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The need to visualise the complexity of the determinants of population health and their interactions inspired the development of the rainbow model. In this commentary we chronicle how variations of this model have emerged, including the initial models of Haglund and Svanström (1982), Dahlgren and Whitehead (1991), and the Östgöta model (2014), and we illustrate how these models have been influential in both public health and beyond. All these models have strong Nordic connections and are thus an important Nordic contribution to public health. Further, these models have underpinned and facilitated other examples of Nordic leadership in public health, including practical efforts to address health inequalities and design new health policy approaches. Apart from documenting the emergence of rainbow models and their wide range of contemporary uses, we examine a range of criticisms levelled at these models – including limitations in methodological development and in scope. We propose the time is ripe for an updated generic determinants of health model, one that elucidates and preserves the core value in older models, while recognising the developments that have occurred over the past decades in our understanding of the determinants of health. We conclude with an example of a generic model that fulfills the general purposes of a determinants of health model while maintaining the necessary scope for further adjustments to be made in the future, as well as adjustments to location or context-specific purposes, in education, research, health promotion and beyond.

International audience; PURPOSE: Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising.METHODS: We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks.RESULTS: Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices.CONCLUSION: Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.

Our aim was to evaluate the effectiveness of an intervention for residents in rural China on knowledge, attitudes and reported practices (KAP) on antibiotic use in humans and pigs. A quasi-experimental study was conducted in 12 villages in rural Shandong province, divided into intervention and control groups, covering a two-year period from July 2015 to June 2017. A package of health education-based interventions including training sessions, speakerphone messages, posters and handbooks for residents was developed and implemented over a one-year period to improve the use of antibiotics in humans and pigs. The intervention net effects were evaluated by Difference-in-Difference (DID) analysis based on responses to a questionnaire concerning KAP towards antibiotic use in humans and pigs. A total of 629 participants completed both baseline and post-trial questionnaires, including 127 participants with backyard pig farms. Significant improvements were found in KAP towards antibiotic use in humans, but changes related to antibiotic use for pigs were not significant. Participants who were in the intervention group (p &lt, 0.001) were more likely to have improved their knowledge on antibiotic use in humans. Participants who had higher attitude scores were less likely to report self-medicating with stored antibiotics in the previous year (p &lt, 0.001). Our results suggest that our health education-based intervention was effective in improving KAP on human antibiotic use, but it had little effect regarding antibiotic use for pigs.

BackgroundHealthcare professionals are increasingly expected to lead antimicrobial stewardship (AMS) initiatives. This role in complex healthcare environments requires specialized training.ObjectivesLittle is known about the types of AMS training programmes available to clinicians seeking to play a lead role in AMS. We aimed to identify clinicians’ awareness of AMS training programmes, characteristics of AMS training programmes available and potential barriers to participation.MethodsAMS training programmes available were identified by members of the ESCMID Study Group for Antimicrobial Stewardship (ESGAP) via an online survey and through an online search in 2018. Individual training programme course coordinators were then contacted (September–October 2018) for data on the target audience(s), methods of delivery, intended outcomes and potential barriers to accessing the training programme.ResultsA total of 166/250 ESGAP members (66%) responded to the survey, nominating 48 unique AMS training programmes. An additional 32 training programmes were identified through an online search. AMS training programmes were from around the world. Less than half (44.4%) of respondents were aware of one or more AMS training programmes available, with pharmacists more aware compared with medical doctors and other professionals (73% versus 46% and 25%, respectively). AMS training programmes were most commonly delivered online (59%) and aimed at medical doctors (46%). Training costs and a lack of recognition by health professional societies were the most frequently cited barriers to participation in AMS training programmes.ConclusionsThe development of a systematic inventory of AMS training programmes around the globe identifies opportunities and limitations to current training available. Improving access and increasing awareness amongst target participants will support improved education in AMS.

BackgroundPrevious studies have highlighted that medical students do not feel well prepared to prescribe antimicrobials. The ESCMID Study Group for Antimicrobial stewardshiP (ESGAP) conducted a survey among European medical students to assess self-reported preparedness about prudent antibiotic use and the perceived lack of education. The aim of the present study was to specifically focus on the perceptions of Swiss medical students. MethodsA cross-sectional web-based survey was conducted in 2015 by ESGAP involving sixth-year medical students from Switzerland. The survey investigated self-reported preparedness on diagnosis and treatment of infections, availability and perceived usefulness of different teaching methods and the perceived need for further education on antibiotic use. “Preparedness scores” were created by calculating the percentage of students who felt sufficiently prepared on each topic. ResultsWe received responses from 137 medical students from 4 medical schools (Bern, Geneva, Lausanne and Zurich). The overall estimated response rate was 19%. Overall, 62% of Swiss students reported needing more education on antibiotics or at least on their prudent use. Teaching methods perceived as more useful were discussion of clinical cases (80.2%), clinical rotation in infectious diseases (77.0%) and small group teaching (75.0%), but the latter 2 were reported as unavailable for nearly half of the students (36.5% and 47.5%, respectively). Almost all of the students felt sufficiently prepared to recognize clinical signs of infection (99.3%), to interpret inflammation markers (94.9%) and to have sufficient knowledge of consequences of antibiotic misuse (95.5%). Less than half of them felt prepared to select the right empirical treatment without using guidelines (33.8%), to identify the need for combination therapy (39.7%) or to select the shortest adequate treatment duration (39.3%). ConclusionsMost Swiss final year medical students feel they need more education on antibiotics. Some of the teaching methods perceived as more useful by students seem still insufficiently available in Swiss medical schools. Active and interprofessional teaching activities can be a first step towards more effective education on prudent antibiotic use.

ObjectivesTo assess variation in antibiotic prescribing practices among village doctors in a rural region of Shandong province, China.Design, setting and participantsAlmost all outpatient encounters at village clinics result in a prescription being issued. Prescriptions were collected over a 2.5-year period from 8 primary care village clinics staffed by 24 doctors located around a town in rural Shandong province. A target of 60 prescriptions per clinic per month was sampled from an average total of around 300. Prescriptions were analysed at both aggregate and individual-prescriber levels, with a focus on diagnoses of likely viral acute upper respiratory tract infections (AURIs), defined as International Classification of Diseases, 10th Revision codes J00 and J06.9.Main outcome measuresProportions of prescriptions for AURIs containing (1) at least one antibiotic, (2) multiple antibiotics, (3) at least one parenteral antibiotic; classes and agents of antibiotics prescribed.ResultsIn total, 14 471 prescriptions from 23 prescribers were ultimately included, of which 5833 (40.3%) contained at least 1 antibiotic. Nearly two-thirds 62.5% (3237/5177) of likely viral AURI prescriptions contained an antibiotic, accounting for 55.5% (3237/5833) of all antibiotic-containing prescriptions. For AURIs, there was wide variation at the individual level in antibiotic prescribing rates (33.1%–88.0%), as well multiple antibiotic prescribing rates (1.3%–60.2%) and parenteral antibiotic prescribing rates (3.2%–62.1%). Each village doctor prescribed between 11 and 21 unique agents for AURIs, including many broad-spectrum antibiotics. Doctors in the highest quartile for antibiotic prescribing rates for AURI also had higher antibiotic prescribing rates than doctors in the lowest quartile for potentially bacterial upper respiratory tract infections (pharyngitis, tonsillitis, laryngopharyngitis; 89.1% vs 72.4%, p=0.002).ConclusionsAll village doctors overused antibiotics for respiratory tract infections. Variations in individual prescriber practices are significant even in a small homogenous setting and should be accounted for when developing targets and interventions to improve antibiotic use.

Introduction One of the main tools to optimise antibiotics use is education of prescribers. The aim of this article is to study undergraduate education in the field of infectious diseases, antimicrobial resistance and antibiotic stewardship from the perspective of Spanish medical students. Material and methods An anonymous online questionnaire was distributed among sixth grade students using different channels in Europe, within the ESGAP Student-Prepare survey. The questionnaire included 45 questions about knowledge, attitudes and perceptions about diagnosis, bacterial resistance, use of antibiotics and undergraduate training in infectious diseases. We present here the Spanish results. Results A total of 441 surveys were received from 21 medical schools. A total of 374 responses (84.8%) were obtained from the 8 most represented faculties, with a response rate of 28.9%. Most students felt adequately prepared to identify clinical signs of infection (418; 94.8%) and to accurately interpret laboratory tests (382; 86.6%). A total of 178 (40.4%) acknowledged being able to choose an antibiotic with confidence without consulting books or guidelines. Only 107 (24.3%) students considered that they had received sufficient training in judicious use of antibiotics. Regarding learning methods, the discussion of clinical cases, infectious disease unit rotatories and small group workshops were considered the most useful, being evaluated favourably in 76.9%, 76% and 68.8% of the cases. Conclusion Medical students feel more confident in the diagnosis of infectious diseases than in antibiotic treatment. They also feel the need to receive more training in antibiotics and judicious antibiotic use.

China is among the world's largest consumers of antibiotics for livestock, and the demand for meat protein continues to rise. Pig production takes place at a range of facilities, including backyard pig farms. The aim of this study was to describe the knowledge, attitudes and practices of backyard pig farmers concerning antibiotic use and resistance, and to observe household storage of antibiotics for use in pigs. We conducted a cross-sectional questionnaire survey among 271 rural residents with backyard pig farms in 12 villages in one town in Shandong province. The median number of pigs per backyard farm was 14, and 82 % (222/271) of participants reported not having had any training about raising pigs. Eighteen percent of participants (48/271) reported always or often adding antibiotics to feed to keep pigs healthy and prevent diseases, and a third (88/271) of participants believed that pigs should be given antibiotics when they stop eating. Thirty percent (82/271) reported having bought antibiotics in the previous year without having first spoken with a veterinarian. Antibiotics accounted for over half of all medicines stored (55 %, 197/358), and were observed in 31 % of all households (83/271). Less than half of participants (45 %, 37/83) from households in which antibiotics for pig use were found knew that they were storing antibiotics. The most common class of antibiotics stored for use in pigs was (Q)J01C betalactam antibiotics, penicillins (19 %, 37/197), followed by (Q)J01F macrolides, lincosamides and streptogramins (14 %, 28/197), and (Q)J01M quinolones (12 %, 25/197). These results provide important insights into how backyard pig farmers are using antibiotics in rural China and suggest potential targets for interventions to reduce unnecessary and inappropriate use.

Objectives: To investigate the occurrence of antibiotic residues in different types of environmental samples including water samples in rural Shandong province, China. Further, to characterize the potential ecological risk for development of antibiotic resistance in the environment, and the potential direct human health risk of exposure to antibiotics via drinking water and vegetables. Methods: Environmental samples (n = 214) (river water, waste water, drinking water, sediments, manure, soil and edible parts of vegetables) were collected in twelve villages in Shandong province in eastern China. High performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS) was used to determine the concentration of antibiotic residues. The ratio of the measured environmental concentrations (MEC) to the predicted no-effect concentrations (PNEC) was used to evaluate the ecological risk (risk quotient, RQ) for development of antibiotic resistance. The potential risks to human health through exposure to antibiotics in drinking water were assessed by comparing measured environmental concentrations (MEC) and predicted no-effect concentration in drinking water (PNECDW), and in vegetables by comparing estimated daily intake (EDI) to ADI. Results: Sulfapyridine, sulfamethoxazole, ciprofloxacin, enrofloxacin, levofloxacin, norfloxacin, chloramphenicol, florfenicol, doxycycline, and metronidazole were detected at concentrations ranging between 0.3 and 3.9 ng/L in river water, 1.3 and 12.5 ng/L in waste water, 0.5 and 21.4 ng/L in drinking water, 0.31 and 1.21 μg/kg in river sediment, 0.82 and 1.91 μg/kg in pig manure, 0.1 and 11.68 μg/kg in outlet sediment, 0.5 and 2.5 μg/kg in soil, and 6.3 and 27.2 μg/kg in vegetables. The RQs for resistance development were >1 for enrofloxacin, levofloxacin, and ranged between 0.1 and 1 for ciprofloxacin. MECs/PNECDW ratios were

International audience; Objectives:To investigate fear of legal claims and defensive behaviours among specialists in infectious diseases (ID) and clinical microbiology (CM) and to identify associated demographic and professional characteristics.Methods:AntibioLegalMap was an international cross-sectional internet-based survey targeting specialists in ID and CM. Three variables were explored: fear of legal liability in antibiotic prescribing/advising on antibiotic prescription; defensive behaviours in antibiotic prescribing; and defensive behaviours in advising. A multivariable logistic regression analysis was performed to identify factors significantly associated with each of the three variables.Results:Eight hundred and thirty individuals from 74 countries participated. Only 0.4% (3/779) had any kind of condemnation for malpractice related to antibiotic prescription. Concerning the fear of liability, 21.2% (164/774) of respondents said they never worried, 45.1% (349/774) sometimes worried and 28.6% (221/774) frequently worried when prescribing/advising on antibiotic prescription. Being female, younger than or equal to 35 years and aware of previous cases of litigation were independently associated with fear. Most respondents (85.0%, 525/618) reported some defensive behaviour in antibiotic prescribing. These behaviours were independently associated with being younger than or equal to 35 years and sometimes or often worried about liability. Similarly, 76.4% (505/661) reported defensive behaviours in advising. These behaviours were associated with being sometimes or often worried about liability. The preferred measures to reduce fear and defensive behaviours were having local guidelines and sharing decisions through teamwork.Conclusions:A significant proportion of specialists in ID and CM reported some form of defensive behaviour in prescribing or advising to prescribe antibiotics. Defensive medicine should be considered when implementing antibiotic stewardship programmes.

Students should graduate from medical school feeling prepared to prescribe antibiotics responsibly. We assessed self-reported preparedness among students at medical schools in Europe, and we focus here on the results from students in Sweden and France, countries with wide differences in the intensity of antibiotic consumption and burden of antibiotic resistance. We conducted a cross-sectional web-based survey in 2015, based on a comprehensive set of topics related to prudent antibiotic use. All final year students at a medical school in France or Sweden were eligible to participate. Preparedness scores were calculated for each student, and mean scores were compared at medical school and country levels. Comparisons were also made on availability of teaching methods. We received responses from 2085/7653 (response rate 27.2%) students from 31/34 eligible medical schools in France and 302/1124 (26.9%) students from 7/7 schools in Sweden. The relative ranking order of curriculum topics by preparedness level was consistent between countries, but students in Sweden had higher self-reported levels of preparedness in 21/27 topics. There was higher availability for eight of nine teaching methods at Swedish medical schools. Students in France were more likely to report a need for further education on antibiotic use (63.5% vs. 20.3%, p

Background This study describes the patterns of antibiotic prescribing in eight village clinics in rural China and evaluates factors associated with antibiotic prescribing using quantitative and qualitative methods. Methods From January 2015 to July 2017, 60 prescriptions were collected monthly from selected village clinics in Shandong, China. Village clinic doctors completed a questionnaire regarding their knowledge of antibiotic prescribing. Semi-structured interviews were conducted with 15 village doctors and 1 deputy director from the township hospital. Results Of the 14 526 prescriptions collected, 5851 (40.3%) contained at least one antibiotic, among which 18.4% had two or more antibiotics and 24.3% had parenteral antibiotics. The antibiotic prescribing rate (β=−0.007 [95% confidence interval −0.009 to −0.004]) showed a declining trend (1.7% per month). Higher antibiotic prescribing rates were observed for patients Conclusions Antibiotic prescribing has declined in the included village clinics, which may be due to the policy of reducing antibiotic overuse in primary health care centres in China.

Problems of antibiotic access and excess coexist in the world today and are compounded by rising rates of antibiotic resistance. We introduce two dimensions of responsibility to this context: responsible individual practices and a broad societal obligation centered on sustainability. Acting on these responsibilities requires recognizing the potential tensions between an individual optimum for antibiotic use and the societal optimum. We relate the tragedy of the commons metaphor to this situation to illustrate the complexity involved, and we draw on real-world experiences in Uganda, India, China and France. We conclude that we must form a global stewardship of antibiotics that can link access, innovation and conservation efforts across countries to ensure sustainable access to effective antibiotics for all who need them.

International audience

International audience; Objectives: To evaluate the current practice and the willingness to shorten the duration of antibiotic therapy among infection specialists.Methods: Infection specialists giving at least weekly advice on antibiotic prescriptions were invited to participate in an online cross-sectional survey between September and December 2016. The questionnaire included 15 clinical vignettes corresponding to common clinical cases with favourable outcomes; part A asked about the antibiotic treatment duration they would usually advise to prescribers and part B asked about the shortest duration they were willing to recommend.Results: We included 866 participants, mostly clinical microbiologists (22.8%, 197/863) or infectious diseases specialists (58.7%, 507/863), members of an antibiotic stewardship team in 73% (624/854) of the cases, coming from 58 countries on all continents. Thirty-six percent of participants (271/749) already advised short durations of antibiotic therapy (compared with the literature) to prescribers for more than half of the vignettes and 47% (312/662) chose shorter durations in part B compared with part A for more than half of the vignettes. Twenty-two percent (192/861) of the participants declared that their regional/national guidelines expressed durations of antibiotic therapy for a specific clinical situation as a fixed duration as opposed to a range and in the multivariable analysis this was associated with respondents advising short durations for more than half of the vignettes (adjusted OR 1.5, P = 0.02).Conclusions: The majority of infection specialists currently do not advise the shortest possible duration of antibiotic therapy to prescribers. Promoting short durations among these experts is urgently needed.

Summary Background The spread of antibiotic-resistant bacteria poses a substantial threat to morbidity and mortality worldwide. Due to its large public health and societal implications, multidrug-resistant tuberculosis has been long regarded by WHO as a global priority for investment in new drugs. In 2016, WHO was requested by member states to create a priority list of other antibiotic-resistant bacteria to support research and development of effective drugs. Methods We used a multicriteria decision analysis method to prioritise antibiotic-resistant bacteria; this method involved the identification of relevant criteria to assess priority against which each antibiotic-resistant bacterium was rated. The final priority ranking of the antibiotic-resistant bacteria was established after a preference-based survey was used to obtain expert weighting of criteria. Findings We selected 20 bacterial species with 25 patterns of acquired resistance and ten criteria to assess priority: mortality, health-care burden, community burden, prevalence of resistance, 10-year trend of resistance, transmissibility, preventability in the community setting, preventability in the health-care setting, treatability, and pipeline. We stratified the priority list into three tiers (critical, high, and medium priority), using the 33rd percentile of the bacterium's total scores as the cutoff. Critical-priority bacteria included carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa , and carbapenem-resistant and third-generation cephalosporin-resistant Enterobacteriaceae. The highest ranked Gram-positive bacteria (high priority) were vancomycin-resistant Enterococcus faecium and meticillin-resistant Staphylococcus aureus . Of the bacteria typically responsible for community-acquired infections, clarithromycin-resistant Helicobacter pylori , and fluoroquinolone-resistant Campylobacter spp, Neisseria gonorrhoeae , and Salmonella typhi were included in the high-priority tier. Interpretation Future development strategies should focus on antibiotics that are active against multidrug-resistant tuberculosis and Gram-negative bacteria. The global strategy should include antibiotic-resistant bacteria responsible for community-acquired infections such as Salmonella spp, Campylobacter spp, N gonorrhoeae , and H pylori . Funding World Health Organization.

The Global Action Plan on Antimicrobial Resistance highlights the importance of training all healthcare professionals. No study has assessed patterns of students’ knowledge, attitudes and practices concerning antibiotic use simultaneously across different healthcare course types. We conducted a cross-sectional multi-center survey among UK students. The survey was advertised through local survey coordinators at 25 universities. The online survey was accessible from 10th October to 17th November 2016 (before European Antibiotic Awareness Day). A total of 255 students from 25 universities participated, including students on medicine, pharmacy, nursing, physician associate, dentistry and veterinary medicine courses. Antibiotic resistance was considered to be a more important global challenge than climate change, obesity or food security (p < 0.001). Most students (95%) believed that antibiotic resistance will be a problem for their future practice, but fewer (69%) thought that the antibiotics they will prescribe, administer or dispense will contribute to the problem. A fifth of students felt they had sufficient knowledge of antibiotic use for their future work. Our exploratory study suggests that UK human and animal healthcare students are aware of the importance of antibiotic resistance, but many still have certain misconceptions. Campaigns and improved educational efforts applying behavioral insights methodology could address these.

Antimicrobial stewardship (AMS) is the cornerstone activity in the combat against antimicrobial resistance. In order to ensure sustainable deployment and development of AMS, a strategic and regulatory framework needs to be provided by national healthcare authorities. Experts from 32 European countries, Israel and Turkey were invited to participate in a cross-sectional internet-based survey from October 2016 to May 2017 on the legal framework and mandatory components (structures, activities) of AMS in hospitals, i.e. components required by legislation or regulations. We collected data from 25 countries and two regions (in countries with federal health administration). Laws regulating AMS existed in seven countries and one region. Other health ministry regulations were applicable in 13 countries and one region. National strategies and/or action plans approved by ministries of health were in place in 13 countries and one region. Conversely, five countries and one region had no regulation of AMS in hospitals. Funding for AMS in hospitals was provided in five countries and one region. Eight countries and one region reported mandatory AMS structures and activities complying with the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) structure, policy and practice indicators. In 10/27 cases, however, the mandatory AMS activities were not being fully carried out. The survey showed heterogeneous legal frameworks for AMS in hospitals, and in many countries it was even lacking. The situation may be critical in countries with poor control of antimicrobial use and resistance. Recent international initiatives calling on policy-makers to address the threat of antimicrobial resistance could yield improvement., peer-reviewed

Background The use of the term ‘antimicrobial stewardship' has grown exponentially in recent years, typically referring to programmes and interventions that aim to optimize antimicrobial use. Although antimicrobial stewardship originated within human healthcare, it is increasingly applied in broader contexts including animal health and One Health. As the use of the term ‘antimicrobial stewardship' becomes more common, it is important to consider what antimicrobial stewardship is, as well as what it is not. Aims To review the emergence and evolution of the term ‘antimicrobial stewardship'. Sources We searched and reviewed existing literature and official documents, which mostly focused on antibiotics. We contacted the authors of the first publications that mentioned antimicrobial stewardship. Content We describe the historical background behind how antimicrobial stewardship came into use in clinical settings. We discuss challenges emerging from the varied descriptions of antimicrobial stewardship in the literature, including an over-emphasis on individual prescriptions, an under-emphasis on the societal implications of antimicrobial use, and language translation problems. Implications To help address these challenges, we suggest viewing antimicrobial stewardship as a strategy, a coherent set of actions which promote using antimicrobials responsibly. We stress the continuous need for ‘responsible use' to be defined and translated into context-specific and time-specific actions. Furthermore, we present examples of actions that can be undertaken within antimicrobial stewardship across human and animal health.

One of the main tools to optimize antibiotics use is education of prescribers. The aim of this article is to study undergraduate education in the field of infectious diseases, antimicrobial resistance and antibiotic stewardship from the perspective of Spanish medical students.An anonymous online questionnaire was distributed among sixth grade students using different channels in Europe, within the ESGAP Student-Prepare survey. The questionnaire included 45 questions about knowledge, attitudes and perceptions about diagnosis, bacterial resistance, use of antibiotics and undergraduate training in infectious diseases. We present here the Spanish results.A total of 441 surveys were received from 21 medical schools. A total of 374 responses (84.8%) were obtained from the 8 most represented faculties, with a response rate of 28.9%. Most students felt adequately prepared to identify clinical signs of infection (418; 94.8%) and to accurately interpret laboratory tests (382; 86.6%). A total of 178 (40.4%) acknowledged being able to choose an antibiotic with confidence without consulting books or guidelines. Only 107 (24.3%) students considered that they had received sufficient training in judicious use of antibiotics. Regarding learning methods, the discussion of clinical cases, infectious diseases units rotatories and small group workshops were considered the most useful, being evaluated favorably in 76.9%, 76% and 68.8% of the cases.Medical students feel more confident in the diagnosis of infectious diseases than in antibiotic treatment. They also feel the need to receive more training in antibiotics and judicious antibiotic use.

Background Healthcare systems consist of building blocks. Shaping how these building blocks function and interact can promote responsible antimicrobial use, and this represents an important opportunity for managers at different points within healthcare systems to act upon. Aims To review real-world examples of how healthcare systems can promote responsible antimicrobial use, focusing on the role of governance and managers. Sources We searched and reviewed existing literature and official documents, which mostly focused on antibiotics. We also drew on the diverse experiences of the ESGAP (the ESCMID (European Society of Clinical Microbiology and Infectious Diseases) Study Group for Antimicrobial stewardshiP) network. Content First, we explored at the institution level the implementation of antimicrobial stewardship programmes, the need to embrace multidisciplinary approaches, the benefits of engaging with social sciences experts, and the role of governance and leadership. We look beyond individual institutions and highlight the urgent need for workforce capacity estimates for antimicrobial stewardship activities, how antimicrobial stewardship efforts can connect to form networks, and the importance of governance and regulation at national and international levels. Implications Managers in the healthcare system are in a strong position to look beyond individual prescriptions and to recognize the many ways in which different healthcare system building blocks can contribute to responsible use of antimicrobials. At the institution level this can be achieved by implementing antimicrobial stewardship programmes, ensuring they are adequately resourced, and driving buy-in across clinical leadership. At regional and national levels this includes facilitating the sharing of experiences and resources between institutions, and developing the standards and regulations needed to support responsible antimicrobial use.

Objectives To learn about medical students' knowledge of and perspectives on antibiotic prescribing and resistance, with the aim of helping to develop educational programmes. Methods Final-year students at seven European medical schools were invited to participate in an online survey in 2012. Results The response rate was 35% (338/961). Most students (74%) wanted more education on choosing antibiotic treatments. Students at all schools felt most confident in diagnosing an infection and least confident in choosing combination therapies, choosing the correct dose and interval of administration and not prescribing in cases of diagnostic uncertainty. Students felt that too many prescriptions and too much broad-spectrum antibiotic use were the most important contributors to resistance; some (24%) believed poor hand hygiene was not at all important. Most students (92%) believed that resistance is a national problem. Most (66%) felt that the antibiotics they would prescribe would contribute to resistance, and almost all (98%) felt that resistance would be a greater problem in the future. Most students (83%) incorrectly thought that rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia had significantly increased over the past decade in their countries. There was little appreciation of the relative burden of resistance in Europe compared with road traffic accidents (around two to three times greater mortality) and lung cancer (around 10 times greater mortality). Conclusions Students wanted further education on antibiotic prescribing, and areas of lack of confidence were found. Students overestimated the current burden of resistant bacteria and were unaware of successes in reducing MRSA infections. Educational and stewardship programmes may benefit from including more cases of diagnostic uncertainty, and highlighting successes such as MRSA prevention, as evidence for the importance of current interventions.

Objectives We had for aim to learn about medical students’ knowledge and perspectives on antibiotic prescribing and bacterial resistance. Methods Penultimate and final year students at a French medical school were invited to participate in an anonymous online survey in summer 2012. Results The response rate was 20% (60/297). Penultimate and final year students gave similar answers. Students felt more confident in diagnosing an infection, and less confident in choosing the correct dose and interval of antibiotic administration. Seventy-nine percent of students wanted more training on antibiotic treatments. Sixty-nine percent of students knew that antibiotic prescriptions were inappropriate or unnecessary in 21–60% of the cases, and 95% believed that these prescriptions were unethical. Only 27% knew that more than 80% of antibiotic prescriptions were made in community practice. Students believed that the most important causes of resistance were that too many prescriptions were made and broad-spectrum antibiotic use; 27% believed poor hand hygiene was “not at all important”. Ninety-four percent believed resistance was a national problem, and 69% mentioned it as a problem in their hospital. Sixty-three percent thought that the antibiotics they would prescribe would contribute to resistance, and 96% thought resistance would be a greater problem in the future. Twenty-two percent knew MRSA bacteremia rates had decreased over the past decade in France. Conclusions Medical students are aware that antibiotic resistance is a current and growing problem. They would like more training on antibiotic selection.

Nurses play important and diverse roles in optimizing antibiotic use in both inpatient and outpatient settings. In hospitals, patients and their relatives will usually spend more time in contact with nurses than with any other healthcare professional. In this chapter, we discuss the many activities related to the use of antibiotics that nurses engage in on a daily basis, focusing on nurses with prescribing rights, nonprescribing staff nurses, and nurses working within an antimicrobial stewardship (AMS) team. We include suggestions for how these roles can be developed and better integrated into AMS efforts in the future.

Education lies at the heart of antimicrobial stewardship and should target antimicrobial prescribers and other healthcare professionals. Education can improve knowledge and attitudes among prescribers and help make them aware of the broader contextual and cultural factors that affect prescribing behaviors. In this chapter, we discuss the structure and content of formal teaching programs in undergraduate and postgraduate training on responsible antibiotic prescribing.

Objective: A major site of action for the atheroprotective drug nicotinic acid (NA) is adipose tissue, via the G-protein-coupled receptor, GPR109A. Since, adipose tissue is an active secretory organ that contributes both positively and negatively to systemic inflammatory processes associated with cardiovascular disease, we hypothesized that NA would act directly upon adipocytes to alter the expression of pro-inflammatory chemokines, and the anti-inflammatory adipokine adiponectin. Methods and results: TNF-α treatment (1.0 ng/mL) of 3T3-L1 adipocytes resulted in an increase in gene expression of fractalkine (9 ± 3.3-fold, P < 0.01); monocyte chemoattractant protein-1 (MCP-1) (24 ± 1.2-fold, P < 0.001), 'regulated upon activation, normal T cell expressed and secreted' (RANTES) (500 ± 55-fold, P < 0.001) and inducible nitric oxide synthase (iNOS) (200 ± 70-fold, P < 0.05). The addition of NA (10-4 M) to TNF-α-treated adipocytes attenuated expression of fractalkine (50 ± 12%, P < 0.01); MCP-1 (50 ± 6%, P < 0.01), RANTES (70 ± 3%, P < 0.01) and iNOS (60 ± 16%). This pattern was mirrored in protein released from the adipocytes into the surrounding media. The effect on gene expression was neutralised by pre-treatment with pertussis toxin. NA attenuated macrophage chemotaxis (by 27 ± 3.5%, P < 0.001) towards adipocyte conditioned media. By contrast, NA, (10-6-10-3 M) increased, in a dose-dependent manner, mRNA of the atheroprotective hormone adiponectin (3-5-fold n = 6, P < 0.01). Conclusions: NA suppresses pro-atherogenic chemokines and upregulates the atheroprotective adiponectin through a G-protein-coupled pathway. Since adipose tissue has the potential to contribute to both systemic and local (perivascular) inflammation associated with atherosclerosis our results suggest a new "pleiotropic" role for NA. © 2009 Elsevier Ireland Ltd. All rights reserved.

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Background To improve antibiotic use globally, we must deepen our understanding of the public’s knowledge, attitudes and practices (KAP) concerning antibiotics. Children are frequent users of antibiotics, and their caregivers play important roles in determining how antibiotics are used. The purpose of this study was to describe caregivers’ KAP in a rural province in eastern China, and to identify socio-demographic factors associated with inappropriate antibiotic use. Methods A cross-sectional questionnaire based survey was conducted in 12 villages in one county in Shandong Province. A total of 727 individuals who were the primary day-to-day caregiver for a child aged 0–7 years were randomly selected and invited to participate. All caregivers were surveyed face-to-face using a semi-structured questionnaire focusing on the use of antibiotics in children. Results Almost all invited caregivers (99.3 %) completed the questionnaire in full. Caregivers expressed high levels of over-expectation for antibiotics for common childhood symptoms, stating that antibiotics were always or usually necessary when a child has a fever (46 %) or dry cough (42 %). Most caregivers (93 %) were aware that they should follow the doctor’s advice when giving their children antibiotics. Many, however, reported that they had previously deviated from advice; this was most commonly through using antibiotics intermittently rather than regularly, but also by increasing and decreasing doses. Caregivers that were older and that had less formal education had higher levels of self-reported adherence (p

Objectives The objective of this study was to identify the trends and patterns of total antibiotic use in Shanghai from 2009 to 2014. Methods Sales records were collected from a minimum of 160 hospitals and 241 primary healthcare settings and used as a proxy for consumption. Antibiotic sales expressed in DDD per 1000 inhabitants per day (DID) were calculated. We compared patterns of antibiotic use in the Shanghai municipality, populated by 24 million inhabitants, with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC). Results Total antibiotic use was highest at 25.9 DID in 2010, fell to 17.8 DID in 2012 and remained stable thereafter. The majority of this reduction occurred over 6 months in 2011. In 2014, two-thirds of the antibiotic sales were to hospitals (serving both inpatients and outpatients) and one-third to primary healthcare institutions. Cephalosporins accounted for 50.2% of total DID, followed by macrolides (18.2%), quinolones (16.0%) and penicillins (7.3%). A fifth of all antibiotics were used in parenteral form. Conclusions We have successfully used aggregated sales data to monitor antibiotic usage across a large urban population over a 6 year period. A rapid, substantial and sustained reduction in antibiotic usage across the entire health system occurred. This coincided with several interventions across hierarchies in the health sector, including a national campaign. The patterns of antibiotic use indicate persistent preferences for cephalosporins, macrolides, quinolones and parenteral preparations. Further efforts are needed to investigate and improve the quality of antibiotic use.

Background: Irrational antibiotic use is common in rural areas of China, despite the growing recognition of the importance of appropriate prescribing to contain antibiotic resistance. The aim of this study was to analyze doctors attitudes and prescribing practices related to antibiotics in rural areas of Shandong province, focusing on patients with the common cold. Methods: A survey was conducted with doctors working at thirty health facilities (village clinics, township health centers and county general hospitals) in three counties within Shandong province. Questions were included on knowledge and attitudes towards antibiotic prescribing. Separately, a random selection of prescriptions for patients with the common cold was collected from the healthcare institutions at which the doctors worked, to investigate actual prescribing behaviors. Results: A total of 188 doctors completed the survey. Most doctors (83%, 149/180) had attended training on antibiotic use since the beginning of their medical practice as a doctor, irrespective of the academic level of their undergraduate training. Of those that had training, most had attended it within the past three years (97%, 112/116). Very few doctors (2%, 3/187) said they would give antibiotics to a patient with symptoms of a common cold, and the majority (87%, 156/179) would refuse to prescribe an antibiotic even if patients were insistent on getting them. Doctors who had attended training were less likely to give antibiotics in this circumstance (29% vs. 14%, p less than 0.001). A diagnosis of common cold was the only diagnosis reported on 1590 out of 8400 prescriptions. Over half (55%, 869/1590) of them included an antibiotic. Prescriptions from village clinics were more likely to contain an antibiotic than those from other healthcare institutions (71% vs. 44% [township] vs. 47% [ county], p less than 0.001). Conclusions: Most doctors have recently attended training on antibiotic use and report they would not prescribe antibiotics for patients with a common cold, even when placed under pressure by patients. However, more than half of the prescriptions from these healthcare institutions for patients with the common cold included an antibiotic. Exploring and addressing gaps between knowledge and practice is critical to improving antibiotic use in rural China. Funding Agencies|National Nature Science Foundation of China [71073098]; Swedish International Development Cooperation Agency (Sida) [2010-001861]

Introduction Reduire les durees d’antibiotherapie limite l’emergence des resistances bacteriennes. Les pratiques actuelles concernant les durees des antibiotherapies sont cependant mal connues. Materiels et methodes Cette enquete internationale ESCMID-SPILF, ouverte du 1 er septembre au 1 er decembre 2016, avait pour but d’evaluer les durees d’antibiotherapie conseillees par les medecins/pharmaciens seniors donnant des avis au minimum hebdomadaires en antibiotherapie. Nous avons evalue leurs pratiques a l’aide de quinze vignettes presentant des situations cliniques d’evolution favorable frequemment rencontrees en pratique courante. Les participants ont ensuite ete interroges sur la duree minimale de traitement qu’ils seraient prets a prescrire dans les memes situations. Resultats Huit cent soixante-six professionnels (infectiologues 59 % et microbiologistes 23 %) provenant de 58 pays (France 19 %, Royaume-Uni 16 %, Espagne 9 % et Allemagne 8 %) ont participe. La duree de prescription conseillee par les participants excedait parfois la duree minimale validee dans la litterature : 8 jours conseilles versus 7 jours valides dans la litterature pour un erysipele, 7 vs 5 jours pour une exacerbation de BPCO, ou 7 vs 5 jours pour une cholecystite aigue non compliquee et operee dans les 24 heures. Les durees conseillees etaient cependant majoritairement (10/15 vignettes) en accord avec la litterature. Les participants declaraient etre prets a raccourcir les durees conseillees dans 8/15 vignettes, avec par exemple 28 jours de traitement pour une infection de pied diabetique, 5 jours pour une exacerbation de BPCO ou 10 jours pour une bacteriemie a S . aureus non compliquee. Conclusion Les professionnels ayant une activite de conseil en antibiotherapie declarent recommander des durees plutot courtes d’antibiotherapie, et semblent meme enclins a raccourcir encore ces durees. L’application des futures propositions de la SPILF sur le sujet semble donc possible en pratique.

International audience; Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of the utmost importance. We present a narrative review of the impact of infectious disease specialists (IDSs) on the quality and quantity of antibiotic use in acute-care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings, and types of antibiotic prescription. Seven of 31 studies were randomized controlled trials, before/after controlled studies, or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDSs, informal (curbside) consultations and the involvement of junior IDSs are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDSs in acute-care hospitals that are rarely reported in the published literature. Overall, IDSs are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organizational factors.

Around 90% of antibiotics used in human medicine are prescribed in primary care. At least half of these prescriptions are either unnecessary or inappropriate. Multifaceted interventions have proved useful in improving antibiotic prescribing, but they should be adapted to the context (‘One size does not fit all’ and ‘No magic bullet’ concepts). Behavior change theories are helpful for designing interventions that target healthcare professionals. Recent evidence related to various interventions targeting healthcare professionals are described here (Table 1): education, guidelines, clinical decision support systems, delayed prescribing, patient materials, public commitment, POC diagnostic tests, selective susceptibility reporting, quality indicators, audit and feedback, and restrictive prescribing measures. Interventions targeting the healthcare system have been overlooked so far, even though their impact can be large and sustained. Some examples are given here, including dispensing of antibiotics, financial incentives, and public reporting. Most published studies come from Europe or North America. We need studies from a much greater range of settings. Most interventions have focussed on GPs. In the future, all healthcare professionals should be targeted. Most studies have focussed on RTIs ; we need to develop a better understanding of how much improvement is possible for other conditions and how well suited our current interventions are to achieving this. Patient-centered outcomes remain largely underdeveloped and underreported. Innovative strategies, including those targeting the system organization, should be tested.

Introduction: The atheroprotective effects of nicotinic acid (NA) may be mediated through well-defined effects on plasma lipoproteins. However, a major site of action for nicotinic acid is adipose tissue, via the G-protein coupled receptor, GPR109A. Since, adipose tissue is an active secretory organ that contributes both positively and negatively to the systemic inflammatory process associated with cardiovascular disease, we hypothesized that: NA would act directly upon adipocytes to alter the expression of pro-inflammatory chemokines, and the anti-inflammatory adipokine adiponectin. Methods and Results: 3T3-L1 pre-adipocytes were differentiated into adipocytes using insulin and dexamethasone (10 −7 M) for 10 days. Adipocytes were incubated with NA (10 −6 M to 10 −3 M) under basal conditions, and/or with TNFα (1.0 ng/ml for 4 hours) to provoke inflammation. Quantitative real-time PCR for mRNA showed increased fractalkine (CX3CL1) (9-fold ± 3.3: P < 0.01), monocyte chemoattractant protein-1 (MCP-1) (24-fold ± 1.2: P < 0.001), and RANTES (CCL5) (500-fold ± 55: P < 0.001) in response to TNFα treatment (n=6). The addition of nicotinic acid (10 −4 M) to TNFα treated adipocytes attenuated expression of CXCL3 (50 ±12%: P < 0.01); MCP-1 (50 ± 6%: P < 0.01) and CCL5 (70 ± 3%: P < 0.01). By contrast, NA, (10 −6 M to 10 −3 M) increased in a dose-dependent manner mRNA of the atheroprotective hormone adiponectin (3- to 5-fold n=6, P P < 0.05). Conclusions: NA directly suppresses pro-atherogenic chemokines and promotes secretion of atheroprotective adiponectin by adipocytes. This is the first report of fracktalkine expression by adipose tissue. Since adipose tissue has the potential to contribute to both systemic and local (perivascular) inflammation associated with atherosclerosis our results suggest a new “pleiotropic” role for NA.

Results The response rate was 35% (322/961). Regarding prescribing according to stewardship principles, students at all medical schools felt most confident in diagnosing infections and choosing the right antibiotic, and least confident in choosing combination therapies, and making the decision to not prescribe antibiotics in cases of diagnostic uncertainty. With respect to the success of stewardship efforts thus far, the majority of students (83%) incorrectly thought MRSA bacteraemia rates had significantly increased over the past decade in their countries, and a quarter of students thought that handwashing was not at all an important contributor to resistance. Most students (66%) thought the antibiotics they will prescribe will contribute to resistance, with almost all (98%) acknowledging that resistance will be a greater problem in the future. Students were aware that around 30% of antibiotic usage was unnecessary or inappropriate, with 83% feeling that such prescribing is unethical. Only 65% of students had been shown how to access their hospital’s guidelines. As in previous single centre studies of both doctors and students, the majority of students (74%) in our survey still wanted further education on antibiotic selection.

Background Commensal bacteria represent an important reservoir of antibiotic resistance genes. Few community-based studies of antibiotic resistance in commensal bacteria have been conducted in Southeast Asia. We investigated the prevalence of resistance in commensal Escherichia coli in preschool children in rural Vietnam, and factors associated with carriage of resistant bacteria. Methods We tested isolates of E. coli from faecal samples of 818 children aged 6-60 months living in FilaBavi, a demographic surveillance site near Hanoi. Daily antibiotic use data was collected for participating children for three weeks prior to sampling and analysed with socioeconomic and demographic characteristics extracted from FilaBavi's re-census survey 2007. Descriptive statistics were generated, and a logistic regression model was used to identify contributions of the examined factors. Results High prevalences of resistance were found to tetracycline (74%), co-trimoxazole (68%), ampicillin (65%), chloramphenicol (40%), and nalidixic acid (27%). Two isolates were resistant to ciprofloxacin. Sixty percent of isolates were resistant to three or more antibiotics. Recent sulphonamide use was associated with co-trimoxazole resistance [OR 3.2, 95% CI 1.8-5.7], and beta-lactam use with ampicillin resistance [OR 1.8, 95% CI 1.3-2.4]. Isolates from children aged 6-23 months were more likely to be resistant to ampicillin [OR 1.8, 95% CI 1.3-2.4] and co-trimoxazole [OR 1.5, 95% CI 1.1-2.0]. Associations were identified between geographical areas and tetracycline and ampicillin resistance. Conclusions We present high prevalence of carriage of commensal E. coli resistant to commonly used antibiotics. The identified associations with recent antibiotic use, age, and geographical location might contribute to our understanding of carriage of antibiotic resistant commensal bacteria.

Antibiotic resistance is a complex global health challenge. The recent Global Action Plan on antimicrobial resistance highlights the importance of adopting One Health approaches that can cross traditional disciplinary boundaries. We report on the early experiences of a multisectoral Sino-Swedish research project that aims to address gaps in our current knowledge and seeks to improve the situation through system-wide interventions. Our research project is investigating antibiotic use and resistance in a rural area of China through a combination of epidemiological, health systems and laboratory investigations. We reflect here on the challenges inherent in conducting long distance cross-disciplinary collaborations, having now completed data and sample collection for a baseline situation analysis. In particular, we recognise the importance of investing in aspects such as effective communication, shared conceptual frameworks and leadership. We suggest that our experiences will be instructive to others planning to develop similar international One Health collaborations., Highlights • Antibiotic resistance is a complex global health challenge • One Health approaches are needed to facilitate understanding and action • China is one of the largest producers and consumers of antibiotics in the world • China is giving attention to antibiotic resistance at the highest political level • We report on the early stages of a Sino-Swedish One Health research programme

International audience; As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.