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Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement. [ABSTRACT FROM AUTHOR]

Introduction: The burden from infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in the European Union/European Economic Area (EU/EEA) has increased in recent years, especially in the higher prevalence southern and eastern countries. Addressing this challenge requires a clear knowledge of the factors driving this epidemiology to inform effective national interventions and campaigns. Methods: We identified national quality metrics for antibiotic use and hand hygiene from the 2016/2017 European Centre for Disease Control (ECDC) Point Prevalence study as well as structural, cultural, and governance indicators from other sources. We then utilized general linear modeling to identify parsimonious correlations with national MRSA proportions reported by the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results: The main process predictor of MRSA prevalence in EU/EEA countries was the use of more than one concurrent antibiotic per patient. The impact of hand hygiene was less clear, possibly because consumption of alcohol hand-rub was suboptimal throughout Europe. Hospital and infection control structural factors did not appear relevant at overall national level. Culture and governance were collectively key predictor groups; uncertainty avoidance, masculinity, and corruption indices strongly correlated with MRSA prevalence. Discussion: Our results suggest that the critical antibiotic stewardship factor associated with MRSA in EU/EEA countries is the quality of antibiotic prescribing, especially spectrum of activity, rather than overall consumption levels in hospitals or proportion of patients treated. Above all, MRSA hyperendemicity is correlated with a set of sociocultural behavioral constructs that typically manifest themselves in lack of urgency to address risk and normalization of deviance in relation to noncompliant practices. [ABSTRACT FROM AUTHOR]

Background: Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta. Methods: Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour. Findings: We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed. Conclusion: This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment. Trial registration number: NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930. [ABSTRACT FROM AUTHOR]

Background: Antibiotic use is a major driver of antibiotic resistance. Although delayed antibiotic prescription is a recommended strategy to reduce antibiotic use, practices vary; it appears less commonly used in southern European countries where antibiotic consumption is highest. Despite these variations, few qualitative studies have explored general practitioners' perceptions of delayed antibiotic prescription. We therefore aimed to explore and describe the perceptions of delayed antibiotic prescription for respiratory tract infections among general practitioners in Malta. Methods: This qualitative phenomenographic study was conducted in Malta. A semi-structured interview guide was developed in English, pilot tested and revised accordingly. Interview topics included views on antibiotic resistance, antibiotic use and delayed antibiotic prescription for respiratory tract infections, and barriers and facilitators to antibiotic prescription. Individual, face-to-face interviews were held in 2014 with a quota sample of 20 general practitioners and transcribed verbatim. Data were subsequently analysed using a phenomenographic approach. Findings: General practitioners perceived delayed antibiotic prescription in five qualitatively different ways: (A) "The Service Provider"–maintaining a good general practitioner-patient relationship to retain patients and avoid doctor-shopping, (B) "The Uncertainty Avoider"–reaching a compromise and providing treatment just in case, (C) "The Comforter"–providing the patient comfort and reassurance, (D) "The Conscientious Practitioner"–empowering and educating patients, and limiting antibiotic use, and (E) "The Holder of Professional Power"–retaining general practitioner responsibility by employing a wait-and-see approach. Although general practitioners were largely positive towards delayed antibiotic prescription, not all supported the strategy; some preferred a wait-and-see approach with follow-up. Many delayed antibiotic prescription users selectively practiced delayed prescription with patients they trusted or who they believed had a certain level of knowledge and understanding. They also preferred a patient-led approach with a one to three day delay; post-dating delayed antibiotic prescriptions was uncommon. Conclusions: In this study we have shown that general practitioners hold varying perceptions about delayed antibiotic prescription and that there is variation in the way delayed antibiotic prescription is employed in Malta. Whilst delayed antibiotic prescription is utilised in Malta, not all general practitioners support the strategy, and motivations and practices differ. In high consumption settings, formal and standardised implementation of delayed antibiotic prescription could help curb antibiotic overuse. Diagnosis-specific delayed antibiotic prescription recommendations should also be incorporated into guidelines. Finally, further investigation into patients' and pharmacists' views on delayed antibiotic prescription is required. Trial registration number: NCT03218930 [ABSTRACT FROM AUTHOR]

Objectives: Sociocultural factors have been hypothesized as important drivers of inappropriate antibiotic prescribing in European ambulatory care. This study sought to assess whether they can also explain the reported variation in broad-spectrum antibiotic (Br-Ab) use among EU/European Economic Area (EEA) countries.Methods: Correlation and regression analysis were performed, using the bootstrap method, between Br-Ab ratios reported from 28 EU countries by the ECDC, and national Hofstede cultural dimensions and control of corruption (CoC) scores.Results: Significant bootstrapping correlation coefficients were identified between Br-Ab ratios and the dimension of uncertainty avoidance (UAI) as well as CoC. However, following both bootstrapping multiple regression and generalized linear modelling, only UAI was retained as the sole predictor. A logarithmic model explained 58.6% of the variation in European Br-Ab variability solely using national UAI scores (P < 0.001).Conclusions: Br-Ab prescribing appears to be driven by the level of UAI within the country. Any interventions aimed at reducing Br-Ab in high-consuming EU/EEA countries need to address this cultural perception to maximize their chances of success. [ABSTRACT FROM AUTHOR]

Objectives: To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta.Methods: In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs' prescribing patterns.Results: Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed.Conclusions: GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing. [ABSTRACT FROM AUTHOR]

Objectives European countries exhibit significant geographical differences in antibiotic consumption per capita within ambulatory care, especially inappropriate use for colds/flu/sore throat (CFSt). One potential explanation could be national cultural differences resulting in varying perceptions and, therefore, influences. Methods Publicly available data on the proportions of respondents in the 2009 Eurobarometer survey who had taken antibiotics for CFSt were tested for association against country scores derived from the Hofstede cultural dimension model. They were also correlated with knowledge of respondents about various key antibiotic facts. Results The Eurobarometer dataset incorporated 26 259 responses from all European Union (EU) countries except Cyprus. Using multiple regression, uncertainty avoidance and masculinity were identified as the two national cultural dimensions significantly associated with the use of antibiotics for CFSt (R-adjusted = 0.45; P < 0.001). After controlling for these cultural influences, individuals who stated they had received information about antibiotics in the previous year were also more likely to correctly answer antibiotic-related questions (r = 0.721; P < 0.001). The use of antibiotics for CFSt was found to be inversely correlated with respondents' knowledge that antibiotics are ineffective against viruses (r = −0.724; P < 0.001) and that misuse will render them ineffective in the longer term (r = −0.775; P < 0.001). Conclusions National cultural dimensions, especially uncertainty avoidance and masculinity, appear to have a very significant impact on inappropriate antibiotic use within European countries. Nevertheless, their influence can be reduced by making EU citizens more knowledgeable about antibiotics through appropriate messages and targeted campaigns. [ABSTRACT FROM PUBLISHER]

Background: Antibiotic use is recognised as the most important driver for the development of antimicrobial resistance in community pathogens. Surveillance is therefore critical for improvement programmes. Methods: Antimicrobial distribution data for the years 2007 to 2009 were collected retrospectively by the National Antibiotic Committee from all licensed wholesale distributors (WSL) in Malta and analysed according the World Health Organization Anatomical Therapeutic Chemical classification (ATC) level 4 criteria. Results: Overall consumption increased from 18.6 defined-daily-doses/1000-inhabitant-days (DID) in 2007 to 22.7 DID in 2008 and reached 24.4 DID in 2009 - an increase of more than 30% over the three years, Penicillins with beta-lactamase inhibitor increased in volume (7.1 to 8.8 DID) but decreased in proportion (38.4% to 36.0%) between 2007 and 2009. On the other hand, second generation cephalosporins increased in both volume and proportion (2.8 to 5.4 DID; 15.0% to 22.0%). The proportion for macrolides remained stable at approximately 16% but the volume of use again increased (2.9 DID to 3.9 DID). Fluoroquinolone proportion decreased from 9.1% to 6.8%, maintaining a stable volume of use in the region of 1.7 DID. [ABSTRACT FROM AUTHOR]

Summary: Anecdotal data from the southern and eastern Mediterranean region suggests that self-medication with antibiotics is commonly practiced in many countries. In order to provide proper information on the situation, we undertook short structured interviews in out-patients clinics or primary health centres in Cyprus, Egypt, Jordan, Lebanon, Libya, Tunisia and Turkey. A total of 2109 interviews were undertaken of which 1705 completed the full questionnaire. Self-medication was reported by 19.1% (<0.1% in Cyprus to 37% in Lebanon) of respondents. Intended self-medication ranged from 1.3% (95% CI 0%, 3%) in Cyprus to 70.7% (95% CI 64%, 77%) in Jordan. Upper respiratory tract symptoms were the most frequent reasons for which respondents indicated they would self-medicate. 48.4% of the whole group replied that they kept antibiotics at home, being highest in Lebanon (60%, 95% CI 51%, 69%). We found a significant association between antibiotic hoarders and intended users of antibiotics for self-medication. Our data confirms that non-prescribed antibiotic use is high within ambulatory care in southern and eastern Mediterranean countries, being almost twice that reported in a similar European study. Corrective efforts are clearly required in the region to ensure proper use of antimicrobials so as to reduce pressure for antimicrobial resistance. [Copyright &y& Elsevier]

Antimicrobial resistance results in substantial adverse outcomes and negatively impacts mortality, morbidity and economic expenditure. This review focuses on the costs of antibiotic resistance to both patient as well as health-care settings and highlights interventions proven to be effective in curtailing its continued escalation. These concentrate predominantly on initiatives to improve antibiotic prescribing as well as prevent the spread of multi-resistant organisms, amongst which hand hygiene is of paramount importance. With the prevalence of resistance in Malta, amongst the highest in Europe, such interventions need acceptance and implementation by all stakeholders if the current alarming situation is to be controlled and possibly improved. [ABSTRACT FROM AUTHOR]

Few studies have studied the frequency of over-the-counter acquisition of antibiotics in western countries. In order to provide an insight into these practices in Malta, attitudes towards antibiotic use in the general public were researched through a structured interview. Nineteen percent admitted that they took antibiotics without prescription and 11% of parents replied that they had given antibiotics to their children without prescription. These antibiotics were mainly self-administered for upper respiratory tract symptoms, particularly sore throat, with community pharmacies being the major source in more than 85% of cases. The study indicates the need for an educational campaign on proper antibiotic use amongst the Maltese general public. [Copyright &y& Elsevier]

Objectives Socio-cultural factors have been hypothesized to be important drivers for inappropriate antibiotic prescribing in ambulatory care. This study sought to assess any potential role in perioperative surgical prophylaxis (PAP) administered for >24 h (PAP > 24). Within hospitals, PAP continues to be administered for longer than 24 h, despite unequivocal evidence of ineffectiveness beyond this period. A recently published European Centre for Disease Prevention and Control (ECDC) point prevalence survey (PPS) has reported that in 70% of participating countries, PAP > 24 was administered in more than half of the surgical operations surveyed. Methods Correlation and simple linear regression modelling was performed using the PAP > 24 proportions for the countries in the ECDC PPS report and the respective scores for the cultural construct of uncertainty avoidance (UA), as detailed by Hofstede. Results Pearson correlation analysis produced a moderately strong coefficient (r) of 0.50 (95% CI 0.16–0.74; P = 0.007). Simple regression yielded a model of PAP > 24 = 29.87 + 0.40UA (R2 = 0.25; P = 0.007). Conclusions Cultural factors, namely UA, appear to be an important driver for PAP > 24. Any strategy aimed at improving prolonged PAP should be informed by clear knowledge of local socio-cultural barriers, so as to achieve the most successful intervention possible. [ABSTRACT FROM PUBLISHER]