Effect of point-of-care C-reactive protein testing on antibiotic prescription in febrile patients attending primary care in Thailand and Myanmar : an open-label, randomised, controlled trial

Background In southeast Asia, antibiotic prescription in febrile patients attending primary care is common, and a probable contributor to the high burden of antimicrobial resistance. The objective of this trial was to explore whether C-reactive protein (CRP) testing at point of care could rationalise antibiotic prescription in primary care, comparing two proposed thresholds to classify CRP concentrations as low or high to guide antibiotic treatment. Methods We did a multicentre, open-label, randomised, controlled trial in participants aged at least 1 year with a documented fever or a chief complaint of fever (regardless of previous antibiotic intake and comorbidities other than malignancies) recruited from six public primary care units in Thailand and three primary care clinics and one outpatient department in Myanmar. Individuals were randomly assigned using a computer-based randomisation system at a ratio of 1:1:1 to either the control group or one of two CRP testing groups, which used thresholds of 20 mg/L (group A) or 40 mg/L CRP (group B) to guide antibiotic prescription. Health-care providers were masked to allocation between the two intervention groups but not to the control group. The primary outcome was the prescription of any antibiotic from day 0 to day 5 and the proportion of patients who were prescribed an antibiotic when CRP concentrations were above and below the 20 mg/L or 40 mg/L thresholds. The primary outcome was analysed in the intention-to-treat and per-protocol populations. The trial is registered with ClinicalTrials.gov, number NCT02758821, and is now completed. Findings Between June 8, 2016, and Aug 25, 2017, we recruited 2410 patients, of whom 803 patients were randomly assigned to CRP group A, 800 to CRP group B, and 807 to the control group. 598 patients in CRP group A, 593 in CRP group B, and 767 in the control group had follow-up data for both day 5 and day 14 and had been prescribed antibiotics (or not) in accordance with test results (per-protocol population). During the trial, 318 (39%) of 807 patients in the control group were prescribed an antibiotic by day 5, compared with 290 (36%) of 803 patients in CRP group A and 275 (34%) of 800 in CRP group B. The adjusted odds ratio (aOR) of 0·80 (95% CI 0·65–0·98) and risk difference of −5·0 percentage points (95% CI −9·7 to −0·3) between group B and the control group were significant, although lower than anticipated, whereas the reduction in prescribing in group A compared with the control group was not significant (aOR 0·86 [0·70–1·06]; risk difference −3·3 percentage points [–8·0 to 1·4]). Patients with high CRP concentrations in both intervention groups were more likely to be prescribed an antibiotic than in the control group (CRP ≥20 mg/L: group A vs control group, p<0·0001; CRP ≥40 mg/L: group B vs control group, p<0·0001), and those with low CRP concentrations were more likely to have an antibiotic withheld (CRP <20 mg/L: group A vs control group, p<0·0001; CRP <40 mg/L: group B vs control group, p<0·0001). 24 serious adverse events were recorded, consisting of 23 hospital admissions and one death, which occurred in CRP group A. Only one serious adverse event was thought to be possibly related to the study (a hospital admission in CRP group A). Interpretation In febrile patients attending primary care, testing for CRP at point of care with a threshold of 40 mg/L resulted in a modest but significant reduction in antibiotic prescribing, with patients with high CRP being more likely to be prescribed an antibiotic, and no evidence of a difference in clinical outcomes. This study extends the evidence base from lower-income settings supporting the use of CRP tests to rationalise antibiotic use in primary care patients with an acute febrile illness. A key limitation of this study is the individual rather than cluster randomised study design which might have resulted in contamination between the study groups, reducing the effect size of the intervention

The utility of an AMR dictionary as an educational tool to improve public understanding of antimicrobial resistance

Background: Communicating about antimicrobial resistance (AMR) to the public is challenging.   Methods: We developed a dictionary of terms commonly used to communicate about AMR. For each term, we developed learning points to explain AMR and related concepts in plain language.  We conducted a pilot evaluation in 374 high school students in Ubon Ratchathani, Thailand. In three 50-minute sessions, students were asked to answer five true/false questions using a paper-based questionnaire. The first session assessed their understanding of AMR at baseline, the second after searching the internet, and the third after the provision of the printed AMR dictionary and its web address.    Results: We developed the AMR dictionary as a web-based application (www.amrdictionary.net). The Thai version of the AMR dictionary included 35 terms and associated learning points, seven figures displaying posters promoting AMR awareness in Thailand, and 66 recommended online videos. In the pretest, the proportion of correct responses to each question ranged from 10% to 57%; 10% of the students correctly answered that antibiotics cannot kill viruses and 57% correctly answered that unnecessary use of antibiotics makes them ineffective. After the internet searches, the proportions of correct answers increased, ranging from 62% to 89% (all p&lt;0.001). After providing the AMR dictionary, the proportions of correct answers increased further, ranging from 79% to 89% for three questions (p&lt;0.001), and did not change for one question (p=0.15). Correct responses as to whether taking antibiotics often has side-effects such as diarrhoea reduced from 85% to 74% (p&lt;0.001). The dictionary was revised based on the findings and comments received. Conclusions: Understanding of AMR among Thai high school students is limited. The AMR dictionary can be a useful supportive tool to increase awareness and improve understanding of AMR. Our findings support the need to evaluate the effectiveness of communication tools in the real-world setting.</ns3:p

Consumers' motivation in responding to prescription drug advertising.

This study examined how Direct-to-Consumer (DTC) advertising of prescription drugs motivates consumers to take particular actions, based on the combined framework of the self-regulatory focus theory and the self-construal orientation. The self-regulatory focus theory posits that behavior is regulated by two systems: promotion (emphasizing achievements) and prevention (emphasizing safety/obligations). The self-construal orientation suggests that behavior is guided by two self-views: independent-self (emphasizing autonomy/uniqueness) and interdependent-self (emphasizing family/social relationships). The study included three sets of hypotheses. In the first, we hypothesized that the motivational power of the ad will create a more favorable ad/brand attitude, greater intention-to-act, and greater likelihood-of-action, when the ad conveys goal compatible messages. The goal compatible messages occur with (1) a promotion focus and an independent self-construal and (2) a prevention focus and an interdependent self-construal. The second set of hypotheses suggests that prevention-focused ads (versus promotion-focused ads) will elicit better risk information recall. The third set of hypotheses predicts that the individual will engage in a particular set of actions (e.g., requesting a prescription or seeking more information) as a result of seeing the ad. A 2 (independence versus interdependence) x 2 (promotion versus prevention) factorial study design was used. A sample of 220 university female staff aged 40 years old or older were randomly assigned to view one of the four mock anti-hyperlipidemia drug advertisements and completed a questionnaire. The results from the main analyses marginally supported the first set of hypotheses regarding the goal compatibility effects but did support the third set of hypotheses about the hierarchy of advertising effects. The result for the second set of hypotheses regarding the effects of self-regulatory focus on risk information recall was in the opposite direction than we predicted. Post hoc analyses for the first set of hypotheses revealed that overall data from participants who had positive/neutral DTC advertising attitudes supported the hypotheses about goal compatibility, whereas the results from those with negative DTC advertising attitudes appeared to be in opposite directions. Our conclusion is that self-regulatory focus theory and self-construal orientation is a useful framework for understanding the mechanisms by which DTC ads influence consumer behavior.Ph.D.Health and Environmental SciencesPharmaceutical sciencesPsychologySocial psychologyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/123962/2/3106171.pd

“Give Me Happiness” or “Take Away My Pain”: Explaining consumer responses to prescription drug advertising

We examine how consumers react to direct-to-consumer advertising (DTCA) by investigating the role of goal compatibility between motivation to process advertisements and consumer self-concept. Specifically, we examine the interaction between self-regulatory (prevention versus promotion) focus and self-construal orientation (independent versus interdependent) and find that prevention (versus promotion) focused consumers form stronger intentions to speak with physicians and are more likely to discuss an advertised drug, when the ad uses an interdependence self-construal theme, whereas promotion (versus prevention) focused consumers form stronger intentions to speak with physicians and are more likely to discuss an advertised drug, when the ad uses an independent self-construal theme. The above two-way interaction was further found to be governed by attitudes toward DTCA. Under goal compatibility, consumers who had positive or neutral attitudes toward DTCA (versus negative) had stronger (a) intentions to speak with physicians about the advertised drug, (b) stronger intentions to speak with physicians about high cholesterol, (c) greater likelihood of discussing the drug with health professionals, and (d) greater likelihood of requesting a prescription, yet did not differ in perceptions of drug benefits and risks. Hypotheses were tested on a sample of 197 female staff and retirees (aged 40–80 years) at a large university

Pharmacy practice in Thailand

Pharmacy education was established in Thailand in 1913 and gradually evolved to pharmaceutical care in recent decades. By the year 2014, all schools of pharmacy were required by the Pharmacy Council of Thailand to offer only a 6-year Doctor of Pharmacy (PharmD) program. The paradigm shift to the PharmD program and the implementation of a quality assurance system have tremendously influenced pharmacy practice in Thailand. Hospital pharmacists have become more involved in pharmacy education through preceptorships and are an integral part of inpatient and outpatient care teams. In community pharmacy practice, a number of services have recently been provided and are reimbursable, ranging from public health practice (i.e., health prevention/promotion) to advanced professional practice (e.g., medication use review). Challenges to Thai pharmacy practice include the distribution of pharmacists to meet the workforce demands. Evidence synthesis is needed to guide the implementation and course of Thai pharmacy practice in the future

The Lancet Infectious Diseases

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.volumen 13; número 1