duration and many indicated that they were seeking care in the OPD while at the hospital for another reason. While patients generally expected to receive medication prescriptions at their visit, most patients were not specifically seeking an antibiotic prescription. However, more than 70% of patients received antibiotic prescriptions at their OPD visit. Physicians incorrectly perceived that patients desired antibiotics or “capsules,” a common formulation of antibiotics dispensed in this outpatient setting, and cited patient demand as an important cause of antibiotic overuse. Physicians also indicated that high patient volume and fear of bacterial superinfection drove antibiotic overuse. Conclusions Patients in this study were seeking medication prescriptions for their ARTIs, but physicians incorrectly perceived that antibiotic prescriptions were desired. High patient volume and fear of bacterial superinfection were also important factors in antibiotic overuse. Training of physicians regarding guideline-concordant management and dealing with diagnostic uncertainty, education of patients regarding ARTI etiology and management, and systematic changes in the public outpatient care structure may help decrease unnecessary antibiotic prescriptions for ARTIs in this setting.
Article
Full-text available
Data on causative agents and antibiotic susceptibility patterns of blood stream infections in Sri Lanka is scarce. Information on trends of antibiotic resistance is necessary for the prescribers to treat patients effectively and policy makers to develop policies and guidelines. To lay the foundation for a national data base on antimicrobial resistance in Sri Lanka. A prospective study was carried out in seven hospitals to study the Gram negative aetiological agents and their susceptibility patterns in patients suspected of having bacteraemia. We reviewed 817 patients with clinically significant blood cultures including both adults and children. Data were complete for analysis in 733 Gram negative isolates only. Of the 733 isolates, 488 were from adults (> 12 years), 109 were from children (1-12 years) and 136 were from infants (<1 year). Intensive care units represented 18.4% of the isolates (123 adult patients and 27 paediatric patients). The highest number of isolates (33.7%) was from patients with septicaemia of unknown origin. Enteric fever, pyelonephritis and respiratory tract infections accounted for 20% of the isolates. Bacteraemia with underline malignancies were responsible for 24.5% of infections. Salmonella paratyphi A was the commonest cause of enteric fever in adults with 92% resistance to ciprofloxacin. The prevalence of extended spectrum beta lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae was high in this study population. It is essential to introduce multidisciplinary interventions to reduce the inappropriate use of antibiotics to increase the lifespan of precious antibiotics. Introduction of a National antibiotic policy with strict implementation and a well-planned stewardship programme is essential to control antimicrobial resistance in our country.
Article
Full-text available
This article gives a very brief overview of the antibiotic era, beginning from the discovery of first antibiotics until the present day situation, which is marred by the emergence of hard-to-treat multiple antibiotic-resistant infections. The ways of responding to the antibiotic resistance challenges such as the development of novel strategies in the search for new antimicrobials, designing more effective preventive measures and, importantly, better understanding the ecology of antibiotics and antibiotic resistance are discussed. The expansion of conceptual frameworks based on recent developments in the field of antimicrobials, antibiotic resistance, and chemotherapy is also discussed.
Article
Full-text available
The threat to human health posed by antibiotic resistance is of growing concern. Many commensal and pathogenic organisms have developed resistance to well established and newer antibiotics. The major selection pressure driving changes in the frequency of antibiotic resistance is the volume of drug use. However, establishing a quantitative relationship between the frequency of resistance and volume of drug use has proved difficult. Using population genetic methods and epidemiological observations, we report an analysis of the influence of the selective pressure imposed by the volume of drug use on temporal changes in resistance. Analytical expressions are derived to delineate key relationships between resistance and drug consumption. The analyses indicate that the time scale for emergence of resistance under a constant selective pressure is typically much shorter than the decay time after cessation or decline in the volume of drug use and that significant reductions in resistance require equally significant reductions in drug consumption. These results highlight the need for early intervention once resistance is detected.
Article
Full-text available
The intense use and misuse of antibiotics are undoubtedly the major forces associated with the high numbers of resistant pathogenic and commensal bacteria worldwide. Both the volume and the way antibiotics are applied contributes to the selection of resistant strains. Still, other social, ecological and genetic factors affect a direct relationship between use and frequency of resistance. Resistant bacteria, following their emergence and evolution in the presence of antibiotics, appear to acquire a 'life of their own'. They proliferate and maintain the resistance traits even in the absence of antibiotics, thus jeopardizing the reversal of bacterial resistance by simple reduction in antibiotic use. Reversing resistance requires restoration of the former susceptible flora in people and in the environment. Copyright 2000 Harcourt Publishers Ltd.
Article
Full-text available
In Europe, antimicrobial resistance has been monitored since 1998 by the European Antimicrobial Resistance Surveillance System (EARSS). We examined the relationship between penicillin nonsusceptibility of invasive isolates of Streptococcus pneumoniae and antibiotic sales. Information was collected on 1998-99 resistance data for invasive isolates of S. pneumoniae to penicillin, based on surveillance data from EARSS and on outpatient sales during 1997 for beta-lactam antibiotics and macrolides. Our results show that in Europe antimicrobial resistance of S. pneumoniae to penicillin is correlated with use of beta-lactam antibiotics and macrolides.
Article
Full-text available
The optimism of the early period of antimicrobial discovery has been tempered by the emergence of bacterial strains with resistance to these therapeutics. Today, clinically important bacteria are characterized not only by single drug resistance but also by multiple antibiotic resistance--the legacy of past decades of antimicrobial use and misuse. Drug resistance presents an ever-increasing global public health threat that involves all major microbial pathogens and antimicrobial drugs.
Article
In 2013, a Lancet Infectious Diseases Commission described the state of antimicrobial resistance worldwide. Since then, greater awareness of the public health ramifications of antimicrobial resistance has led to national actions and global initiatives, including a resolution at the high-level meeting of the UN General Assembly in 2016. Progress in addressing this issue has ranged from a ban on irrational drug combinations in India to commitments to ban colistin as a growth promoter in animals, improve hospital infection control, and implement better antimicrobial stewardship. Funds have been mobilised, and regulatory barriers to new antibiotic development have been relaxed. These efforts have been episodic and uneven across countries, however. Sustained funding for antimicrobial resistance and globally harmonised targets to monitor progress are still urgently needed. Except for in a few leading countries, antimicrobial resistance has not captured the sustained focus of national leaders and country-level actors, including care providers.
Article
Antimicrobial resistance is a serious threat to global health. Despite numerous initiatives designed to curb excessive and inappropriate use of antibiotics, a recent report (Klein et al. (2018) Proc. Natl. Acad. Sci. U. S. A., 115, E3463) finds that there was a substantial increase in global antibiotic consumption by humans from 2000 to 2015 and predicts a further 200% increase by 2030. Alarmingly, much of this growth is occurring in “last-resort” antibiotics. The study excludes the extensive use of antibiotics in agriculture and aquaculture. This Viewpoint examines the report’s findings and discusses them in the context of other recent developments in antimicrobial resistance.
Article
Background: Acute otitis media (AOM) is a common childhood disease, with an enormous economic and healthcare-related burden. Guidelines and consensus papers for AOM diagnosis and management were published in many countries. Our objective was to study the differences and similarities between these protocols in developing and developed countries. Methods: The key-words: 'acute otitis media' AND 'children' AND ['treatment' or 'management'] AND ['guideline' or 'consensus'] were used in various electronic databases between 1/1/1989 through 12/31/2015. Overall, 99 sources from 62 countries were retrieved: 53 from 22 developed countries, and 46 from 40 developing countries. Representative guidelines from America (USA, Argentina), Europe (Italy, Moldova), Africa (South Africa, Tanzania, Ethiopia), Asia (Japan, Afghanistan, Sri Lanka), and Oceania (South Australia, Fiji) were compared. Results: Paediatric societies publish guidelines in most developed countries; in developing countries, the Ministry of Health usually initiates guideline formulation. Most guidelines use the same diagnostic criteria, and offer watchful waiting in mild-moderate scenarios. Amoxicillin is the suggested first-line antibiotic, whereas options for second- and third-line therapies vary. Duration of therapy varies, and is usually age-dependent: 5-7 days for children <2 yrs, and 10 days for children >2 yrs in developed countries, while duration and age-groups vary greatly in developing countries. Reduction of AOM risk factors is encouraged in developed countries, but rarely in developing countries. Conclusion: Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reducing AOM burden.
Article
Acute respiratory infection (ARI) is a common diagnosis in outpatient and emergent care settings. Currently available diagnostics are limited, creating uncertainty in the use of antibacterial, antiviral, or supportive care. Up to 72% of ambulatory care patients with ARI are treated with an antibacterial, despite only a small fraction actually needing one. Antibiotic overuse is not restricted to ambulatory care: ARI accounts for approximately 5 million emergency department (ED) visits annually in the USA, where 52–61% of such patients receive antibiotics. Thus, an accurate test for the presence or absence of viral or bacterial infection is needed. In this review, we focus on recent research showing that the host-response (genomic, proteomic, or miRNA) can accomplish this task.
Article
Inappropriate prescription has been associated with mounting rates of antibiotic resistance worldwide, demanding more detailed studies into physicians' decision-making process. Accordingly, this study sought to explore physicians' perceptions of factors influencing antibiotic prescribing. A systematic search was performed for qualitative studies focused on understanding physicians' perceptions of the factors, attitudes and knowledge influencing antibiotic prescription. Of the total of 35 papers selected for review purposes, 18 solely included physicians and the remaining 17 also included patients and/or other healthcare providers. Data collection was based mainly on interviews, followed by questionnaires and focus groups, and the methodologies mainly used for data analysis were grounded theory and thematic analysis. Factors cited by physicians as having an impact on antibiotic prescribing were grouped into those that were intrinsic (group 1) and those that were extrinsic (group 2) to the healthcare professional. Among the former, physicians' attitudes, such as complacency or fear, were rated as being most influential on antibiotic prescribing, whilst patient-related factors (e.g. signs and symptoms) or healthcare system-related factors (e.g. time pressure and policies/guidelines implemented) were the most commonly reported extrinsic factors. These findings revealed that: (i) antibiotic prescribing is a complex process influenced by factors affecting all the actors involved, including physicians, other healthcare providers, healthcare system, patients and the general public; and (ii) such factors are mutually dependent. Hence, by shedding new light on the process, these findings will hopefully contribute to generating new and more effective strategies for improving antibiotic prescribing and allaying global concern about antibiotic resistance.
Article
Trust is central to good relationships between patients and health-care providers because, firstly, patient uncertainty about health conditions requires them to have confidence in a doctor's motives and decisions, and secondly, trust facilitates communication and patient focus which encourages people to utilise health services. This paper focuses on patient trust because of its effect on treatment-seeking behaviour and the treatment costs incurred by poor households. Drawing from other studies the paper distinguishes between trust based on the perceived technical competence of the provider, and on inter-personal dimensions of quality of care. Trust is also analysed at two inter-related levels: personal trust that is built through face-to-face encounters with providers; and more abstract institution-level trust. The paper applies these notions of trust to examine treatment-seeking behaviour in two poor urban communities in Colombo, Sri Lanka. Household survey data and qualitative data show that people from a range of income groups preferred to use public providers for more serious illnesses because public services were free and they trusted the technical competence of public providers at both a personal and institutional level. The data also show, however, that inter-personal quality of care was lacking in the public sector and that residents from the two communities, including a considerable minority of the poorest, preferred to use private providers for moderate acute illnesses. People were willing to pay for private services because it saved time, doctors listened and they could build better relationships with private doctors. Despite the strengths of Sri Lanka's public health sector, poor relationships act as an access barrier and push a range of income groups to the private sector. The threat to access and affordability posed by these poor relationships should be the focus of current reform debates.