- Email: [email protected]
Antimicrobial stewardship and public knowledge of antibiotics
Correspondence
collegues conclude that ”presence of symptoms beyond 28 days… reflect[s] age and comorbidity rather than the persistent effects of the pneumonia itself”.3 We do not generalise the results outside of the study population; however, we consider the overall conclusions to be justified based not only on the clinical results but also on the microbiological and pharmacokinetic data outlined in the discussion, which include greater invitro potency against trial isolates, lower protein binding, and possibly improved lung tissue penetration for ceftaroline versus ceftriaxone. Finally, we acknowledge that ceftaroline fosamil is not yet a standard therapy for communityacquired pneumonia; guidelines inevitably take time to catch up with clinical evidence (although some, such as the National Institute for Health and Care Excellence in the UK, have already incorporated some of the evidence about ceftaroline fosamil).4 However, we stand by the suggestion that ceftaroline fosamil should be a comparator in future communityacquired pneumonia trials because it is the only agent to have shown superiority to an established standard of care. NSZ and TS received institutional research funding from AstraZeneca for the trial. DW is an employee of AstraZeneca, and DM is a former employee of AstraZeneca. Medical writing support was provided by Mark Waterlow (Prime Medica Ltd) and funded by AstraZeneca.
*Nan Shan Zhong, Tieying Sun, David Wilson, David Melnick [email protected] State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510120, China (NSZ); Beijing, Hospital, Beijing, China (TS); AstraZeneca, Macclesfield, UK (DW); and Allergan Inc, Jersey City, NJ, USA (DM) 1
1000
File TM Jr, Low DE, Eckburg PB, et al. Integrated analysis of FOCUS 1 and FOCUS 2: randomized, doubled-blinded, multicenter phase 3 trials of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in patients with community-acquired pneumonia. Clin Infect Dis 2010; 51: 1395–1405.
2
3
4
Taboada M, Melnick D, Iaconis J, et al. Antecedent antibiotic therapy decreases effect size in community-acquired pneumonia (CAP) therapy trials: meta-analysis of randomized trials of ceftaroline fosamil vs ceftriaxone. 54th Interscience Conference on Antimicrobial Agents and Chemotherapy; Washington DC, USA; Sept 5–8, 2014. L-1748a (abstr). El Moussaoui R, Opmeer BC, de Borgie CA, et al. Long-term symptom recovery and healthrelated quality of life in patients with mild-tomoderate-severe community-acquired pneumonia. Chest 2006; 130: 1165–72. NICE. Diagnosis and management of community- and hospital-acquired pneumonia in adults. http://www.nice.org.uk/ guidance/cg191 (accessed July 1, 2015).
Antimicrobial stewardship and public knowledge of antibiotics Haley Morrill and Kerry LaPlante report that several US states have announced policies to promote responsible antibiotic use among health-care providers. 1 In March 2015, in recognition of the public health threat and economic costs of antimicrobial resistance, the Obama administration made a commitment to reduce inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings by 2020, compared with 2011. However, the national plan to combat antibiotic resistance does not address the effect of patient knowledge and expectations on the overconsumption of antibiotics. Data from the National Science Foundation’s nationally re presentative Survey of Public Attitudes Toward and Understanding of Science and Technology show that public knowledge of antibiotics in the USA remains suboptimum. 2 Nationally, correct responses to the question “Antibiotics kill viruses as well as bacteria. Is that true or false?” increased from 30% in 1990 to 50% in 2000 but then mostly plateaued until 2012 (figure). Women were more likely to answer the question correctly
(51%), compared with men (44%). Respondents without postsecondary education were less likely to answer the question correctly (37%), compared with those who completed university (70%). Hispanic people (29%) and non-Hispanic black people (35%) were also less likely than non-Hispanic white people (63%) to correctly identify that antibiotics do not kill viruses. In a parallel survey in the European Union, 46% of respondents correctly identified antibiotics as ineffective against viruses. Even fewer respondents in China and India answered the question correctly— raising troubling implications for the future of infectious disease control in emerging economies.2,3 These deficits in the public’s knowledge of the ineffectiveness of antibiotics against viral infections might be contributing factors to the overprescribing of antibiotics. It has been well documented that the knowledge and attitudes of both the prescribing physician and the patient influence the prescribing of antibiotics.4 However, little empirical data exist about the effect of national campaigns on public knowledge regarding antibiotics. Continued surveillance of global attitudes toward antibiotics could help policymakers design more effective campaigns to raise public awareness of the necessity of prudent antibiotic use. Survey data suggest that there are important disparities in knowledge by race, ethnic origin, sex, and educational status—factors that point to the importance of ensuring that educational campaigns reach underserved populations. Prior studies have suggested that physicians are significantly more likely to prescribe antibiotics inappropriately to children of parents with low socioeconomic status.5 There might also be substantial differences in expectations. For example, Latino parents were significantly more likely than non-Hispanic white parents to expect antibiotics for the common cold.6 Targeting prescribers
www.thelancet.com/infection Vol 15 September 2015
Correspondence
A
1
100
Proportion of correct responses (%)
2 75
3 50
4 25
5 2011
2012
2010
2009
2007
2008
2005
2006
2003
2004
2001
2002
2000
1999
1997
1998
1995
1996
1993
1994
1991
1992
1990
0
6
Year
B Female Male
Proportion of correct responses (%)
100
GS BA HS
75
7
Morrill HJ, LaPlante KL. Overconsumption of antibiotics. Lancet Infect Dis 2015; 15: 377–78. National Science Foundation. Science and Engineering Indicators 2014. NSF, 2014. http:// www.nsf.gov/statistics/seind14/ (accessed April 12, 2015). Huttner B, Goossens H, Verheij T, et al. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 2010; 10: 17–31. Podolsky SH. The antibiotic era: reform, resistance, and the pursuit of a rational therapeutics. Baltimore, MD, USA: Johns Hopkins University Press, 2014. Mangione-Smith R, Elliott MN, Stivers T, McDonald LL, Heritage J. Ruling out the need for antibiotics: are we sending the right message? Arch Pediatr Adolesc Med 2006; 160: 945–52. Mangione-Smith R, Elliott MN, Stivers T, McDonald LL, Heritage J. McGlynn EA. Racial/ ethnic variation in parent expectations for antibiotics: implications for public health campaigns. Pediatrics 2004; 113: e385–94. Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014; 348: g1606.
50
Artemisinin resistance in Myanmar
25
Year
2012
2010
2006
2008
2004
2002
2000
1998
1996
1992
1994
1990
2012
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
0
Year
Figure: Public knowledge of antibiotics in the USA, 1990–2012 (A) Proportion of correct responses for all respondents to the survey question “Antibiotics kill viruses as well as bacteria” (false; p<0·001 for trend). (B) Proportion of correct responses to the survey question “Antibiotics kill viruses as well as bacteria” by sex and highest level of educational attainment. HS=high school or less. BA=college. GS=graduate school or higher.
practicing in predominately low socioeconomic status regions might have a dis proportionate effect on overall antibiotic use. Deferral or no antibiotic prescribing has been associated with a softening of beliefs among patients in the necessity of antibiotics,7 suggesting that coordinated efforts to reduce antibiotic prescribing could have a virtuous downstream effect on patient knowledge and outcomes. Public health officials and clinicians must better assess the state of knowledge of the public as a precursor to the design and implementation of more effective interventions to promote understanding, and encourage the judicious use of antibiotics.
This study was supported by grants from the Interfaculty Initiative in Health Policy (Cordeiro Research Fellowship to Mr Hwang), Center for American Political Studies, and Dunwalke Fund, all at Harvard University. Dr. Gibbs is supported by a grant from the David and Lucile Packard Foundation. Dr Linder was supported by grants from the National Institutes of Health (RC4 AG039115), the National Institute of Allergy and Infectious Diseases (R21 AI097759), and the Agency for Healthcare Research and Quality (R18 HS018419).
*Thomas J Hwang, Karine A Gibbs, Scott H Podolsky, Jeffrey A Linder [email protected] Faculty of Arts and Sciences (TJH), and Department of Molecular and Cellular Biology (KAG) , Harvard University, Cambridge, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (SHP); Center for the History of Medicine, Francis Countway Library of Medicine, Boston, MA, USA (SHP); and Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA (JAL)
www.thelancet.com/infection Vol 15 September 2015
We were surprised to read in Kyaw Tun and colleagues’ report1 in The Lancet Infectious Diseases that artemisinin resistance is spreading in Myanmar. In 2014, we reported no evidence of spread of artemisinin resistance from Cambodia to Myanmar.2 Genotyping of the adjacent region of Plasmodium falciparum chromosome 13 showed that some of the same K13 mutants in Cambodia and Vietnam arose on the same genetic background, whereas those in Myanmar and Cambodia emerged on different backgrounds, suggesting spread between Cambodia and Vietnam but independent emergence of artemisinin resistance in Myanmar.2 Another report confirmed this finding.3 The possibility was also raised of a spread in the past of a resistance-prone (but not resistant) strain upon which K13 mutations arose, but this scenario is hard to reconcile with the evidence of K13 mutations arising on different extended haplotypes surrounding K13. Both papers2,3 showing independent emergence of artemisinin resistance 1001
collegues conclude that ”presence of symptoms beyond 28 days… reflect[s] age and comorbidity rather than the persistent effects of the pneumonia itself”.3 We do not generalise the results outside of the study population; however, we consider the overall conclusions to be justified based not only on the clinical results but also on the microbiological and pharmacokinetic data outlined in the discussion, which include greater invitro potency against trial isolates, lower protein binding, and possibly improved lung tissue penetration for ceftaroline versus ceftriaxone. Finally, we acknowledge that ceftaroline fosamil is not yet a standard therapy for communityacquired pneumonia; guidelines inevitably take time to catch up with clinical evidence (although some, such as the National Institute for Health and Care Excellence in the UK, have already incorporated some of the evidence about ceftaroline fosamil).4 However, we stand by the suggestion that ceftaroline fosamil should be a comparator in future communityacquired pneumonia trials because it is the only agent to have shown superiority to an established standard of care. NSZ and TS received institutional research funding from AstraZeneca for the trial. DW is an employee of AstraZeneca, and DM is a former employee of AstraZeneca. Medical writing support was provided by Mark Waterlow (Prime Medica Ltd) and funded by AstraZeneca.
*Nan Shan Zhong, Tieying Sun, David Wilson, David Melnick [email protected] State Key Laboratory of Respiratory Diseases, First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong 510120, China (NSZ); Beijing, Hospital, Beijing, China (TS); AstraZeneca, Macclesfield, UK (DW); and Allergan Inc, Jersey City, NJ, USA (DM) 1
1000
File TM Jr, Low DE, Eckburg PB, et al. Integrated analysis of FOCUS 1 and FOCUS 2: randomized, doubled-blinded, multicenter phase 3 trials of the efficacy and safety of ceftaroline fosamil versus ceftriaxone in patients with community-acquired pneumonia. Clin Infect Dis 2010; 51: 1395–1405.
2
3
4
Taboada M, Melnick D, Iaconis J, et al. Antecedent antibiotic therapy decreases effect size in community-acquired pneumonia (CAP) therapy trials: meta-analysis of randomized trials of ceftaroline fosamil vs ceftriaxone. 54th Interscience Conference on Antimicrobial Agents and Chemotherapy; Washington DC, USA; Sept 5–8, 2014. L-1748a (abstr). El Moussaoui R, Opmeer BC, de Borgie CA, et al. Long-term symptom recovery and healthrelated quality of life in patients with mild-tomoderate-severe community-acquired pneumonia. Chest 2006; 130: 1165–72. NICE. Diagnosis and management of community- and hospital-acquired pneumonia in adults. http://www.nice.org.uk/ guidance/cg191 (accessed July 1, 2015).
Antimicrobial stewardship and public knowledge of antibiotics Haley Morrill and Kerry LaPlante report that several US states have announced policies to promote responsible antibiotic use among health-care providers. 1 In March 2015, in recognition of the public health threat and economic costs of antimicrobial resistance, the Obama administration made a commitment to reduce inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings by 2020, compared with 2011. However, the national plan to combat antibiotic resistance does not address the effect of patient knowledge and expectations on the overconsumption of antibiotics. Data from the National Science Foundation’s nationally re presentative Survey of Public Attitudes Toward and Understanding of Science and Technology show that public knowledge of antibiotics in the USA remains suboptimum. 2 Nationally, correct responses to the question “Antibiotics kill viruses as well as bacteria. Is that true or false?” increased from 30% in 1990 to 50% in 2000 but then mostly plateaued until 2012 (figure). Women were more likely to answer the question correctly
(51%), compared with men (44%). Respondents without postsecondary education were less likely to answer the question correctly (37%), compared with those who completed university (70%). Hispanic people (29%) and non-Hispanic black people (35%) were also less likely than non-Hispanic white people (63%) to correctly identify that antibiotics do not kill viruses. In a parallel survey in the European Union, 46% of respondents correctly identified antibiotics as ineffective against viruses. Even fewer respondents in China and India answered the question correctly— raising troubling implications for the future of infectious disease control in emerging economies.2,3 These deficits in the public’s knowledge of the ineffectiveness of antibiotics against viral infections might be contributing factors to the overprescribing of antibiotics. It has been well documented that the knowledge and attitudes of both the prescribing physician and the patient influence the prescribing of antibiotics.4 However, little empirical data exist about the effect of national campaigns on public knowledge regarding antibiotics. Continued surveillance of global attitudes toward antibiotics could help policymakers design more effective campaigns to raise public awareness of the necessity of prudent antibiotic use. Survey data suggest that there are important disparities in knowledge by race, ethnic origin, sex, and educational status—factors that point to the importance of ensuring that educational campaigns reach underserved populations. Prior studies have suggested that physicians are significantly more likely to prescribe antibiotics inappropriately to children of parents with low socioeconomic status.5 There might also be substantial differences in expectations. For example, Latino parents were significantly more likely than non-Hispanic white parents to expect antibiotics for the common cold.6 Targeting prescribers
www.thelancet.com/infection Vol 15 September 2015
Correspondence
A
1
100
Proportion of correct responses (%)
2 75
3 50
4 25
5 2011
2012
2010
2009
2007
2008
2005
2006
2003
2004
2001
2002
2000
1999
1997
1998
1995
1996
1993
1994
1991
1992
1990
0
6
Year
B Female Male
Proportion of correct responses (%)
100
GS BA HS
75
7
Morrill HJ, LaPlante KL. Overconsumption of antibiotics. Lancet Infect Dis 2015; 15: 377–78. National Science Foundation. Science and Engineering Indicators 2014. NSF, 2014. http:// www.nsf.gov/statistics/seind14/ (accessed April 12, 2015). Huttner B, Goossens H, Verheij T, et al. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 2010; 10: 17–31. Podolsky SH. The antibiotic era: reform, resistance, and the pursuit of a rational therapeutics. Baltimore, MD, USA: Johns Hopkins University Press, 2014. Mangione-Smith R, Elliott MN, Stivers T, McDonald LL, Heritage J. Ruling out the need for antibiotics: are we sending the right message? Arch Pediatr Adolesc Med 2006; 160: 945–52. Mangione-Smith R, Elliott MN, Stivers T, McDonald LL, Heritage J. McGlynn EA. Racial/ ethnic variation in parent expectations for antibiotics: implications for public health campaigns. Pediatrics 2004; 113: e385–94. Little P, Moore M, Kelly J, et al. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014; 348: g1606.
50
Artemisinin resistance in Myanmar
25
Year
2012
2010
2006
2008
2004
2002
2000
1998
1996
1992
1994
1990
2012
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
0
Year
Figure: Public knowledge of antibiotics in the USA, 1990–2012 (A) Proportion of correct responses for all respondents to the survey question “Antibiotics kill viruses as well as bacteria” (false; p<0·001 for trend). (B) Proportion of correct responses to the survey question “Antibiotics kill viruses as well as bacteria” by sex and highest level of educational attainment. HS=high school or less. BA=college. GS=graduate school or higher.
practicing in predominately low socioeconomic status regions might have a dis proportionate effect on overall antibiotic use. Deferral or no antibiotic prescribing has been associated with a softening of beliefs among patients in the necessity of antibiotics,7 suggesting that coordinated efforts to reduce antibiotic prescribing could have a virtuous downstream effect on patient knowledge and outcomes. Public health officials and clinicians must better assess the state of knowledge of the public as a precursor to the design and implementation of more effective interventions to promote understanding, and encourage the judicious use of antibiotics.
This study was supported by grants from the Interfaculty Initiative in Health Policy (Cordeiro Research Fellowship to Mr Hwang), Center for American Political Studies, and Dunwalke Fund, all at Harvard University. Dr. Gibbs is supported by a grant from the David and Lucile Packard Foundation. Dr Linder was supported by grants from the National Institutes of Health (RC4 AG039115), the National Institute of Allergy and Infectious Diseases (R21 AI097759), and the Agency for Healthcare Research and Quality (R18 HS018419).
*Thomas J Hwang, Karine A Gibbs, Scott H Podolsky, Jeffrey A Linder [email protected] Faculty of Arts and Sciences (TJH), and Department of Molecular and Cellular Biology (KAG) , Harvard University, Cambridge, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA (SHP); Center for the History of Medicine, Francis Countway Library of Medicine, Boston, MA, USA (SHP); and Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA (JAL)
www.thelancet.com/infection Vol 15 September 2015
We were surprised to read in Kyaw Tun and colleagues’ report1 in The Lancet Infectious Diseases that artemisinin resistance is spreading in Myanmar. In 2014, we reported no evidence of spread of artemisinin resistance from Cambodia to Myanmar.2 Genotyping of the adjacent region of Plasmodium falciparum chromosome 13 showed that some of the same K13 mutants in Cambodia and Vietnam arose on the same genetic background, whereas those in Myanmar and Cambodia emerged on different backgrounds, suggesting spread between Cambodia and Vietnam but independent emergence of artemisinin resistance in Myanmar.2 Another report confirmed this finding.3 The possibility was also raised of a spread in the past of a resistance-prone (but not resistant) strain upon which K13 mutations arose, but this scenario is hard to reconcile with the evidence of K13 mutations arising on different extended haplotypes surrounding K13. Both papers2,3 showing independent emergence of artemisinin resistance 1001