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Multivariable linear and negative binomial models were produced to assess relationships among socioeconomic and influenza rate data with the use of macrolide and fluoroquinolone antimicrobials by Canadians. Varying results were found both among and between the macrolide and fluoroquinolone groups; however, a pattern of accessibility to care was apparent. Cheaper antimicrobials were used most often in the most disadvantaged populations, and more expensive antimicrobials were used most frequently in advantaged populations. Significant interactions were found between influenza and socioeconomic variables relating to unemployment, education, and degree of poverty in a population. Results suggest that antimicrobials are being prescribed and consumed at inappropriate rates in both disadvantaged and affluent populations in Canada. In order to reduce antimicrobial use and the further development of antimicrobial resistance in Canada, we suggest that responsible antimicrobial stewardship be practiced and promoted by all physicians in community and hospital settings, particularly during the influenza season. / Public Health Agency of Canada

N. Gonorrhoeae is a major public health concern due to its capacity to develop antibiotic resistance and its potential complications including pelvic inflammatory disease, epididymitis, infertility, and disseminated infection. In order to keep up with resistance trends, the treatment recommendations for gonorrhea have changed frequently. In other areas of medicine, guideline adherence has been shown to be limited, even without frequent guideline changes. In the case of gonorrhea, inappropriate treatment can have serious individual and public health implications, making the quality of and compliance with clinical guidelines critical. This thesis is a three-part mixed methods research project assessing the development and uptake of gonorrhea treatment guidelines. We conducted a systematic review of current gonorrhea treatment guidelines and used the AGREE II tool to assess the quality of guideline development (Chapter 2). We observed that guideline quality varied greatly with many guidelines having weaknesses in their use of existing evidence to develop recommendations, their reporting of potential conflicts of interest and how they were addressed, and their consideration of barriers to the implementation of their recommendations. We then assessed physician adherence to first-line treatment recommendations in Ontario by conducting a segmented time series analysis of Ontario gonorrhea treatment data from iPHIS, the province’s reportable disease database (Chapter 3). Following the introduction of new guidelines that recommended substantial changes from current practice, we found very dramatic drops in guidelines adherence that then improved slowly over time. We then explored the use of process mapping as a tool to look at the local management of cases in the City of Ottawa by following them across the various possible treatment pathways (Chapter 4). Here, we noted differences in practice between the management of cases at Ottawa Public Health’s Sexual Health Clinic and the management of cases elsewhere in the community.

Antibiotics are commonly prescribed and requested for viral illnesses despite evidence-based research studies and societal guidelines that advise against this practice. Literature has indicated that antibiotic decision-making comes from a provider's experience or exposure to illness, uncertainty of illness, or from being pressured by the patient. Nurses and advanced practice nurses are important participants in the antibiotic stewardship initiative. The purpose of this project was to examine potential knowledge deficits responsible for inappropriate antibiotic prescribing at a rural urgent care clinic in the southeastern United States, which when addressed could promote an educational in-service to decrease the number of antibiotics prescribed during a high-volume cough, cold, and flu months. The health belief model was used as a foundational model and a knowledge, attitude, and practice survey to collect data. Antibiotic prescribing habits were evaluated in the preintervention group (n = 250) and a year later in the postintervention group (n = 265). Antibiotic prescribing decreased positively from 80% to 70% and watchful waiting also increased positively from 4% to 30%; X-² (1) = 12.302, p = .000. The increase in educational awareness from these results can support a decrease in inappropriate antibiotic prescriptions, which prevents the emergence of antibiotic-resistant bacteria, contributing to positive social change.

La maitrise de la résistance bactérienne et l’utilisation prudente des antibiotiques à l’hôpital constituent des enjeux majeurs pour les autorités de santé dans tous les pays européens. Toutefois, les connaissances en matière de consommation des antibiotiques et de politique de bon usage des antibiotiques dans les établissements sont limitées. Dans ce contexte, le travail de cette thèse permet de donner une meilleure vision de la consommation des antibiotiques dans les pays européens à partir des données de surveillance disponibles. Il apporte également des cibles d’amélioration de la prescription des antibiotiques et identifie plusieurs indicateurs de qualité pour mener à bien une politique de bon usage des antibiotiques. De plus, ce travail utilise le modèle des hôpitaux français pour identifier des critères d’ajustement de la consommation des antibiotiques facilement disponibles qui sont essentiels à mettre en œuvre pour établir des comparaisons entre les différents hôpitaux. Il s’intéresse également à la relation entre la politique de bon usage des antibiotiques dans les hôpitaux et une moindre consommation des antibiotiques. En conclusion, les données de surveillance de la consommation des antibiotiques ont donc permis de répondre à plusieurs hypothèses de recherche et de dégager de nouveaux axes de réflexions. / The control of bacterial resistance and the prudent use of antibiotics in hospitals are major challenges for health authorities in all European countries. However, little is known regarding antibiotic consumption and antibiotic policies in hospitals. In this context, this thesis provides insight into the antibiotic consumption using available survey databases. It also identifies targets for quality improvement and several quality indicators which are essencial to carry out a prudent use antibiotic policy. Moreover, the model of French hospitals was used to explore easily available adjustment criteria for the antibiotic consumption which are crucial to implement comparisons between different types of hospitals. This work brings light onto the relationship between the antibiotic policy and a low level of antibiotic use in French hospitals. In conclusion, survey databases have enabled us to answer several research assumptions and to generate new horizons of reflection.

Antimicrobials are unique drugs in that they target "infectious" or "transferable" diseases. There is considerable evidence linking increasing antimicrobial use withincreasing resistance. Resistant bacteria do not know the boundaries, either between countries or within a society between hospital and primary care. Inappropriate prescribing of antimicrobials in hospitals therefore has consequences for whole communities and problems may spread both nationally and internationally. The gathering of reliable measurements of antibiotic use in hospitals employing standardised methods is essential to building an evidence base and highlighting inconsistencies at national and international levels. In this study, after data processing, validating and record linkage, a method forelectronic conversion of drug supply data to the ATC/DDD classification and forlongitudinal analysis was established for Tayside and then for a set of Europeanhospitals. Time series analysis and interrupted time series analysis were described and used for longitudinal surveillance and interventional study of antimicrobial use. This thesis explores issues concerning the evolution and management of hospital antimicrobial use using a wide range of methods. A series of drug utilisation research studies were implemented as the basis of research methods that, in combination of previously described methods, provided novel studies. No single measure can currently capture all of the aspects of hospital antibiotic use. However, a combination of detailed, point prevalence data from individual patients with longitudinal analysis of total consumption can provide meaningful data for comparison between hospitals and for analysis of the relationship between use and outcome. Additionally, there is a need to apply standard processes and novel methods to produce more meaningful surveillances. Longitudinal and point prevalence surveillances together with an explanation ofvariations in hospital characteristics are used to produce a set of coherent measurements of hospital antimicrobial use. Administrative data for longitudinal surveys requires continuous quality control.Whereas drug utilisation researchers and clinicians should target a set of indicators for interventional studies, large studies at national or international level need central data processing by country to identify targets for evaluation and for interventional studies. Support from experts in other fields is needed to address any shortcomings that may be experienced during continuous antibiotic drug utilisation monitoring at national and international levels.

<p>Objective: To explore views of medical doctors, veterinarians and drug sellers on use of antibiotics on humans and nonhumans and on factors that influences the development of resistance to antibacterial agents. Further, to look at the bi-directional relationship between antibiotic use and environment. </p><p>Methods: The study was a qualitative explorative interview study, analysed using conventional content analysis. It was conducted in Orissa, India. Data were collected by face to face semi structured interview. The interviews were tape recorded and transcribed into Oriya, then translated in to English. Each paragraph or sentence was coded. Similar codes were clustered together and collapsed into sub categories and categories. The main themes were allowed to emerge, based on the relationship between categories.</p><p>Findings: The main finding of the study was mishandling and abuse of antibiotics in patients as well as at professional level due to weak implementation of legislation, which appears to be the major cause of antibacterial agent resistance. Incomplete course or dose due to poverty in rural area and self medication in urban area are more common. The study also showed that climatic factors, pollution and population density are the major ecological factors which influence antibiotic prescriptions. Another major finding of this study was that, due to improper disposal system of pharmaceuticals; antibiotics are contaminating air, water and terrains which can cause major risk to aquatic and grazing animals. </p><p>Conclusion: This study emphasises the need for comprehensive actions including information, training, legislation and education at all levels of drug delivery system to rationalize antibiotic use by improving prescribing pattern and creating awareness among consumers. Proper disposal of pharmaceutical wastes is required to prevent the contamination of environment from pharmaceutical pollutants. Further study is essential concerning environmental impact of antibiotics.</p><p>Key words: Antibiotic use; antibiotic resistance; environment; qualitative; conventional; content analysis; veterinarians; medical doctors; drug sellers; Orissa; India.</p>

Objective: To explore views of medical doctors, veterinarians and drug sellers on use of antibiotics on humans and nonhumans and on factors that influences the development of resistance to antibacterial agents. Further, to look at the bi-directional relationship between antibiotic use and environment. Methods: The study was a qualitative explorative interview study, analysed using conventional content analysis. It was conducted in Orissa, India. Data were collected by face to face semi structured interview. The interviews were tape recorded and transcribed into Oriya, then translated in to English. Each paragraph or sentence was coded. Similar codes were clustered together and collapsed into sub categories and categories. The main themes were allowed to emerge, based on the relationship between categories. Findings: The main finding of the study was mishandling and abuse of antibiotics in patients as well as at professional level due to weak implementation of legislation, which appears to be the major cause of antibacterial agent resistance. Incomplete course or dose due to poverty in rural area and self medication in urban area are more common. The study also showed that climatic factors, pollution and population density are the major ecological factors which influence antibiotic prescriptions. Another major finding of this study was that, due to improper disposal system of pharmaceuticals; antibiotics are contaminating air, water and terrains which can cause major risk to aquatic and grazing animals. Conclusion: This study emphasises the need for comprehensive actions including information, training, legislation and education at all levels of drug delivery system to rationalize antibiotic use by improving prescribing pattern and creating awareness among consumers. Proper disposal of pharmaceutical wastes is required to prevent the contamination of environment from pharmaceutical pollutants. Further study is essential concerning environmental impact of antibiotics. Key words: Antibiotic use; antibiotic resistance; environment; qualitative; conventional; content analysis; veterinarians; medical doctors; drug sellers; Orissa; India.

Methicillin-resistant Staphylococcus aureus (MRSA) is a growing concern in Canada especially in Aboriginal communities in remote regions. The northern and remote communities possess some or many of the risk factors that are identified in previous research to be associated with Community-Associated Methicillin-resistant Staphylococcus aureus (CA-MRSA) infections such as overcrowding, challenges in maintaining personal hygiene and limited access to healthcare. CA-MRSA spreads rapidly in the communities. It is known to not only affect young and healthy individuals, but it is also associated with high morbidity and mortality rates. Furthermore, antibiotic resistance in CA-MRSA is increasing in Canada. It is known that inappropriate and greater use of antibiotics is associated with increased antibiotic resistance. Resistant CA-MRSA infections are more difficult to treat. To reduce and to control the antibiotic resistance, monitoring the prevalence of CA-MRSA and the changing antibiotic susceptibility profiles at the population level, especially in highly affected communities, is crucial. By monitoring this trend, it will enable healthcare practitioners to provide more adequate and appropriate treatment. To our knowledge, there was no community-based study that examined the epidemiology of CA-MRSA skin and soft-tissue infections (SSTIs) in First Nations communities in Canada at large scale, and the knowledge on the risk factors, outcomes and antibiotic susceptibility profiles is still very limited. This study aimed to describe the local epidemiology of SSTIs at the community level in selected First Nations communities as well as to describe the antibiotic use to treat SSTIs and the antibiotic susceptibility patterns of CA-MRSA. A retrospective chart review was conducted in 12 nursing stations in the First Nations communities across 5 provinces in Canada. The charts of individuals over 18 years of age who had received service at the nursing station in the previous 12 months, starting retrospectively from the date of collection, were reviewed in this study. Each antibiotic prescription that was noted in the chart in this period prior to chart review was recorded in the antibiotic tracking case report form. Data collected included demographics, indication for antibiotic use, antibiotic prescription parameters and patient outcomes. In total, of 372 patient charts reviewed, 224 patient charts contained at least one case (an encounter that resulted in an antibiotic prescription during the study period). Of those 224 charts, 459 cases were recorded and, of those, 137 cases had a diagnosis of an SSTI. In the 65 patients accounting for all cases of SSTI patients, more than 80% of the study population were under the age of 50. The prevalence of impaired renal function was low, diabetes was present in 20% of cases, cardiac disease was present in 15% of cases, and reported alcohol misuse was present in 30% of cases. The presence of indwelling devices was very rare. There were 137 cases of SSTIs over 372 charts reviewed in total. The prevalence of SSTI among the selected First Nations communities in 2012-2013 was estimated at almost 37% (137 cases of SSTIs / 372 charts reviewed). In the 137 SSTI cases, 55 cases were identified as MRSA infections either by laboratory test such as wound culture or by history of colonization documented in the chart. The overall prevalence of MRSA in all SSTI cases was estimated at 40.1% (55 confirmed MRSA positive cases / 137 cases of SSTIs). The majority of SSTIs were purulent infections and wounds. We also found that a wound culture and susceptibility test were performed only in 29% of all SSTI cases. An orally administered antibiotic was most frequently used (in 71.5% of treatments). Topical antibiotics were used in 18.3% and IV antibiotics were used in 8.8%. Other than the antibiotic treatment, wound care was performed in 49% of the SSTI cases and incision and drainage (I&D) procedure in 9%. The majority of MRSA isolates in this study were susceptible to clindamycin and co-trimoxazole (90.5% and 95.2%), but only 29% were susceptible to erythromycin. In general, higher rates of SSTIs were seen in communities where overcrowding and poor access to running water are more prevalent. In this study, we found that the diagnostic tests such as wound culture and sensitivity test was not ordered very often and there was also lack of follow-up or lack of documentation of the follow-up. More research is needed to better understand some of the challenges and risk factors associated with CA-MRSA infections in remote communities. Developing a national-level surveillance system that can help with monitoring the epidemiology of SSTIs and the antibiotic susceptibility test results of CA-MRSA at community level would be essential for better prevention, control, and management. Furthermore, adopting other initiatives such as antibiotic stewardship programs at community and healthcare settings as well as addressing the socio-environmental factors such as housing and access to water would be all very important in the steps to curb antibiotic resistance.