Parental experience of prophylactic antibiotics.

BACKGROUND AND OBJECTIVES: Long-term prophylactic antibiotics are often used to prevent bacterial infections. However, supporting evidence for this is not always robust. Including parents in decisions relating to medication is key to medicines optimisation. Parental concern regarding medication is a major determinant of poor adherence. This study explores parental experiences of having a child prescribed prophylactic antibiotics and how that affects their antibiotic use behaviour. METHODS: We conducted a prospective, single-centre, exploratory, qualitative study at Sheffield Children's Hospital. Through 15 interviews, involving 18 participants, we explored parental 'lived experiences' and attitudes towards azithromycin prophylaxis prescribed for various respiratory conditions. Thematic analysis was conducted. RESULTS: The overriding factor influencing parental decisions about the uptake of antibiotic prophylaxis is wanting their child to be well now. The main concern voiced by parents is that of antibiotic resistance given their children are high users of antibiotics. This is however seen as a problem for the future, not the present. Preparing families adequately helps prevent practical difficulties relating to medication. Facilitating 'normalisation' of prophylaxis through daily routines and minimising disruption to the family environment may reduce parental anxiety, promote adherence and result in easing of potential restrictions to the child's daily activities. CONCLUSION: Grounded in our deeper understanding, we propose a behavioural model that describes phases parents go through while having a child on prophylactic antibiotics. Time invested in holistically addressing the parental experience and having an awareness of potential issues parents face, may facilitate medication adherence, reduce anxieties and improve doctor-parent relationships.

Prophylactic antibiotics prior to dental procedures: A cross-disciplinary survey of dentists and medical providers.

The prescription of prophylactic antibiotics prior to dental procedures is common, although factors influencing prescribing are poorly understood. We surveyed general and specialist medical providers and dentists on beliefs and attitudes regarding prophylactic antibiotic prescribing prior to dental procedures. There were significant differences in factors influencing decisions and perceived responsibility regarding prophylactic antibiotic prescribing between groups, although interest in additional education on the subject was high across both groups.

Influence of newborn health messages on care-seeking practices and community health behaviors among participants in the Zambia Chlorhexidine Application Trial.

BACKGROUND: Identifying and understanding traditional perceptions that influence newborn care practices and care-seeking behavior are crucial to developing sustainable interventions to improve neonatal health. The Zambia Chlorhexidine Application Trial (ZamCAT), a large-scale cluster randomized trial, assessed the impact of 4% chlorhexidine on neonatal mortality and omphalitis in Southern Province, Zambia. The main purpose of this post-ZamCAT qualitative study was to understand the impact of newborn care health messages on care-seeking behavior for neonates and the acceptability, knowledge, and attitudes towards chlorhexidine cord care among community members and health workers in Southern Province. METHODS & FINDINGS: Five focus group discussions and twenty-six in-depth interviews were conducted with mothers and health workers from ten health centers (5 rural and 5 peri-urban/urban). Community perceptions and local realities were identified as fundamental to care-seeking decisions and influenced individual participation in particular health-seeking behaviors. ZamCAT field monitors (data collectors) disseminated health messages at the time of recruitment at the health center and during subsequent home visits. Mothers noted that ZamCAT field monitors were effective in providing lessons and education on newborn care practices and participating mothers were able to share these messages with others in their communities. Although the study found no effect of chlorhexidine cord washes on neonatal mortality, community members had positive views towards chlorhexidine as they perceived that it reduced umbilical cord infections and was a beneficial alternative to traditional cord applications. CONCLUSION: The acceptability of health initiatives, such as chlorhexidine cord application, in community settings, is dependent on community education, understanding, and engagement. Community-based approaches, such as using community-based cadres of health workers to strengthen referrals, are an acceptable and potentially effective strategy to improve care-seeking behaviors and practices.

Impact of oral antibiotics on health-related quality of life after mandibular third molar surgery: An observational study.

AIM: To compare the impact of antibiotics on health-related quality of life (QoL) outcomes following third molar surgery. MATERIALS AND METHODS: The study population consisted of 135 subjects that required surgical extraction of mandibular third molar under local anesthesia and met the inclusion criteria. The subjects were randomized into three study groups of 45 subjects each: Group A - extended amoxicillin/clavulanic acid (GlaxoSmithKline Beecham England), 1 gram pre-operatively and then 625 mg BD for 5 days Group B - prophylactic amoxicillin/clavulanic acid (GlaxoSmithKline Beecham England) 1 gram pre-operatively only, and Group C - prophylactic levofloxacin 1 gram pre-operatively only. Patients were assessed pre- and post-operatively on days 1, 3, 5, 7, and 14 using the United Kingdom oral health-related QoL (OHRQoL) questionnaire. RESULTS: This study showed that surgical removal of impacted teeth exerted a negative influence on patient's QoL across various physical, social, and psychological aspects of life. Comparing the three groups, Group A showed a slightly better QoL score; although, there was no statistically significant difference among them. Studies have shown better clinical recovery following administration of antibiotics after third molar surgery. CONCLUSION: There was a significant deterioration in OHRQoL in the immediate postoperative period, particularly postoperative days 1 and 3 following third molar surgery. QoL was also observed to be slightly better in Group A than Groups B and C, although this was not statistically significant.

Surgical antibiotic prophylaxis in children: a mixed method study on healthcare professionals attitudes.

BACKGROUND: Qualitative and quantitative research investigating determinants of adherence to clinical guidelines (GLs) on surgical antibiotic prophylaxis (SAP) are scarce. We conducted a mixed-method study aimed at investigating barriers and at describing attitudes of healthcare professionals (HCPs) regarding SAP in three Italian children's hospitals. METHODS: The study comprised two sequential phases: 1) collection of qualitative data through focus groups; 2) conduction of a survey on HCPs attitudes towards SAP. Focus groups were carried out in each hospital with a theoretical convenience sample of 10-15 HCPs. Categorical analysis was conducted. Emerging categories and additional topics derived by literature search were used to develop the survey questionnaire, which included 13 questions expressed through a 4-point Likert scale. Members of surgical teams were invited by e-mail to fill in the questionnaire. We summed up the points assigned to each 4-point Likert scale response and calculated a cumulative score expressing overall concordance to expected HCPs attitudes on SAP. We conducted univariate and multivariate analysis to evaluate the relationship among characteristics of respondents and concordance with expected attitudes. RESULTS: The main categories identified in the qualitative phase included determinants of general adherence to GLs (e.g., relevance of clinical judgment), individual determinants (e.g., poor knowledge on hospital data) and organizational/structural determinants (e.g., patient flows). A total of 357 HCPs participated in the survey (response rate: 82.1%). Among respondents, 75% reported that SAP should be performed with first or second-generation cephalosporins, 44% that 2-3 days of antibiotic administration are useful as a precaution after surgery, 32% that SAP is needed for all surgical procedures. At multivariate analysis, professional category (physicians vs nurses; OR: 3.31; 95%CI: 1.88-5.82), and hospital (hospital 1 and 2 vs hospital 3; ORs: 2.79, 95%CI: 1.22-6.36; 2.40, 95%CI: 1.30-4.43, respectively) were significantly and independently associated with higher concordance with expected attitudes on SAP. CONCLUSIONS: Results from this study were useful to identify obstacles to appropriate SAP use in children. In our setting, findings support that a quality-improvement intervention should take into account local contexts, with development of hospital policies, education on SAP recommendations, and dissemination of data on adherence to recommendations.

Medication adherence among pediatric patients with sickle cell disease: a systematic review.

OBJECTIVES: Describe rates of adherence for sickle cell disease (SCD) medications, identify patient and medication characteristics associated with nonadherence, and determine the effect of nonadherence and moderate adherence (defined as taking 60%-80% of doses) on clinical outcomes. METHODS: In February 2012 we systematically searched 6 databases for peer-reviewed articles published after 1940. We identified articles evaluating medication adherence among patients <25 years old with SCD. Two authors reviewed each article to determine whether it should be included. Two authors extracted data, including medication studied, adherence measures used, rates of adherence, and barriers to adherence. RESULTS: Of 24 articles in the final review, 23 focused on 1 medication type: antibiotic prophylaxis (13 articles), iron chelation (5 articles), or hydroxyurea (5 articles). Adherence rates ranged from 16% to 89%; most reported moderate adherence. Medication factors contributed to adherence. For example, prophylactic antibiotic adherence was better with intramuscular than oral administration. Barriers included fear of side effects, incorrect dosing, and forgetting. Nonadherence was associated with more vaso-occlusive crises and hospitalizations. The limited data available on moderate adherence to iron chelation and hydroxyurea indicates some clinical benefit. CONCLUSIONS: Moderate adherence is typical among pediatric patients with SCD. Multicomponent interventions are needed to optimally deliver life-changing medications to these children and should include routine monitoring of adherence, support to prevent mistakes, and education to improve understanding of medication risks and benefits.

Low adherence to secondary prophylaxis among clients diagnosed with rheumatic fever, Jamaica.

OBJECTIVES: To determine the level of adherence and possible barriers to secondary prophylaxis among clients with rheumatic fever in Kingston, Jamaica. METHODS: Cross-sectional survey of 39 clients diagnosed with rheumatic fever, receiving penicillin prophylaxis for more than a year using a 22-item self-administered questionnaire on adherence to secondary prophylaxis and knowledge of rheumatic fever. The patients' records were reviewed to determine the number of prophylaxis injections the patients received for the year 2010. RESULTS: The majority of participants (74%) were females and 51% were adults. Only 48·7% had a high level of adherence. The majority (72%) had low knowledge levels regarding their illness, while only 5% had a high knowledge level score. Most clients (70%) strongly agreed that nurses and doctors encouraged them to take their prophylaxis. However, over 60% reported that they travelled long distances and or waited long periods to get their injections. One-third reported that they missed appointments because of fear of injections and having to take time off from work or school. DISCUSSION: Clients attending the health centers studied had limited knowledge about rheumatic fever. Barriers to adherence included fear of the injections, long commutes, and long waiting periods at the facilities studied.

The views of health care professionals about selective decontamination of the digestive tract: an international, theoretically informed interview study.

PURPOSE: Selective decontamination of the digestive tract (SDD) as a prophylactic intervention improves hospital-acquired infection and survival rates. Uptake of SDD is low and remains controversial. This study applied the theoretical domains framework to assess intensive care unit clinicians' views about SDD in regions with limited or no adoption of SDD. MATERIALS AND METHODS: Participants were health professionals with "decisional authority" for the adoption of SDD. Semistructured interviews were conducted as the first round of a Delphi study. Views about SDD adoption, delivery, and further SDD research were explored. Directed content analysis of interview data identified subthemes, which informed item development for subsequent Delphi rounds. Linguistic features of interview data were also explored. RESULTS: One hundred forty-one participants provided interview data. Fifty-six subthemes were identified; 46 were common across regions. Beliefs about consequences were the most widely elaborated theme. Linguistic features of how participants discussed SDD included caution expressed when discussing the risks and benefits and words such as "worry," "anxiety," and "fear" when discussing potential antibiotic resistance associated with SDD. CONCLUSIONS: We identified salient beliefs, barriers, and facilitators to SDD adoption and delivery. What participants said about SDD and the way in which they said it demonstrated the degree of clinical caution, uncertainty, and concern that SDD evokes.

Breastfeeding: the hidden barrier in Côte d'Ivoire's quest to eliminate mother-to-child transmission of HIV.

INTRODUCTION: Côte d'Ivoire has one of the worst HIV/AIDS epidemics in West Africa. This study sought to understand how HIV-positive women's life circumstances and interactions with the public health care system in Bouaké, Côte d'Ivoire, influence their self-reported ability to adhere to antiretroviral prophylaxis during pregnancy. METHODS: Semistructured interviews were conducted with 24 HIV-positive women not eligible for antiretroviral therapy and five health care workers recruited from four public clinics in which prevention of mother-to-child transmission services had been integrated into routine antenatal care. RESULTS: Self-reported adherence to prophylaxis is high, but women struggle to observe (outdated) guidelines for rapid infant weaning. Women's positive interactions with health providers, their motivation to protect their infants and the availability of free antiretrovirals seem to override most potential barriers to prophylaxis adherence. CONCLUSIONS: This study reveals the importance of considering the full continuum of prevention of mother-to-child transmission interventions, including infant feeding, instead of focussing primarily on prophylaxis for the mother and newborn.

Communicating new policy on antibiotic prophylaxis with patients: a randomised controlled trial.

OBJECTIVES: This trial aimed to assess the effectiveness of two different communication tools on the levels of anxiety and concern when a change in patients' treatment was introduced. METHOD: Patients previously advised to have antibiotic prophylaxis before their dental treatments were randomised to receive information about the new policy either through a video accompanied by a written leaflet or just the leaflet. All patients completed a questionnaire to assess anxiety and concern as well as intentions regarding accepting dental treatment without antibiotic prophylaxis at enrolment point, after intervention and after meeting the cardiologist. RESULTS: Ninety questionnaires were analysed (45 in each group). The mean level of anxiety and concern scores were significantly reduced after the intervention point (p <0.05). The ANOVA model revealed a significant reduction in the levels of anxiety and concern during the trial (p <0.001). However, the main effect of group (intervention versus control) and the interaction term were not significant. At the end of trial there was no difference in the number of patients accepting dental treatment without cover in the two groups. CONCLUSION: Patients appear more likely to accept a change if it is communicated directly to them by their practitioners via face to face consultation compared with video or leaflet. When there is a lack of time for in-depth consultation, video could be a more effective method than leaflet alone.

Awareness and knowledge of prophylaxis for infective endocarditis in patients with severe rheumatic heart disease.

Prevention of infective endocardit s (IE) is mportant because it has a high mortalty rate.This study sets out to to gather information from patients who were at risk of developing IE of their knowledge of the need for prophylaxis for the disease. Forty-one black patients suffering from severe rheumatic heart disease (RHD) were interviewed. Only one patient (2.4%) was regularly visiting a dentist to maintain good oral health and only five (12.2%) had received advice about the need for antibiotic cover prior to dental extraction. The vast majority of patients (97.5%) visited a dentist only when driven by dental pain, 36.6 % had to travel for more than an hour to reach their nearest dentist, and 87.8% indicated that they brushed their teeth. It may be concluded that in this group of black patients with severe RHD there was a lack of knowledge of the need for and of measures recommended for prophylaxs against IE. In addition, attempts by the health care team to ensure good oral health and access to dental care for these patients were inadequate, if not non-existent.

NICE guidance on antibiotic prophylaxis to prevent infective endocarditis: a survey of clinicians' attitudes.

BACKGROUND: Since the introduction of the National Institute for Health and Clinical Excellence (NICE) guideline (CG064) in 2008 recommending cessation of antibiotic prophylaxis (AP) against infective endocarditis (IE), low level prescribing persists in the UK and is a potential reason why there has been no significant change in the general upward trend in cases of IE. AIM: To undertake a survey of dentists (Ds), cardiologists and cardiothoracic surgeons (C/CTSs) and infection specialists (ISs) to determine why this might be the case. DESIGN: Internet questionnaire-based survey. METHODS: A questionnaire was distributed by email to specialists via UK national societies. RESULTS: A total of 1168 responses were received. All the specialist groups are aware of the guideline (99%). Ds are broadly satisfied, whereas C/CTSs are not. Most Ds follow the NICE guidance (87%), whereas many C/CTSs (39%) do not; ISs adopt a middle course (56%). Even amongst Ds, a significant proportion believe that patients with a prosthetic heart valve (25%) or previous history of IE (38%) should receive AP. A total of 36% of Ds have prescribed AP since March 2008 and many have undertaken procedures where AP has been prescribed by someone else. The majority of respondents (65%) feel that more evidence is required, preferably in the form of a randomized controlled trial. CONCLUSION: Many patients perceived to be at high risk of IE are still receiving AP in conflict with current NICE guidance.

Public response to an anthrax attack: a multiethnic perspective.

The 2001 anthrax attacks emphasized the need to develop outreach that would more effectively support racial/ethnic minority populations during a bioterrorism incident. Given the importance of antibiotic prophylaxis in a future anthrax attack, it should be a priority to better support racial/ethnic minorities in mass dispensing programs. To examine the needs and perspectives of racial/ethnic minorities, this study used a nationally representative poll of 1,852 adults, including 1,240 whites, 261 African Americans, and 282 Hispanics. The poll examined public reactions to a ''worst-case scenario'' in which cases of inhalation anthrax are discovered without an identified source and the entire population of a city or town is asked to receive antibiotic prophylaxis within 48 hours. Findings suggest willingness across all racial/ethnic groups to comply with recommendations to seek prophylaxis at dispensing sites. However, findings also indicate possible barriers for racial/ethnic minorities, including greater concern about pill safety and multiple attacks as well as lesser knowledge about inhalation anthrax. Across all racial/ethnic groups, roughly half would prefer to receive antibiotics at mass dispensing sites rather than through the US Postal Service. People in racial/ethnic minority groups were more likely to say this preference stems from a desire to speak with staff or to exchange medication formulation or type. Findings suggest the need for tailored outreach to racial/ethnic minorities through, for example, emphasis on key messages and enhanced understandability in communications, increased staff for answering questions in relevant dispensing sites, and long-term trust building with racial/ethnic minority communities.

Cognitive, psychosocial, and sociodemographic predictors of willingness to use HIV pre-exposure prophylaxis among Chinese men who have sex with men.

This study was designed to identify predictors of lower versus higher willingness to use pre-exposure prophylaxis (PrEP) to reduce HIV among men who have sex with men (MSM) in China. Participants were 570 MSM who completed self-report measures of willingness to use HIV PrEP, beliefs about HIV, psychosocial factors, sexual experiences and sociodemographic characteristics. Results of a hierarchical binary logistic regression analysis indicated that membership in a higher willingness group was predicted by previous consultation about HIV, more reported barriers to using condoms, and elevations in depressive symptoms. Independent of these factors, higher willingness to use HIV PrEP was predicted by beliefs that the intervention was low in stigma and high in potential benefits. In sum, the study highlighted the utility of broad-based assessment of demographic, behavioral, personality, and cognitive factors in identifying Chinese MSM who express willingness to use a promising biologically-based intervention to lower HIV risk.

Public response to an anthrax attack: reactions to mass prophylaxis in a scenario involving inhalation anthrax from an unidentified source.

An attack with Bacillus anthracis ("anthrax") is a known threat to the United States. When weaponized, it can cause inhalation anthrax, the deadliest form of the disease. Due to the rapid course of inhalation anthrax, delays in initiation of antibiotics may decrease survival chances. Because a rapid response would require cooperation from the public, there is a need to understand the public's response to possible mass dispensing programs. To examine the public's response to a mass prophylaxis program, this study used a nationally representative poll of 1,092 adults, supplemented by a targeted focus on 3 metropolitan areas where anthrax attacks occurred in 2001: New York City (n=517), Washington, DC (n=509), and Trenton/Mercer County, NJ (n=507). The poll was built around a "worst-case scenario" in which cases of inhalation anthrax are discovered without an identified source and the entire population of a city or town is asked to receive antibiotic prophylaxis within a 48-hour period. Findings from this poll provide important signs of public willingness to comply with public health recommendations for obtaining antibiotics from a dispensing site, although they also indicate that public health officials may face several challenges to compliance, including misinformation about the contagiousness of inhalation anthrax; fears about personal safety in crowds; distrust of government agencies to provide sufficient, safe, and effective medicine; and hesitation about ingesting antibiotic pills after receiving them. In general, people living in areas where anthrax attacks occurred in 2001 had responses similar to those of the nation as a whole.

Physicians' and nurses' opinions on selective decontamination of the digestive tract and selective oropharyngeal decontamination: a survey.

INTRODUCTION: Use of selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) in intensive care patients has been controversial for years. Through regular questionnaires we determined expectations concerning SDD (effectiveness) and experience with SDD and SOD (workload and patient friendliness), as perceived by nurses and physicians. METHODS: A survey was embedded in a group-randomized, controlled, cross-over multicenter study in the Netherlands in which, during three 6-month periods, SDD, SOD or standard care was used in random order. At the end of each study period, all nurses and physicians from participating intensive care units received study questionnaires. RESULTS: In all, 1024 (71%) of 1450 questionnaires were returned by nurses and 253 (82%) of 307 by physicians. Expectations that SDD improved patient outcome increased from 71% and 77% of respondents after the first two study periods to 82% at the end of the study (P = 0.004), with comparable trends among nurses and physicians. Nurses considered SDD to impose a higher workload (median 5.0, on a scale from 1 (low) to 10 (high)) than SOD (median 4.0) and standard care (median 2.0). Both SDD and SOD were considered less patient friendly than standard care (medians 4.0, 4.0 and 6.0, respectively). According to physicians, SDD had a higher workload (median 5.5) than SOD (median 5.0), which in turn was higher than standard care (median 2.5). Furthermore, physicians graded patient friendliness of standard care (median 8.0) higher than that of SDD and SOD (both median 6.0). CONCLUSIONS: Although perceived effectiveness of SDD increased as the trial proceeded, both among physicians and nurses, SOD and SDD were, as compared to standard care, considered to increase workload and to reduce patient friendliness. Therefore, education about the importance of oral care and on the effects of SDD and SOD on patient outcomes will be important when implementing these strategies. TRIAL REGISTRATION: ISRCTN35176830.

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference.

UNLABELLED: Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR. OBJECTIVE: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III). SUBJECTS AND METHODS: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment. RESULTS: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended. CONCLUSION: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.

[Determination of indicators for non-compliance with guidelines for surgical antimicrobial prophylaxis]. / Quelles sont les situations de non-conformité de l'antibioprophylaxie chirurgicale par rapport aux recommandations nationales ?

We conducted a prospective study to identify predictors of inappropriateness of surgical prophylaxis. A total of 72 surgeon-anaesthesist pairs participated in data collection. We assessed practices by addressing 5 questions: did the surgical procedure justify the use of antimicrobial prophylaxis, and was it provided? Was the correct agent used? Was the timing of prophylaxis optimal? Was the duration of prophylaxis correct? Was the dose correct? We reviewed 687 procedures, 513 (74.7%) of which were included in the analysis. The proportion of these procedures with totally compliant prescriptions was 41.7%. Of the 156 patients who received an inappropriate drug, 133 (85.3%) received a drug with a broader spectrum than that recommended. Prophylaxis lasted too long in 81 (89.0%) of the 91 patients who received prophylaxis of incorrect duration. Multivariate analysis revealed a clear association between non-compliant prophylaxis and two operation-specific factors: prosthesis implantation (with a relative risk of 2.52) and clean-contaminated operations (with a relative risk of 4.19). More than 50% of patients received inappropriate surgical prophylaxis. Non-observance of guidelines was related to factors that did not influence the infectious potential of the flora.