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

This study was aimed to explore thresholds with interaction effects among antibiotic usage, covariates (alcohol-based hand rub (ABHR)), and their effect on extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-producing K. pneumoniae) in hospitalized patients.
Multivariate Adaptive Regression Spline models were used. These considered second-order interactions among antibiotic use and ABHR in addition to potential thresholds that further improve explained variance in the ESBL-producing K. pneumoniae response. The study involved collecting monthly hospital-level data for January 2017-December 2021.
Analysis of the main effects showed that third-generation cephalosporins above 2.00 DDD/100 occupied bed days (OBD) generally increased ESBL-producing K. pneumoniae incidence (cases/100 OBD). Levels of ABHR above 6.61 L/100 OBD were shown to generally decrease ESBL-producing K. pneumoniae incidence. Second-order interactions revealed that when third-generation cephalosporin use was greater than 3.71 DDD/100 OBD, and ABHR was greater than 6.6 L/100 OBD (same as main effect threshold), ABHR partially lost effectiveness in its ability to reduce ESBL-producing K. pneumoniae incidence. This demonstrates the importance of not exceeding the identified thresholds of 3.71 DDD/100 OBD for third-generation cephalosporin use.
The main-effect thresholds in third-generation cephalosporins and ABHR, and the identified interaction between third-generation cephalosporins and ABHR can inform effective hospital antimicrobial stewardship.

We investigated whether prior use of antibiotics affects the risk of mecillinam/trimethoprim/nitrofurantoin/multi-resistant Escherichia coli urinary tract infection (UTI) among elderly patients in general practice. Data on urine culture came from urine samples performed in general practice and sent to hospitals in the Capital Region of Denmark, and prescription data came from a nationwide prescription database. The study population consisted of patients with UTI episodes (n = 41,027) caused by E. coli that received a concurrent antibiotic prescription against UTI from 2012 to 2017. We used a case-control design. Cases were UTI episodes caused by mecillinam, trimethoprim, nitrofurantoin or multi-resistant E. coli and controls were UTI episodes caused by E. coli not displaying the respective resistance pattern. We analyzed whether exposure to antibiotics in a period of 8-90 days prior to the UTI episode affected the risk of antibiotic resistant uropathogenic E coli. The analyses were adjusted for age, sex, hospital admission and nursing home status. The odds of resistance to all of the four antibiotics increased significantly after exposure to antibiotics within 90 days prior to the UTI episode. In general, mecillinam showed the lowest increase in the odds for selection of resistance. The results indicate that mecillinam is a favorable antibiotic choice in terms of selection of resistance.

The aim of this study was to develop a logistic modeling concept to improve understanding of the relationship between antibiotic use thresholds and the incidence of resistant pathogens. A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-level incidence rates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli). Threshold logistic models identified thresholds for fluoroquinolones (61.1 DDD/1000 occupied bed days (OBD)) and third-generation cephalosporins (9.2 DDD/1000 OBD) to control hospital ESBL-producing E. coli incidence. The 60th percentile of ESBL-producing E. coli was determined as the cutoff for defining high incidence rates. Threshold logistic analysis showed that for every one-unit increase in fluoroquinolones and third-generation cephalosporins above 61.1 and 9.2 DDD/1000 OBD levels, the average odds of the ESBL-producing E. coli incidence rate being ≥60th percentile of historical levels increased by 4.5% and 12%, respectively. Threshold logistic models estimated the risk scores of exceeding the 60th percentile of a historical ESBL-producing E. coli incidence rate. Threshold logistic models can help hospitals in defining critical levels of antibiotic use and resistant pathogen incidence and provide targets for antibiotic consumption and a near real-time performance monitoring feedback system.

UNASSIGNED: Overuse of antibiotics and inappropriate prescribing has resulted in rapid development of antimicrobial resistance. Most antibiotics in the United Kingdom (71.4%) are prescribed in primary care by general practitioners, with about half prescribed for viral rather than bacterial illnesses.
UNASSIGNED: To explore antibiotic prescribing and factors which may influence maternal decision making to seek antibiotics for their young children.
UNASSIGNED: Data for children under five years were gathered using a mixed-methods case study approach. Quantitative general practice antibiotic prescribing data (n = 697 children) was statistically analysed and these results were further explored in six focus groups with mothers (n = 19) of children under five. The qualitative data was thematically analysed.
UNASSIGNED: Quantitative data identified nearly half of children received antibiotics. Children under one were prescribed the fewest antibiotics. Qualitative focus group data showed mothers trusted their general practitioner to provide expert care for their child and often wanted convenient and timely access to advice and reassurance rather than treatment.
UNASSIGNED: Antibiotics are frequently prescribed for young children in primary care. Healthcare professionals need to understand the maternal influences contributing to antibiotic use in children and consider strategies and interventions to reduce unnecessary antibiotic prescriptions.
UNASSIGNED: Nurses and health visitors should have a greater role in supporting maternal decision making for managing their children\'s illnesses.

Rising levels of antimicrobial resistance pose serious dangers to patients, population health, food security, and economic stability worldwide. In response to this threat, the United Nations and the World Health Organization have called for multisectoral, multidisciplinary action, recognizing that human, animal, and environmental health are interdependent. Although the pharmaceutical industry clearly has a leading role in developing novel antimicrobials and vaccines, it is also active in many areas supporting antimicrobial stewardship. This article describes why pharmaceutical companies invest in antimicrobial stewardship, outlines why they are well suited to help address this issue, and provides examples of how the pharmaceutical industry can support the responsible use of antimicrobials. Merck & Co., Inc. (Kenilworth, NJ, USA), a large, globally operating pharmaceutical company that develops and markets both human and veterinary antimicrobials and vaccines is used as a case study for illustrating industry involvement in antimicrobial stewardship efforts.

Antimicrobial resistance (AMR) is a prominent threat to public health. Although many guidelines have been developed over the years to tackle this issue, their impact on health care practice varies. Guidelines are often based on evidence from clinical trials, but these have limitations, particularly in the breadth and generalisability of the evidence and evaluation of the guidelines\' uptake. The aim of this study was to investigate how national and local guidelines for managing common infections are developed and explore guideline committee members\' opinions about using real-world observational evidence in the guideline development process.
Six semi-structured interviews were completed with participants who had contributed to the development or adjustment of national or local guidelines on antimicrobial prescribing over the past 5 years (from the English National Institute for Health and Care Excellence (NICE)). Interviews were audio recorded and transcribed verbatim. Data was analysed thematically. This also included review of policy documents including guidelines, reports and minutes of guideline development group meetings that were available to the public.
Three key themes emerged through our analysis: perception versus actual guideline development process, using other types of evidence in the guideline development process, and guidelines are not enough to change antibiotic prescribing behaviour. In addition, our study was able to provide some insight between the documented and actual guideline development process within NICE, as well as how local guidelines are developed, including differences in types of evidence used.
This case study indicates that there is the potential for a wider range of evidence to be included as part of the guideline development process at both the national and local levels. There was a general agreement that the inclusion of observational data would be appropriate in enhancing the guideline development process, as well providing a potential solution for monitoring guideline use in clinical practice, and improving the implementation of treatment guidelines in primary care.

Selective reporting of antibiotic susceptibility test (AST) results is a potential intervention for laboratory-based antibiotic stewardship. The aim of this study was to assess the impact of AST reporting on the appropriateness of antibiotics selected by French general practitioners for urinary tract infections (UTIs). A randomised controlled case-vignette study in a region of northeast France surveyed general practitioners between July and October 2015 on treatment of four clinical cases of community-acquired Escherichia coli UTIs (two cases of complicated cystitis, one of acute pyelonephritis and one male UTI). In Group A, selective reporting of AST results was used for the first two cases and complete reporting for the other two cases; these were reversed in Group B. The overall participation rate was 131/198 (66.2%). Provision of selective AST results significantly increased the rate of adherence to national guidelines for first-line antibiotic treatment in Cases 1, 3 and 4 by 22.4% (55.2% vs. 32.8%, P = 0.01), 67.5% (75.0% vs. 7.5%, P <0.001) and 36.3% (45.3% vs. 9.0%, P <0.001), respectively. The improvement in compliance was not significant for Case 2. Prescriptions of amoxicillin-clavulanic acid, fluoroquinolones and cephalosporins decreased by 25.0% to 45.0%, depending on the clinical vignette. Most (106/131, 81.0%) participants favoured the routine use of selective reporting of AST results. In conclusion, selective reporting of AST results seems to improve antibiotic prescribing practices in primary care, and may be considered a key element of antimicrobial stewardship programmes.