Abstract
Antibiotic stewardship programmes, which are a set of interventions aiming at prescribing antibiotics appropriately and responsibly, are one of the key strategies to tackle the current ...worldwide bacterial resistance crisis. We will present here some examples of international and national initiatives, with a focus on Europe, discuss the role of clinical microbiologists, and present some perspectives and future developments.
Antibiotic stewardship programmes, aiming at promoting responsible antibiotic use, will be discussed from a European perspective.
In low-income and middle-income countries, it is difficult to identify specific targets for intervention.3 Furthermore, sustained, reliable availability of antibiotics at an affordable cost and ...adequate quality remains a major concern for high-income, low-income, and middle-income countries.4 Regular shortages and the high cost of older, off-patent antibiotics are an increasing threat to their optimal use.5 Defining which antibiotics should be the focus at different levels of stewardship intervention is a global priority.6 Revision of the Essential Medicines List (EML) entails complex decisions that assess health outcomes while accounting for feasibility, monitoring, registration, and cost of listed medications.7 The last complete revision of antibiotics was done in 2001.8 For the 2017 update on the EML, comprehensive reviews on antibiotic use for specific clinical infections were commissioned by WHO.9 After assessing the evidence on the most frequent and severe bacterial infections, the Expert Committee identified a few options as first-choice and second-choice antibiotics for each type of infection and categorised antibiotics into three groups, with the goals of improved access and clinical outcomes, reduced potential for development of antimicrobial resistance, and preserved effectiveness of the so-called last-resort antibiotics (figure). First choices were generally narrow spectrum agents with a low toxicity risk. ...choices for specific syndromes were broader spectrum antibiotics than the first choices, which might have an increased risk of toxicity or resistance selection.
The WHO Access, Watch, and Reserve (AWaRe) antibiotic classification framework aims to balance appropriate access to antibiotics and stewardship. We aimed to identify how patterns of antibiotic ...consumption in each of the AWaRe categories changed across countries over 15 years.
Antibiotic consumption was classified into Access, Watch, and Reserve categories for 76 countries between 2000, and 2015, using quarterly national sample survey data obtained from IQVIA. We measured the proportion of antibiotic use in each category, and calculated the ratio of Access antibiotics to Watch antibiotics (access-to-watch index), for each country.
Between 2000, and 2015, global per-capita consumption of Watch antibiotics increased by 90·9% (from 3·3 to 6·3 defined daily doses per 1000 inhabitants per day DIDs) compared with an increase of 26·2% (from 8·4 to 10·6 DIDs) in Access antibiotics. The increase in Watch antibiotic consumption was greater in low-income and middle-income countries (LMICs; 165·0%; from 2·0 to 5·3 DIDs) than in high-income countries (HICs; 27·9%; from 6·1 to 7·8 DIDs). The access-to-watch index decreased by 38·5% over the study period globally (from 2·6 to 1·6); 46·7% decrease in LMICs (from 3·0 to 1·6) and 16·7% decrease in HICs (from 1·8 to 1·5), and 37 (90%) of 41 LMICs had a decrease in their relative access-to-watch consumption. The proportion of countries in which Access antibiotics represented at least 60% of their total antibiotic consumption (the WHO national-level target) decreased from 50 (76%) of 66 countries in 2000, to 42 (55%) of 76 countries in 2015.
Rapid increases in Watch antibiotic consumption, particularly in LMICs, reflect challenges in antibiotic stewardship. Without policy changes, the WHO national-level target of at least 60% of total antibiotic consumption being in the Access category by 2023, will be difficult to achieve. The AWaRe framework is an important measure of the effort to combat antimicrobial resistance and to ensure equal access to effective antibiotics between countries.
US Centers for Disease Control and Prevention.
Widespread antimicrobial use has compromised its value, leading to a crisis of antimicrobial resistance. A major cause of misuse is insufficient knowledge of prescribing of antimicrobials in many ...categories of professionals. An important principle of antimicrobial stewardship is avoiding selection pressure in the patient, both on pathogen and commensal by avoiding unnecessary use, choosing the least broad-spectrum antibiotic, adequate doses, a good timing and the shortest possible duration. Up to now, most educational efforts have been targeted at professionals (mostly medical doctors) after their training and at the adult public. In the past few years, progress has been made in educating children. It is now crucial that academia and ministries of Health and Education jointly focus on an adapted undergraduate medical/professional curriculum that teaches all necessary principles of microbiology, infectious diseases and clinical pharmacology, with emphasis on the principles of prudent prescribing.
Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are ...scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available.
We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts.
A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement.
Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.
On 16 March, the United Nations formed an interagency group to coordinate the fight against drug resistance1. We urge that, as one of its first steps, this group coordinate a review of the ...terminology used by key actors. Such an effort could improve understanding across the board and help to engender a consistent and focused global response.
This study aimed to assess: 1) vaccine hesitancy (VH) prevalence among French general practitioners (GPs) through the frequency of their vaccine recommendations, and 2) the determinants of these ...recommendations.
Cross-sectional observational study in 2014 nested in a national panel of 1712 randomly selected GPs in private practice in France. We constructed a score of self-reported recommendation frequency for 6 specific vaccines to target populations.
16% to 43% of GPs sometimes or never recommended at least one specific vaccine to their target patients. Multivariable logistic regressions of the dichotomized score showed that GPs recommended vaccines frequently when they felt comfortable explaining their benefits and risks to patients (OR=1.87; 1.35–2.59), or trusted official sources of information highly (OR=1.40; 1.01–1.93). They recommended vaccines infrequently when they considered that adverse effects were likely (OR=0.71; 0.52–0.96) or doubted the vaccine's utility (OR=0.21; 0.15–0.29).
Our findings show that after repeated vaccine controversies in France, some VH exists among French GPs, whose recommendation behaviors depend on their trust in authorities, their perception of the utility and risks of vaccines, and their comfort in explaining them. Further research is needed to confirm these results among health care workers in other countries.
•We assessed attitudes and behaviours of French GPs for 6 vaccine situations for which coverage in France is suboptimal.•The variation of vaccine recommendations according to vaccine suggests the existence of vaccine hesitancy among GPs.•GPs’ beliefs about vaccine risks and trust in health authorities are linked to vaccine hesitancy for controversial vaccines.•Vaccine hesitancy is also related to GPs' beliefs about vaccines’ utility, regardless of whether they are controversial.
Our objectives were to describe Human Papillomavirus vaccination coverage rates (HPV-VCR), policies, and practical steps for programme implementation that may be linked to high uptake in the ...population targeted by routine programmes across 30 European Union/European Economic Area Member States and Switzerland.
Information from institutional websites and from articles indexed in Medline between 01/2006 and 01/2017 was reviewed and extracted using a standardised form. In 12/2017, a cross-sectional survey was administered to national experts, in order to update the compiled information.
Data were available in 31 countries, and validated by national experts in 28 of them. National vaccination programmes targeted girls 9–15 years of age in 30 countries and boys in 11 countries. HPV-VCR in girls was monitored in 25 countries: VCR was reported ≥71%(high) in ten countries, 51–70% in seven, 31–50% in four, and ≤30%(very low) in four. In high VCR countries, HPV vaccination was mainly delivered through school health services, and invitation and reminders to attend for vaccination were used. In areas with very low VCR, vaccination tended to be opportunistic and no reminders were used.
According to our findings, school delivery within structured vaccination programmes and the use of reminders tended to be associated with highest HPV-VCR.
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