Non-Clinical Factors Determining the Prescription of Antibiotics by Veterinarians: A Systematic Review

The misuse of antibiotics in humans, animals, and plants is related to the spread of resistant antibiotic strains among humans and animals. In this paper, we carry out a bibliographic search of Medline, Web of Knowledge, and Cab Abstracts with the main objective of ascertaining the available evidence on non-clinical factors and attitudes that could influence the prescription of antibiotics by veterinarians. A total of 34 studies fulfilled the inclusion criteria. Whereas, veterinary health professionals’ prescribing habits did not appear to be influenced by their socio-demographic characteristics, they were influenced by different attitudes, such as fear (identified in 19 out of 34 studies), self-confidence (19/34), business factors (19/34), and by complacency (16/34). Certain owner-related factors, such as lack of awareness (16/34) and demand for antibiotics (12/34), were also important, as were concurrent factors, ranging from a lack of appropriate regulations (10/34) to the expense and delays involved in performing culture and sensitivity tests (10/34) and inadequate farm hygiene (8/34). Our results appear to indicate that the non-clinical factors are potentially modifiable. This may be useful for designing interventions targeted at improving antibiotic use in animals, as part of an overall strategy to reduce the global spread of multi-resistant strainsS

Association of knowledge and attitudes with practices of misuse of tranquilizers: a cohort study in Spain

Tranquilizer misuse represents a growing international public health problem with heavy social and economic consequences. We aimed to identify the psychosocial determinants of this misuse practice, focusing on modifiable factors including knowledge and attitudes towards these medicationsThis study was supported by a grant from the Regional Ministry of Education, Universities and Vocational Training, Santiago de Compostela, Spain, (ED431C 2018/20)S

Impact of Extreme Temperatures on Ambulance Dispatches Due to Cardiovascular Causes in North-West Spain

Introduction and objectives. The increase in mortality and hospital admissions associated with high and low temperatures is well established. However, less is known about the influence of extreme ambient temperature conditions on cardiovascular ambulance dispatches. This study seeks to evaluate the effects of minimum and maximum daily temperatures on cardiovascular morbidity in the cities of Vigo and A Coruña in North-West Spain, using emergency medical calls during the period 2005–2017. Methods. For the purposes of analysis, we employed a quasi-Poisson time series regression model, within a distributed non-linear lag model by exposure variable and city. The relative risks of cold- and heat-related calls were estimated for each city and temperature model. Results. A total of 70,537 calls were evaluated, most of which were associated with low maximum and minimum temperatures on cold days in both cities. At maximum temperatures, significant cold-related effects were observed at lags of 3–6 days in Vigo and 5–11 days in A Coruña. At minimum temperatures, cold-related effects registered a similar pattern in both cities, with significant relative risks at lags of 4 to 12 days in A Coruña. Heat-related effects did not display a clearly significant pattern. Conclusions. An increase in cardiovascular morbidity is observed with moderately low temperatures without extremes being required to establish an effect. Public health prevention plans and warning systems should consider including moderate temperature range in the prevention of cardiovascular morbidityD.R. was supported by a postdoctoral research followship of the Xunta de Galicia (Spain)S

Efeito do status socioeconômico na mortalidade em áreas urbanas: análise crítica sistemática

Las desigualdades socioeconómicas son una causa de mortalidad y morbilidad superior a la mayoría de factores de riesgo, especialmente en el entorno urbano. Se llevó a cabo una revisión sistemática de la evidencia científica, en la que se incluyó artículos en inglés, castellano, portugués e italiano y se excluyeron estudios de baja evidencia, y en los que no se analizaba la relación entre mortalidad y nivel socioeconómico en un entorno urbano. La selección de artículos se llevó a cabo por dos revisores independientes y la extracción de datos se realizó con tablas de evidencia. Se obtuvieron 1.509 registros y se incluyeron 24. En todos los trabajos se observó mayor mortalidad en las áreas con peores indicadores de privación. Se observó asociación con patologías cardiovasculares en seis estudios, en cuatro con patologías pulmonares y en tres con SIDA, infecciones y parasitosis y cirrosis. Los estudios incluidos presentan resultados poco consistentes y limitaciones metodológicas importantes que impiden la comparación entre estudios y la extracción de conclusiones relevantes.Socioeconomic inequalities cause more disease and death than most risk factors, especially in cities. This systematic review of the scientific evidence included articles in English, Spanish, Portuguese, and Italian and excluded studies with low levels of evidence and those that did not analyze associations between mortality and socioeconomic status in urban settings. Articles were selected by two independent reviewers, and data extraction used evidence tables. A total of 1,509 records were obtained, and 24 were included. All the studies showed higher mortality rates in poorer areas. Six studies showed an association with cardiovascular diseases, four with lung diseases, and three with AIDS, infectious and parasitic diseases, and cirrhosis. The selected studies showed low consistency in the results and important methodological limitations that prevented comparisons between studies or the extraction of relevant conclusions.As desigualdades socioeconômicas são uma causa de mortalidade e morbidade superior à maioria dos fatores de risco, especialmente no ambiente urbano. Foi realizada uma revisão sistemática da evidência científica, na qual foram incluídos artigos em inglês, espanhol, português e italiano, e da qual foram excluídos estudos de baixa evidência, onde não constava análise da relação entre mortalidade e nível socioeconômico no ambiente urbano. A seleção de artigos foi efetuada por dois revisores independentes e a extração de dados foi feita através de tabelas de evidência. Foram obtidos 1.509 registros e incluídos 24. Em todos os trabalhos, foi observada maior mortalidade nas áreas com os piores indicadores de privação. Observou-se uma associação com patologias cardiovasculares em seis estudos, com patologias pulmonares, em quatro deles, e com a AIDS, infecções, parasitoses e cirrose em três. Os estudos incluídos apresentam resultados pouco consistentes e importantes limitações metodológicas, impedindo a comparação entre estudos e a inferência de conclusões relevantes.S

Attitudes of primary care physicians to the prescribing of antibiotics and antimicrobial resistance: a qualitative study from Spain.

BACKGROUND AND OBJECTIVE: Resistance to antibiotics is a public health threat. A number of studies confirm the relationship between antibiotic use and the resistance rate. As a whole, physicians represent a large proportion of the health professionals involved in the use of this therapeutic group. Our study therefore sought to ascertain the opinions and attitudes of GPs in Spain with respect to antibiotics and resistance. METHODS: We used the focus group (FG) method, with each group comprising 4-12 primary care physicians and a moderator. Based on a previous systematic review, we drew up an agenda to be followed during the holding of the sessions. Group proceedings were recorded and the transcriptions then analysed separately by two researchers. RESULTS: Five FGs were formed, including a total of 33 physicians. The factors/attitudes that influenced the prescribing of antibiotics by GPs were fear, complacency, insufficient knowledge and external responsibility of the pharmaceutical industry, patients and over-the-counter antibiotics. The groups felt that antibiotic resistance was not a problem at a community level. CONCLUSIONS: Identification of attitudes/knowledge related with inappropriate antibiotic prescribing will enable specific interventions to be designed, with the aim of targeting these shortcomings to improve antibiotic use and help reduce resistance

Health professionals perception and beliefs about drug- related problems on polymedicated older adults- a focus group study

Background: Polymedicated older patients are at greater risk of suffering from adverse events. For this reason, the detection of both inappropriate polypharmacy and polypharmacy-associated Drug-Related Problems (DRPs) are essential to improve the health and wellbeing of older adults and to reduce healthcare costs. This work aims to explore health professionals’ perceptions and opinions about polypharmacy and the handling of medicines by polymedicated older adults. Methods: Thirteen focus groups with 94 health professionals (20 community pharmacists, 40 general practitioners and, 34 nurses) were conducted in primary healthcare centers of the center region of Portugal. Participants were asked to discuss their perceptions and beliefs concerning DRPs in polymedicated older adults. The sessions were audiotaped. After the transcription and coding of focus group sessions, a thematic analysis was done. Results: The following four main themes emerged from the 13 focus group sessions: poor compliance and polypharmacy- A perpetuated vicious cycle, organization of the healthcare system, interaction and communication between the health professionals, and strategies to prevent inappropriate polypharmacy. Conclusions: The lack of both an efficient network of information and Interaction and communication between Health professionals makes the detection and/ or prevention of polypharmacy in older adults difficult. The implementation of new models to manage and/or prevent polypharmacy based on health professional perception and beliefs is essential to prevent DRPs and improve compliance among older adultsThis work was financially supported by the MedElderly project [SAICT-POL/23585/2016], funded by Portuguese Foundation for Science and Technology (FCT/MCTES), Portugal 2020 and Centro 2020 grants; and, by the APIMedOlder project [PTDC/MED-FAR/31598/2017], funded by the operational programme of competitiveness and internationalization (POCI), in its FEDER/FNR component POCI-01-0145-FEDER-031598, and the Foundation for Science and Technology, in its state budget component (OE)S

Validation of the eHealthResp online course for pharmacists and physicians: A Delphi method approach

Framework: The inappropriate use of antibiotics for respiratory tract infections is dispersed worldwide, thus being a strong contributor to antibiotic resistances. As the use of educational interventions among health practitioners is shown to have an impact on judicious antibiotic use, an online course (eHealthResp) has been developed, especially targeted to pharmacists and physicians. Thus, the main goal of this study is to validate the contents of the online course eHealthResp. Methods: This two-round Delphi study involved the recruitment of a multidisciplinary panel (n = 19), to which the questionnaires of the first round were sent. After the first round, a report summing up the results has been forwarded to the panel, along with a new, reformulated version of the questionnaire. Results: After the two rounds of the Delphi process, consensus was evaluated. Six clinical cases and fifty-one treatments obtained minor consensus [60–75%] or full consensus (≥75%). The question on antibiotic practice has obtained a consensus >90% on both rounds. Conclusions: The validation of the contents based on experts’ consensus has been an essential approach to improve eHealthResp’s online course, as valuable feedback has been provided by the panel on both roundsProject PTDC/SAU-SER/31678/2017 was supported by the operational program of competitiveness and internationalisation, in its FEDER/FNR component POCI-01-0145-FEDER-031678, the Foundation for Science and Technology, in its state budget component (OE), and the Institute of Biomedicine (iBiMED) (UIDB/04501/2020 and POCI-01-0145-FEDER-007628)S

Physicians' attitudes and knowledge concerning antibiotic prescription and resistance: questionnaire development and reliability

Background Understanding physicians’ antibiotic-prescribing behaviour is fundamental when it comes to improving antibiotic use and tackling the growing rates of antimicrobial resistance. The aim of the study was to develop and validate -in terms of face validity, content validity and reliability- an instrument designed to assess the attitudes and knowledge underlying physician antibiotic prescribing. Methods The questionnaire development and validation process comprised two different steps, namely: (1) content and face validation, which included a literature review and validation both by physicians and by Portuguese language and clinical psychology experts; and (2) reliability analysis, using the test-retest method, to assess the questionnaire’s internal consistency (Cronbach’s alpha) and reproducibility (intraclass correlation coefficient - ICC). The questionnaire includes 17 items assessing attitudes and knowledge about antibiotic prescribing and resistances and 9 items evaluating the importance of different sources of knowledge. The study was conducted in the catchment area covered by Portugal’s Northern Regional Health Administration and used a convenience sample of 61 primary-care and 50 hospital-care physicians. Results Response rate was 64 % (49 % to retest) for primary-care physicians and 66 % (60 % to retest) for hospital-care physicians. Content validity resulted in 9 changes to professional concepts. Face validity assessment resulted in 19 changes to linguistic and interpretative terms. In the case of the reliability analysis, the ICC values indicated a minimum of fair to good reproducibility (ICC > 0.4), and the Cronbach alpha values were satisfactory (α > 0.70). Conclusions The questionnaire developed is valid -in terms of face validity, content validity and reliability- for assessing physicians’ attitudes to and knowledge of antibiotic prescribing and resistance, in both hospital and primary-care settings, and could be a very useful tool for characterising physicians’ antibiotic-prescribing behaviour.This work was supported by the Foundation for Science & Technology (Fundação para a Ciência e Tecnologia - FCT), Portuguese Ministry of Education & Science [PTDC/SAU-ESA/105530/2008] and co-financed by Fundo Europeu de Desenvolvimento Regional (FEDER) through the Programa Operacional Factores de Competitividade (COMPETE) ProgramS

Magnitude and determinants of antibiotic dispensing without prescription in Spain: a simulated patient study

OBJECTIVES: Excessive and inappropriate use of antibiotics increases antimicrobial resistance. The aim of this study was to determine the magnitude and determinants of antibiotic dispensing without prescription in Spain by the simulated patient technique. METHODS: A cross-sectional study was conducted with all the pharmacies in a region of north-west Spain (n = 977), between December 2016 and January 2017. Four actors visited the pharmacies simulating a respiratory infection. Four incremental levels of pressure were used to obtain an antibiotic. The education and sex of the person who was dispensing and the area where the pharmacy was located were recorded. The effect of these independent variables on the dispensing of an antibiotic without prescription (1 = yes, 0 = no) was modelled by logistic regression. RESULTS: An antibiotic was obtained in 18.83% (95% CI = 16.5%-21.41%) of the visits. The area influenced the dispensing of antibiotics without a medical prescription, with a greater likelihood of dispensing in rural (OR = 1.79; 95% CI = 1.20-2.68) or semi-rural (OR = 1.66; 95% CI = 1.13-2.44) areas than in urban areas. No association was found with the sex or the training of the person who dispensed the antibiotic. In the pharmacies in urban areas, a lower level of pressure was needed to obtain the antibiotic. CONCLUSIONS: This study shows that one-fifth of the pharmacies still dispense antibiotics without prescription, especially under patient pressure. A rural setting has been identified as a risk factor for dispensing without prescription, so it must be taken into account for future interventions.Fondo de Investigación SanitariaInstituto de Salud Carlos II

Case-crossover design: Basic essentials and applications

El diseño de casos cruzados es un diseño epidemiológico observacional propuesto por Maclure en 1991 para valorar si alguna exposición intermitente o inusual ha desencadenado un evento agudo a muy corto plazo. En este trabajo se presentan los fundamentos de los diseños de casos cruzados, con sus aplicaciones y limitaciones. El diseño de casos cruzados se basa en seleccionar sólo sujetos caso. Para calcular el riesgo relativo se compara la exposición durante el periodo de tiempo previo al evento (periodo caso) con la exposición del mismo sujeto en uno o varios periodos control. Este método únicamente es adecuado cuando las exposiciones son cambiantes en el tiempo, con efectos a corto plazo, y el efecto es agudo. Para exposiciones en que no existe tendencia, el planteamiento unidireccional es el más frecuente, y consiste en seleccionar uno o varios periodos control previos al momento caso. Cuando la exposición tiene una tendencia temporal (por ejemplo las de contaminación atmosférica), el planteamiento unidireccional proporciona estimaciones sesgadas, por lo que se utilizan diseños de casos cruzados bidireccionales, que seleccionan periodos de tiempo control anteriores y posteriores al del evento. Es un método que cuenta con una creciente utilización en amplios campos: desencadenantes de accidentes de tráfico, laborales y domésticos, o de infarto agudo de miocardio, contaminación atmosférica y salud, farmacoepidemiología, etc. Para el análisis de datos, generalmente se pueden considerar los diseños de casos cruzados como estudios de casos y controles emparejados, por lo que se aplica regresión logística condicional. Finalmente, en este trabajo se analizan ejemplos prácticos de diferentes aplicaciones del diseño de casos cruzadosCase-crossover analysis is an observational epidemiological design that was proposed by Maclure in 1991 to assess whether a given intermittent or unusual exposure may have triggered an immediate short-term, acute event. The present article outlines the basics of case-crossover designs, as well as their applications and limitations. The case-crossover design is based on exclusively selecting case subjects. To calculate relative risk, exposure during the period of time prior to the event (case period) is compared against the same subject's exposure during one or more control periods. This method is only appropriate when the exposures are transient in time and have acute short-term effects. For exposures in which there is no trend, a unidirectional approach is the most frequent and consists of selecting one or more control periods prior to the case period. When the exposure displays a time trend (e.g., air pollution), a unidirectional approach will yield biased estimates, and therefore bidirectional case-crossover designs are used, which select control time intervals preceding and subsequent to that of the event. The case-crossover design is being increasingly used across a wide range of fields, including factors triggering traffic, occupational and domestic accidents and acute myocardial infarction, and those involved in air pollution and health and pharmacoepidemiology, among others. Insofar as data-analysis is concerned, case-crossover designs can generally be regarded as matched case-control studies and consequently conditional logistic regression can be applied. Lastly, this study analyzes practical examples of distinct applications of the case-crossover designEste trabajo se ha financiado por una acción específica del CIBERESP (CIBERESP-MET-007) y por el proyecto intramural del ISCIII: SEPY1106/07S