Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND: The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate. METHODS AND FINDINGS: We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies\u27 estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription. CONCLUSIONS: Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines. TRIAL REGISTRATION: PROSPERO registration number: CRD42019123269

Viability and Burden of Leishmania in Extralesional Sites during Human Dermal Leishmaniasis

Understanding of the dynamics and distribution of Leishmania in the human host is fundamental to the targeting of control measures and their evaluation. Amplification of parasite gene sequences in clinical samples from cutaneous leishmaniasis patients has provided evidence of Leishmania in blood, other tissues and sites distinct from the lesion and of persistence of infection after clinical resolution of disease. However, there is uncertainty about the interpretation of the presence of Leishmania DNA as indicative of viable parasites. Because RNA is short-lived and labile, its presence provides an indicator of viability. We amplified Leishmania 7SLRNA, a molecule involved in intracellular protein translocation, to establish viability and estimate parasite load in blood monocytes, tonsil swab samples, and tissue fluid from healthy skin of patients with dermal leishmaniasis. Results showed that during active dermal leishmaniasis, viable Leishmania are present in blood monocytes, tonsils and normal skin in quantities similar to that in lesions, demonstrating widespread dissemination of infection and subclinical involvement of tissues beyond the lesion site. Leishmania 7SLRNA will be useful in deciphering the role of human infection in transmission

SARS-CoV-2 breakthrough infections among vaccinated individuals with rheumatic disease : Results from the COVID-19 Global Rheumatology Alliance provider registry

Funding Information: members of the COVID-19 Global Rheumatology Alliance and do not necessarily represent the views of the American College of Rheumatology (ACR), EULAR, the UK National Health Service (NHS), the National Institute for Health Research (NIHR), the UK Department of Health or any other organisation. Competing interests KLH reports she has received non-personal speaker’s fees from AbbVie and grant income from BMS, UCB and Pfizer, all unrelated to this manuscript; KLH is supported by the NIHR Manchester Biomedical Research Centre. LG reports personal consultant fees from AbbVie, Amgen, BMS, Biogen, Celgene, Gilead, Janssen, Lilly, Novartis, Pfizer, Samsung Bioepis, Sanofi-Aventis and UCB, and grants from Amgen, Lilly, Janssen, Pfizer, Sandoz, Sanofi and Galapagos, all unrelated to this manuscript. AS reports research grants from a consortium of 14 companies (among them AbbVie, BMS, Celltrion, Fresenius Funding Information: Kabi, Gilead/Galapagos, Lilly, Mylan/Viatris, Hexal, MSD, Pfizer, Roche, Samsung, Sanofi-Aventis and UCB) supporting the German RABBIT register and personal fees from lectures for AbbVie, MSD, Roche, BMS, Lilly and Pfizer, all unrelated to this manuscript. LC has not received fees or personal grants from any laboratory, but her institute works by contract for laboratories among other institutions, such as AbbVie Spain, Eisai, Gebro Pharma, Merck Sharp & Dohme España, Novartis Farmaceutica, Pfizer, Roche Farma, Sanofi-Aventis, Astellas Pharma, Actelion Pharmaceuticals España, Grünenthal and UCB Pharma. EF-M reports personal consultant fees from Boehringer Ingelheim Portugal and that LPCDR received support for specific activities: grants from AbbVie, Novartis, Janssen-Cilag, Lilly Portugal, Sanofi, Grünenthal, MSD, Celgene, Medac, Pharmakern and GAfPA; grants and non-financial support from Pfizer; and non-financial support from Grünenthal, outside the submitted work. IB reports personal consultant fees from AbbVie, Novartis, Pfizer and Janssen, all unrelated to this manuscript. JZ reports speaker fees from AbbVie, Novartis and Janssen/Johnson & Johnson, all unrelated to this manuscript. GR-C reports personal consultant fees from Eli Lilly and Novartis, all unrelated to this manuscript. JS is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers: R01 AR077607, P30 AR070253 and P30 AR072577), and the R Bruce and Joan M Mickey Research Scholar Fund. JS has received research support from Amgen and Bristol Myers Squibb and performed consultancy for Bristol Myers Squibb, Gilead, Inova, Janssen and Optum, unrelated to this work. LW receives speaker’s bureau fees from Aurinia Pharma, unrelated to this manuscript. SB reports no competing interests related to this work. He reports non-branded consulting fees for AbbVie, Horizon and Novartis (all <$10 000). MGM has no competing interests related to this work. She serves as a patient consultant for BMS, BI JNJ and Aurinia (all <$10 000). RG reports no competing interests related to this work. Outside of this work she reports personal and/or speaking fees from AbbVie, Janssen, Novartis, Pfizer and Cornerstones and travel assistance from Pfizer (all <$10 000). JH reports no competing interests related to this work. He is supported by grants from the Rheumatology Research Foundation and has salary support from the Childhood Arthritis and Rheumatology Research Alliance. He has performed consulting for Novartis, Sobi and Biogen, all unrelated to this work (<$10 000). ESi reports non-financial support from Canadian Arthritis Patient Alliance, outside the submitted work. PS reports personal fees from the American College of Rheumatology/Wiley Publishing, outside the submitted work. ZW reports grant support from Bristol Myers Squibb and Principia/Sanofi and performed consultancy for Viela Bio and MedPace, outside the submitted work. His work is supported by grants from the National Institutes of Health. PMM has received consulting/speaker’s fees from AbbVie, BMS, Celgene, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Orphazyme, Pfizer, Roche and UCB, all unrelated to this study. PMM is supported by the National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC). PCR reports no competing interests related to this work. Outside of this work PCR reports personal fees from AbbVie, Atom Bioscience, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, Kukdong, Novartis, UCB, Roche and Pfizer; meeting attendance support from BMS, Pfizer and UCB; and grant funding from Janssen, Novartis, Pfizer and UCB Pharma (all <$10 000). JY reports no competing interests related to this work. Her work is supported by grants from the National Institutes of Health (K24 AR074534 and P30 AR070155). Outside of this work, she has received research grants or performed consulting for Gilead, BMS Foundation, Pfizer, Aurinia and AstraZeneca. Funding Information: Twitter Jean Liew @rheum_cat, Loreto Carmona @carmona_loreto, Pedro M Machado @pedrommcmachado and Philip C Robinson @philipcrobinson Contributors All authors contributed to the study design, data collection, interpretation of results and review/approval of the final submitted manuscript. JL and MG are guarantors for this manuscript. Funding MG reports grants from the National Institutes of Health, NIAMS, outside the submitted work. KLH is supported by the NIHR Manchester Biomedical Research Centre. JS is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers: R01 AR077607, P30 AR070253 and P30 AR072577), and the R Bruce and Joan M Mickey Research Scholar Fund. JH is supported by grants from the Rheumatology Research Foundation. ZW is supported by grants from the National Institutes of Health. PMM is supported by the National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC). JY is supported by grants from the National Institutes of Health (K24 AR074534 and P30 AR070155). Publisher Copyright: ©Objective. While COVID-19 vaccination prevents severe infections, poor immunogenicity in immunocompromised people threatens vaccine effectiveness. We analysed the clinical characteristics of patients with rheumatic disease who developed breakthrough COVID-19 after vaccination against SARS-CoV-2.  Methods. We included people partially or fully vaccinated against SARS-CoV-2 who developed COVID-19 between 5 January and 30 September 2021 and were reported to the Global Rheumatology Alliance registry. Breakthrough infections were defined as occurring ≥14 days after completion of the vaccination series, specifically 14 days after the second dose in a two-dose series or 14 days after a single-dose vaccine. We analysed patients' demographic and clinical characteristics and COVID-19 symptoms and outcomes. Results SARS-CoV-2 infection was reported in 197 partially or fully vaccinated people with rheumatic disease (mean age 54 years, 77% female, 56% white). The majority (n=140/197, 71%) received messenger RNA vaccines. Among the fully vaccinated (n=87), infection occurred a mean of 112 (±60) days after the second vaccine dose. Among those fully vaccinated and hospitalised (n=22, age range 36-83 years), nine had used B cell-depleting therapy (BCDT), with six as monotherapy, at the time of vaccination. Three were on mycophenolate. The majority (n=14/22, 64%) were not taking systemic glucocorticoids. Eight patients had pre-existing lung disease and five patients died. Conclusion. More than half of fully vaccinated individuals with breakthrough infections requiring hospitalisation were on BCDT or mycophenolate. Further risk mitigation strategies are likely needed to protect this selected high-risk population.publishersversionPeer reviewe

Undergraduates Prefer Federated Searching to Searching Databases Individually. A Review of: Belliston, C. Jeffrey, Jared L. Howland, & Brian C. Roberts. “Undergraduate Use of Federated Searching: A Survey of Preferences and Perceptions of Value-Added Functionality.” College & Research Libraries 68.6 (Nov. 2007): 472-86.

Objective – To determine whether use offederated searching by undergraduates saves time, meets their information needs, is preferred over searching databases individually, and provides results of higher quality. Design – Crossover study.Setting – Three American universities, all members of the Consortium of Church Libraries & Archives (CCLA): BYU (Brigham Young University, a large research university); BYUH (Brigham Young University – Hawaii, a small baccalaureate college); and BYUI (Brigham Young University – Idaho, a large baccalaureate college)Subjects – Ninety-five participants recruited via e-mail invitations sent to a random sample of currently enrolled undergraduates at BYU, BYUH, and BYUI.Methods – Participants were given written directions to complete a literature search for journal articles on two biology-related topics using two search methods: 1. federated searching with WebFeat® (implemented in the same way for this study at the three universities) and 2. a hyperlinked list of databases to search individually. Both methods used the same set of seven databases. Each topic was assigned in random order to one of the two search methods, also assigned in random order, for a total of two searches per participant. The time to complete the searches was recorded. Students compiled their list of citations, which were later normalized and graded. To analyze the quality of the citations, one quantitative rubric was created by librarians and one qualitative rubric was approved by a faculty member at BYU. The librarian-created rubric included the journal impact factor (from ISI’s Journal Citation Reports®), the proportion of citations from peer-reviewed journals (determined from Ulrichsweb.com™) to total citations, and the timeliness of the articles. The faculty-approved rubric included three criteria: relevance to the topic, quality of the individual citations (good quality: primary research results, peer-reviewed sources), and number of citations. Data were then analysed using ANOVA and MANOVA. Finally, librarians at the ACRL 13th NationalConference Presentation were polled about their perceptions of the time savings of federated searching, whether the method meets undergraduates’ information needs, undergraduate preference for searching, and the quality of citations found.Main Results – Seventy percent of all participants preferred federated searching. For all schools combined, there was nostatistically significant difference between the average time taken using federated searching (20.34 minutes) vs. non-federated searching (22.72 minutes). For all schools combined, there was a statistically significant difference in satisfaction of results favouring federated searching (5.59/7 vs. 4.80/7 for non-federated searching, α = .05). According to the librarian-created rubric, citations retrieved from federated searching were a statistically significant 6% lower in quality than citations retrieved from non-federated searching (α = .05). The faculty-approved rubric did not detect a difference in the quality of the citations retrieved using the 2 methods. Librarians’ perceptions as assessed at the ACRL 13thNational Conference Presentation generally matched the authors’findings.Conclusion – Overall, students in this study preferred federated searching, were more satisfied with the results of federated searching, and saved time (although the savings were not statistically significant). The quality of citations retrieved via both methods was judged to be similar. The study provides useful information for librarians interested in users’ experiences and perceptions of federated searching, and indicates future studies worth conducting

Undergraduates Prefer Federated Searching to Searching Databases Individually (Review of: Belliston, C. Jeffrey, et al. “UnCollege & Research Libraries 68.6 (Nov. 2007): 472-86.)

Objective: To determine whether use of federated searching by undergraduates saves time, meets their information needs, is preferred over searching databases individually, and provides results of higher quality. [...

Identifying the Most Popular Entry Routes into a Public Library Using GIS Can Be a Tool to Increase Ease of Navigation and Identify Placement of Marketing Materials. A Review of: Mandel, L. H. (2010). Toward an understanding of library patron wayfinding: Observing patrons’ entry routes in a public library. Library & Information Science Research, 32, 116-130.

Objective – To evaluate and measure how patrons physically navigate entry routes within a public library and determine whether GIS is a useful instrument for this purpose.Design – Unobtrusive, covert observational study.Setting – Medium-sized public library in the United States.Subjects – 1,415 patrons were observed as they entered the library.Methods – Routes used by patron cases were selected as the unit of analysis. Patron cases were either individuals entering the building alone or groups entering the building together. Patrons were observed from a stationary and unobtrusive location. ArcMap (GIS software) was used to develop the floor plan instrument on which entry routes were recorded and then later analyzed. The paths analyzed were limited to what was considered the “entry area.” Data were collected during three separate one-hour periods for six consecutive days in the fall of 2008. The researcher chose three purposive one-hour time samples with the intention of distributing them across the library’s opening hours.Main results – The 1,415 patron cases used 195 unique routes that were recorded from the two entrances of the facility, with the east (right) entrance accounting for 83.3% of the cases (n=1178). Two entry routes were consistently the most popular overall and across each of the sample days. The next-most- popular entry routes did not remain constant across the total observed cases and each day’s observed cases or across the sample days. Over 75% of all observed patrons used 22 of the 195 entry routes: 7 routes were used by 30 or more cases each (n=836, 59.1% of all cases), 4 by 20 to 29 cases each (n=95, 6.7% of all cases), and 11 by 10 to 19 cases each (n=159, 11.2% of all cases). The route to the circulation desk was the most popular entry route for patrons. The other most popular route passed toward the rear of the library, but the observer could not record the final destination(s) of that route due to the restricted viewable area.Conclusion – The study helped the researcher to establish what areas would be ideal locations for the placement of marketing materials and a book display. Knowledge of popular entry routes can also be useful in identifying routes that could be enlarged to ease patron navigation. GIS was shown to be a useful mapping instrument for recording and analyzing routes taken

Systematic reviews and librarians: a primer for managers

Systematic reviews—and research syntheses in general—are increasing as a form of research. As a result, academic librarians from across disciplines are seeing a growth in the number of requests for library resources and services to support the development and publication of systematic reviews. In some cases, librarian involvement with systematic reviews takes the form of co-authorship. This article will arm library decision-makers with an overview of systematic reviews and details of how they differ from traditional literature reviews. Systematic reviews provide exciting opportunities for libraries such as potential income, increased use of library services, research output, and alignment with the new roles of academic libraries; however, they also raise issues that managers, administrators, and leaders need to understand and address if librarians are to succeed in these evolving partnerships with their research communities. Significant issues raised include: training and mentoring, time commitment, tenure and promotion, workload, student and research support, and funding