Dr. Ray O’Connor reviews the latest clinical literature on antibiotics and vaccines
Antibiotics
Antimicrobial resistance is a growing public health crisis worldwide, causing an estimated 1.27 million deaths annually worldwide. Overuse and misuse of antibiotics are important modifiable factors in the rise of drug-resistant infections. Most antibiotics are prescribed by primary care physicians. Peer comparison audits and feedback on antibiotic prescribing could be a scalable and effective intervention.
The aim of this pragmatic randomized controlled trial conducted in Canada1 was to evaluate whether providing family physicians with feedback on antibiotic prescribing for older patients reduces antibiotic prescribing compared with their peers. We also sought to identify the impact of case-mix adjusted feedback reports and messages highlighting antibiotic-related harms on antibiotic prescribing.
Letters with peer comparison feedback on antibiotic prescribing compared to the control group were mailed to physicians in January 2022. The results were very encouraging: after 6 months, the mean antibiotic prescription rate in the control group was 59.4 and in the intervention group was 56.0 (relative rate 0.95).
The intervention group also had significantly lower rates of unnecessary antibiotic prescriptions (0.89), long-term prescriptions defined as more than 7 days (0.85), and broad-spectrum prescriptions (0.94) compared with the control group, with results consistent at 12 months post-intervention.
The conclusion was that antibiotic prescribing audit and feedback is a scalable and effective intervention that should become a routine quality improvement initiative in primary care.
With over 50% of women suffering from at least one urinary tract infection (UTI) each year and the increasing prevalence of antimicrobial resistance, efforts are needed to clearly identify evidence supporting potential non-pharmacological interventions. This systematic review and meta-analysis2 compared the effects of cranberry juice, cranberry tablets, and increased fluid intake on the management of UTIs. The primary outcome was number of UTIs, and secondary outcomes were UTI symptoms and antibiotic consumption.
A total of 20 trials (3,091 participants) were included, of which 18 studies showed that cranberry juice was associated with a 54% lower incidence of UTIs than untreated and 27% lower than placebo. Cranberry juice was also associated with a 49% lower incidence of antibiotic use than placebo and 59% lower than untreated. The authors concluded that there is moderate to low certainty of evidence to support the use of cranberry juice to prevent UTIs.
Antibiotics are known to disrupt the composition of the microbiome and are often used during pregnancy and infancy to treat infections. Increasing evidence indicates that microbiome disturbances in early childhood are associated with childhood neurodevelopmental disorders. The aim of this Korean population-based cohort study and sibling analysis3 was to evaluate the association between antibiotic use during pregnancy or early infancy and the risk of childhood neurodevelopmental disorders.
All children born between 2009 and 2020 were followed until 2021 and compared those who were exposed to antibiotics during pregnancy or early infancy (first 6 months of life) with those who were not. Main outcome measures were autism spectrum disorder, intellectual disability, language disorder, and epilepsy.
Reassuringly, the findings showed that exposure to antibiotics during pregnancy or early infancy was not associated with an increased risk of autism spectrum disorder, intellectual disability, or language disorders in children. However, elevated risks were observed in some subgroups, including children who received antibiotics during very early childhood and those who used antibiotics for a long period of time. Furthermore, antibiotic use during infancy was modestly associated with epilepsy.
vaccination
The UK Health Security Agency reported that five infants who developed whooping cough died in England during the first three months of 2024.4,5 Nearly half of the cases (1,420 cases) were in people aged 15 years or older, and 29 percent (799 cases) were in children aged 10 to 14 years. This supports the continued importance of pertussis vaccination for children and pregnant women.
The World Health Organization has recommended a second malaria vaccine, R21/MatrixM, for preventing malaria in children after its safety and efficacy were verified6. Researchers and clinicians have welcomed the decision, hoping that it will help reduce the more than 500,000 malaria deaths each year caused by the limited supply of the other malaria vaccine, RTS,S. Results of a phase 3 trial of the vaccine in 4,800 children in Burkina Faso, Kenya, Mali and Tanzania showed that with a three-dose schedule, the vaccine was 75% effective in seasonal areas and 67% effective in standard areas.
References:
Schwartz K et al. Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years or older: a pragmatic factors randomized controlled trial. BMJ 2024;385:e079329 http://dx.doi.org/10.1136/bmj-2024‑079329 Moro C et al. Cranberry juice, cranberry tablets, or liquid therapy for urinary tract infections: a systematic review and network meta-analysis. Eur Urol Focus 2024 https://doi.org/10.1016/j.euf.2024.07.002 Choi A et al. Association of antibiotic exposure during pregnancy or early infancy with childhood risk of autism spectrum disorder, intellectual disability, language impairment, and epilepsy: a population-based cohort study. BMJ 2024;385:e076885 http://dx.doi.org/10.1136/bmj‑2023‑076885 Health Security Agency. Epidemiology of whooping cough in England 2024. May 2024. https://www.gov.uk/government/publications/pertussis-epidemiology-inengland-2024 Wise J. Whooping cough: what’s behind the rise in cases and deaths in England? BMJ 2024;385:q1118 http://dx.doi.org/10.1136/bmj.q1118 Mahase E. WHO recommends second dose of vaccine to prevent malaria in children. BMJ 2023;383:p2291 http://dx.doi.org/10.1136/bmj.p2291
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