Antibiotic (ATB) overprescription leads to antimicrobial resistance (AMR) and adverse events (AEs) and poses significant economic burdens on European healthcare systems. The aim of this study was to assess the economic impact associated with interventions aimed at reducing unnecessary ATB prescriptions in general practice, and to extrapolate the results at the European Union (EU) level. We used data from the “HAPPY PATIENT” project, a before-and-after study that implemented a multifaceted intervention in primary care settings in France, Greece, Lithuania, Poland, and Spain. Based on the outcomes observed in general practice across these five countries we extrapolated the results to estimate for each of the 27 EU member states: i) the costs of implementing the interventions, ii) the number of potentially unnecessary ATB prescriptions avoided, and iii) the potential savings due to reductions in unnecessary ATB prescriptions. We considered a realistic and an optimistic scenario: using the mean and the largest reduction in unnecessary ATB prescriptions observed across each of the five participating countries, respectively. Across the EU, €2.7 billion are estimated to be spent annually on healthcare resources linked to potentially unnecessary ATB prescribed in general practice. Implementing the interventions across the EU is projected to cost €107 million. Positive net savings were estimated in both scenarios, €151 million in the realistic scenario and €423 million in the optimistic scenario. Several sensitivity analyses were conducted to characterise the substantial uncertainty surrounding these estimates, which yielded considerable potential savings in all cases.

Urinary tract infections (UTIs) are highly prevalent, affecting up to 50

Background Recurrent urinary tract infection (rUTI) in women is common in primary care. Antibiotics can prevent rUTI, but their use is associated with the risk of developing antimicrobial resistance. Thus, non-antibiotic strategies are needed, yet evidence remains limited due to methodologically weak studies. Consequently, potentially effective strategies lack sufficient evidence for guideline inclusion, leaving healthcare professionals (HCPs) and women with little support. This scoping review synthesises preventive strategies for rUTIs in premenopausal women, mapping recommendations and underlying rationales to guide future research and guideline development.Methods This Scoping review was conducted by searching PubMed, Cochrane, EMBASE, Web of Science, and CINAHL. 6170 records were identified for eligibility. A total of 78 publications were included, i.e. reviews, guidelines, and expert reports regarding preventive strategies used for rUTIs for premenopausal women, published between January 2013 and December 2023.Results 78 publications addressed rUTIs prevention in premenopausal women, encompassing both well-studied strategies, such as antibiotic regimens and cranberry products, and less-studied approaches, including behavioural modifications, vitamin supplements, and increased hydration. Recommendations were often unsupported by evidence, and disagreement among sources was common.Discussion To support women with rUTIs, HCPs require an overview of preventive strategies including supporting recommendations and evidence. Our findings highlight a clear contrast between well-studied strategies, such as antibiotic regimens, and behavioural strategies, where evidence is limited, often because some cannot feasibly be evaluated in randomised trials rather than due to limited clinical relevance. These findings may help HCPs and guideline developers assess evidence and prioritise future research.

Objectives The primary driver of antimicrobial resistance is excessive antibiotic use, posing a global threat to public health. Reducing individual exposure to antibiotics is a key to addressing the problem. This study aimed to assess the duration of antibiotic courses administered to patients with acute respiratory tract infections (RTIs) in primary care. Methods Consecutive patients presenting with RTI symptoms were prospectively included from general practices and out-of-hours services in France, Greece, Lithuania, Poland and Spain for two winter periods (February to April 2022 and 2023). Data were collected using a paper-based Audit Project Odense template, with clinicians recording patient age, gender, RTI diagnosis, type of antibiotic prescribed and treatment duration. Results A total of 196 doctors (133 in general practice and 63 in out-of-hours services) registered 11 270 cases, with 34.0% (3835) receiving antibiotics. The mean antibiotic course duration was 7.52 days (SD 2.11), which was significantly longer for pneumonia, COVID-19 infection and pharyngotonsillitis (8.01, 8.00 and 7.74 days, respectively), and lowest for predominantly viral infections, such as the common cold and flu infection, laryngitis and acute bronchitis (6.32, 6.48 and 6.98 days, respectively; P < 0.001). A total of 26.7% of the courses were prescribed for 10 days or longer. Conclusions Antibiotic courses for common RTIs are often prolonged, which does not align with current recommendations for course duration. Antibiotics should be avoided in cases of predominantly viral infections and most mixed infections; however, if deemed necessary, the courses should be substantially reduced to minimize unnecessary exposure.

Background: The primary cause of antimicrobial resistance is excessive and non-indicated antibiotic use. Aim: To evaluate the impact of a multifaceted intervention aimed at various healthcare professionals (HCPs) on antibiotic prescribing and dispensing for common infections. Design and setting: Before-and-after study set in general practice, out-of-hours services, nursing homes, and community pharmacies in France, Greece, Lithuania, Poland, and Spain. Methods: Following the Audit Project Odense method, HCPs from these four settings self-registered encounters with patients related to anti-biotic prescribing and dispensing before and after an intervention (February-April 2022 and February-April 2023). Prior to the second registration, the HCPs undertook a multifaceted intervention, which included reviewing and discussing feedback on the first registration's results, enhancing communication skills, and providing communication tools. Indicators to identify potentially unnecessary prescriptions and non-first-line antibiotic choices were developed, and the results of the two registrations were compared. Results: A total of 345 HCPs registered 10744 infections in the first registration period and 10207 infections in the second period. In general practice, participants showed a significant 9.8% reduction in unnecessary antibiotic prescriptions in the second period, whereas limited or no effect was observed in out-of-hours services and nursing homes (0.8% reduction and 4.5% increase, respectively). Pharmacies demonstrated an 18% increase in safety checks, and correct advice in pharmacies rose by 17%. Conclusion: External factors like COVID-19, antibiotic shortages, and a streptococcal epidemic impacted the intervention's benefits. Despite this, the intervention successfully improved antibiotic use in both settings.

BACKGROUND:Community pharmacies can play a pivotal role in optimising the use of antibiotics through their dispensing practice. AIM:To evaluate the impact of a multifaceted intervention on community pharmacies' quality of antibiotic dispensing. METHOD:A prospective before-after study conducted according to the Audit Project Odense methodology in community pharmacies in France, Greece, Lithuania, Poland, and Spain. Pharmacy staff audited dispensing practices through a self-registry form before and after a multifaceted intervention, comprising feedback to participants on dispensing practice, communication training, and providing educational materials for patients. Dispensing of all oral antibiotics for five days in February 2022 and after interventions in February 2023 was registered. Data were analysed by country and overall using ten quality indicators, with Chi-square tests and Students' t-tests applied. RESULTS:A total of 91 pharmacists registered 5.054 dispenses. There was an 18 % (p < 0.001) improvement in the mean number of safety checks performed and a 17 % (p < 0.001) reduction in the number of dispenses for which no safety checks were performed after the intervention. Pharmacists provided 17 % (p < 0.001) more advice to patients and reduced the dispenses for which no advice was provided by 35 % (p = 0.006). This came with a 44 % (p < 0.001) increase in inappropriate advice that was provided. Large differences between the countries were observed. For performing safety checks, a 13 % (p = 0.004) worsening was seen in Greece and a 72 % (p=<0.001) improvement in Spain. In France, treatment duration and dose were discussed with patients in 97 % and 98 % of the dispenses at baseline, respectively, without improvements after the intervention. In Spain, this was 66 % and 51 % at baseline, significantly improving to 80 % and 64 % after the intervention. CONCLUSION:Quality of antibiotic dispensing increased significantly, indicating that intervention is a promising strategy to improve antibiotic use, especially in countries with lower practice standards.

PURPOSE:Antibiotic use is the main driver of bacterial antimicrobial resistance. Urinary tract infections (UTIs), for which antibiotics are often prescribed, are among the most common infections among residents in nursing homes. This study aimed to estimate and compare the appropriateness of antibiotic use for suspected UTIs among nursing home residents across five European countries. Both the decision to treat and the choice of antibiotics used were explored. METHODS:This cross-sectional study used the Audit Project Odense (APO) method. The appropriateness of the treatment decision for UTIs was evaluated according to symptom presentation in residents without indwelling urinary catheters. The choice of antibiotic used for treatment was evaluated according to the first-line antibiotic recommended for the treatment of UTIs in the respective countries. Data were collected through an institutional sign-up questionnaire and a clinical case registration chart. All residents in new or ongoing treatment with systemic antibiotics were registered during a 6-week period between February and April 2022. RESULTS:A total of 70 nursing homes or wards registered 508 antibiotic treatments for suspected UTIs. The proportion of antibiotics prescribed for UTIs to nursing home residents with no specific UTI symptoms varied from 10% in Poland to 68% in Spain. The proportion of treatments with the first-line choice of antibiotics for UTIs also varied from 28% in France and Poland to 55% in Spain. CONCLUSION:There was a substantial proportion of potentially inappropriate antibiotic treatments, with notable variation among the countries studied.

This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals’ awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.

AIMS:The development of effective interventions to reduce inappropriate use of antibiotics in the elderly population requires knowledge on who can benefit from such interventions. Thus, we aimed to identify and characterise antibiotic heavy users among elderly patients in general practice with respect to sociodemographic variables.METHODS:We conducted a retrospective nationwide register-based study on all Danish elderly citizens (⩾65 years) who redeemed an antibiotic prescription in 2017. Heavy users were defined as the 10% with the highest excess use, that is, their recorded use minus the average use for their sex, age group and comorbidity level as estimated from a linear regression model. Comparative analyses of sociodemographic characteristics (civil status, employment status, urbanity, educational level and country of origin) of heavy users and non-heavy users were performed using logistic regression models.RESULTS:The study population consisted of 251,733 elderly individuals, who in total redeemed 573,265 prescriptions of antibiotics. Heavy users accounted for 68% of all excess use of antibiotics. In multivariable analyses, individuals with an educational level above basic schooling, non-retired, residing in an urban municipality and being born in a country outside Scandinavia all had lower odds of being a heavy user. Widowed, divorced or single individuals had higher odds of being a heavy user compared with married individuals. Relative importance analyses showed that civil status and educational level contributed considerably to the explained variance.CONCLUSIONS:This study found an association between sociodemographic characteristics and risk of being a heavy user, indicating that sociodemographic variation exists with regard to antibiotic prescribing.

Background Evidence shows a high rate of unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) in primary care. There is increasing evidence showing that shorter courses for RTIs are safe and help in reducing antimicrobial resistance (AMR). Stopping antibiotics earlier, as soon as patients feel better, rather than completing antibiotic courses, may help reduce unnecessary exposure to antibiotics and AMR.Objectives The aim of this study was to explore the perceptions and views of primary care healthcare professionals about customising antibiotic duration for RTIs by asking patients to stop the antibiotic course when they feel better.Design Qualitative research.Setting and participants A total of 21 qualitative interviews with primary care professionals (experts and non-experts in AMR) were conducted from June to September 2023. Data were audiorecorded, transcribed and analysed thematically.Results Overall, experts seemed more amenable to tailoring the antibiotic duration for RTIs when patients feel better. They also found the dogma of ‘completing the course’ to be obsolete, as evidence is changing and reducing the duration might lead to less AMR, but claimed that evidence that this strategy is as beneficial and safe as fixed courses was unambiguous. Non-experts, however, believed the dogma of completing the course. Clinicians expressed mixed views on what feeling better might mean, supporting a shared decision-making approach when appropriate. Participants claimed good communication to professionals and patients, but were sceptical about the risk of medicalisation when asking patients to contact clinicians again for a check-up visit.Conclusions Clinicians reported positive and negative views about individualising antibiotic courses for RTIs, but, in general, experts supported a customised antibiotic duration as soon as patients feel better. The information provided by this qualitative study will allow improving the performance of a large randomised clinical trial aimed at evaluating if this strategy is safe and beneficial.

BACKGROUND:Overdiagnosis of urinary tract infections (UTIs) is one of the most common reasons for the unnecessary use of antibiotics in nursing homes, increasing the risk of missing serious conditions. Various decision tools and algorithms aim to aid in UTI diagnosis and the initiation of antibiotic therapy for residents. However, due to the lack of a clear reference standard, these tools vary widely and can be complex, with some requiring urine testing. As part of the European-funded IMAGINE project, aimed at improving antibiotic use for UTIs in nursing home residents, we have reviewed the recommendations. OBJECTIVES:This review provides a comprehensive summary of the more relevant tools and algorithms aimed at identifying true UTIs among residents living in nursing homes and discusses the challenges in using these algorithms based on updated research. SOURCES:The discussion is based on a relevant medical literature search and synthesis of the findings and published tools to provide an overview of the current state of improving the diagnosis of UTIs in nursing homes. CONTENT:The following topics are covered: prevalence of asymptomatic bacteriuria, diagnostic challenges, clinical criteria, urinary testing, and algorithms to be implemented in nursing home facilities. IMPLICATIONS:Diagnosing UTIs in residents is challenging due to the high prevalence of asymptomatic bacteriuria and nonspecific urinary tract signs and symptoms among those with suspected UTIs. The fear of missing a UTI and the perceived antibiotic demands from residents and relatives might lead to overdiagnosis of this common condition. Despite their widespread use, urine dipsticks should not be recommended for geriatric patients. Patients who do not meet the minimum diagnostic criteria for UTIs should be evaluated for alternative conditions. Adherence to a simple algorithm can prevent unnecessary antibiotic courses without compromising resident safety.

Keywords: drug resistance, microbial, nonprescription drugs, over-the-counter (OTC), pharmacists, health policy

Primary care antimicrobial stewardship programs have limited success in reducing antibiotic use, prompting the search for new strategies. Convincing general practitioners to resist antibiotic prescription amid uncertainty or patient demands usually poses a significant challenge. Despite common practice, standard durations for common infections lack support from clinical studies. Contrary to common belief, extending antibiotic treatment beyond the resolution of symptoms does not seem to prevent or reduce antimicrobial resistance. Shortening the duration of antibiotic therapy has shown to be effective in mitigating the spread of resistance, particularly in cases of pneumonia. Recent hospital randomised trials suggest that ending antibiotic courses by day three for most lower respiratory tract infections is effective and safe. While community studies are scarce, it is likely that these shorter, tailored courses to meet patients' needs would also be effective and safe in primary care. Therefore, primary care studies should investigate the outcomes of advising patients to discontinue antibiotic treatment upon symptom resolution. Implementing patient-centred, customised treatment durations, rather than fixed courses, is crucial for meeting individual patient needs.

Over the last years, the susceptibility activity of the most common microorganisms causing community-acquired infections has significantly changed in Spain. Based on the susceptibility rates of Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, and Klebsiella pneumoniae collected from outpatients aged 15 or older with symptoms of respiratory or urinary tract infections in several Microbiology Departments in Catalonia in 2021, penicillin V should be first choice for most respiratory tract infections, amoxicillin and clavulanate for chronic obstructive pulmonary disease exacerbations and a single dose of fosfomycin or a short-course nitrofurantoin should remain first-line treatments for uncomplicated urinary tract infections. Updated information on antimicrobial resistance for general practitioners is crucial for achieving appropriate empirical management of the most common infections by promoting more rational antibiotic use.

Objectives The optimization of antimicrobial therapy remains a challenge that requires an intelligent utilization of all tools and resources at our disposal. Unnecessary antibiotic use significantly contributes to increasing bacterial resistance, medical costs, and the risk of drug-related adverse events. Studies have showed strong evidence of correlation between prescription of antibiotics and selection of resistant bacteria. Ensuring prudent antimicrobial utilisation is key to an effective response to this problem, mainly in primary care, in which nearly 80% of all antibiotics are issued. A strategy to reduce the selection of antimicrobial resistance is by reducing the use of antibiotics or by shortening the length of antibiotic treatments by individualizing duration. More than half of the antibiotics prescribed are for respiratory tract infections (RTI). We explored general practitioners' (GP) views on stopping antibiotics as soon as clinical stability criteria and C-reactive protein (CRP) values are normal when patients feel better. Method We are planning to carry out a randomised clinical trial to assess the feasibility of measuring clinical stability criteria and CRP values as soon as patients are afebrile and feel better after completing two days of antibiotic therapy for a bacterial RTI, but first we wished to explore what clinicians thought about this. We recruited GPs in Catalonia from two large cities and one rural primary care centre, covering clinicians with both low and high antibiotic prescribing rates. We conducted one-to-one interviews. Two researchers collected the data using semi-structured topic guides. We asked doctors about their experiences of managing RTIs, advising patients on these infections and antibiotic therapy, and views on tailoring the antibiotic course based on monitoring of the clinical stability criteria and CRP concentrations after a given number of days of antibiotic course. Data were audio-recorded, transcribed, and analysed thematically. Results We included 12 GPs, six of which were high antibiotic prescribers. All participants considered tailoring antibiotic therapy based on clinical criteria and CRP when patients feel better contradictory to well-known advice to complete antibiotic courses for RTIs and they all were concerned about the burden related to re-visiting patients but were also interested in shortening antibiotic courses if this is not associated with an increased risk of complications and hospitalization, as long as they have completed some days of antibiotic course. GPs stressed the need for unambiguous evidence based on randomized clinical trials showing that tailoring antibiotic duration is safe and beneficial. Participants would be more confident with stopping the antibiotic courses based on monitoring of clinical stability and CRP values rather than using delayed antibiotic prescribing. Although most GPs were amenable in most of the RTIs, they were averse to it in case of a radiologically-confirmed pneumonia. Conclusions Despite being unfamiliar, general practitioners showed interest in shortening antibiotic courses for RTIs if this does not lead to a major number of complications. However, they were reluctant to tailor antibiotic therapy in case of pneumonia. They all agreed that stopping antibiotics when feeling better, clinical stability criteria are normal and CRP values are low could reduce exposure to antibiotics and risks of antimicrobial resistance, but they asked for more evidence before this strategy could be implemented, and if evidence supports this approach, patients need to be offered a clear explanation as to why the advice is different from the long-standing dogma of 'completing the course'. Curiously, GPs preferred tailoring antibiotic courses for RTIs rather than using the delayed antibiotic prescribing as they ensure a minimal antibiotic exposure when they consider antibiotic therapy is warranted.

Misconceptions and knowledge gaps about antibiotics contribute to inappropriate antibiotic use and antimicrobial resistance. This study aimed to identify and prioritize misconceptions and knowledge gaps about antibiotic use from a healthcare professionals' perspective. A modified Delphi study with a predefined list of statements, two questionnaire rounds, and an expert meeting was conducted. The statements were rated by healthcare professionals from France, Greece, Lithuania, Poland, and Spain, and from general practice, out-of-hour services, nursing homes, and pharmacies. A total of 44 pre-defined statements covered the following themes: (1) antimicrobial resistance in general, (2) use of antibiotics in general, (3) use of antibiotics for respiratory tract infections, and (4) use of antibiotics for urinary tract infections. Consensus was defined as ≥80% agreement between the professionals during the second Delphi round. For 30% of the statements, professionals from the four settings together reached consensus. In each setting individually, at least 50% of the statements reached consensus, indicating that there are still many misconceptions and knowledge gaps that need to be addressed. Six educational tools (leaflets, posters, checklists) were developed to address the knowledge gaps and misconceptions. These can be used by patients and healthcare professionals to improve the use of antibiotics in practice.

In the original publication [...].

Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A F may impact its effectiveness. There are no best practice guidelines for peer comparison A F in antibiotic prescribing in primary care. To develop best practice guidelines for peer comparison A F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance—Primary Care Antibiotic Audit and Feedback Network. We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). We report an expert-derived best practice recommendations for designing and evaluating peer comparison A F for antibiotic prescribing in primary care. These 13 statements can be used by A F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.

Objectives Dogmas are taken for granted until new evidence poses questions about their validity. A clear example is the long-standing belief that a course of antibiotics always should last for a defined number of days, despite considering that this antibiotic course is no longer necessary. In a recent randomised clinical trial with patients with uncomplicated respiratory tract infections (RTI) who had already taken a dose of an antibiotic course when clinicians consider it unnecessary, we found that the mean duration of severe symptoms was similar in the group of patients who discontinued antibiotic therapy and among those who completed the therapy. Conversely, those discontinuing antibiotic treatment notably reduced antibiotic consumption. This study was aimed at exploring general practitioners' (GP) opinions about the use of antibiotic deprescribing in general practice. Method Cross-sectional, questionnaire-based study answered from February to March 2022. 6,083 GPs affiliated with the largest Spanish scientific society of primary care were invited to participate. The survey included two statements related to use and fourteen views about antibiotic deprescribing rated by GPs using a 5-item Likert scale. Results A total of 1,107 doctors completed the survey (18.2%). 92.5% of GPs reported having used the antibiotic deprescribing strategy in their practice at least once. GPs felt very confident in using a deprescribing strategy in patients with common cold and flu (97.6% and 93.5%, respectively), but less in acute bronchitis (45.5%). Regarding attitudes towards antibiotic deprescribing, only a minority of GPs (12.1%) considered it harmful to patients. Thus, the majority agreed that this strategy should be included in clinical guidelines. Respondents reported using antibiotic deprescribing more frequently when they themselves initiated the antibiotic course (96.8%; 95% CI, 95.5-97.7) than when the treatment was initiated by another doctor (52.3%; 95% CI, 49.3-55.3%), but doctors aged >60 years were more prone to use antibiotic deprescribing compared with younger colleagues (64.5% vs. 50%; p<0.005). Conclusions Many GPs would consider that discontinuing antibiotics in these circumstances should be the standard of care. However, the decision to discontinue an antibiotic recently started is not easy, particularly if initiated by a colleague. In fact, as suggested by qualitative research, GPs do not feel comfortable discontinuing treatments in general, and guidelines are not as authoritative for discontinuation as they are for starting drugs. Important differences lie in their views of the way the strategy is used. Further studies are warranted to explore the beliefs behind these perceptions and promote wider use of the antibiotic deprescribing by GPs, leading to a lesser overdiagnosis of suspected bacterial infections.