Digital education to improve ambulatory antibiotic use in LatinAmerica

We will develop and implement digital education to improve prescribers, pharmacists, and patients’ knowledge about antibiotics for common conditions driving inappropriate antibiotic use in the ambulatory setting in Latin America including both technical and behavioral aspects related to antibiotic use.

PI: Valeria Fabre, Associate Profesor of Medicine, Division of Infectious Diseases, Johns Hopkins University.

Co-PI: Rodolfo E. Quiros, Infectious Disease Physician, Founder of PROAnet app.

Optimizing antibiotic use is a key strategy to tackle the current antimicrobial resistance (AMR) problem threatening human health. There is an urgent need to implement strategies to improve antibiotic use in the ambulatory (outpatient) setting where 80-90% of antibiotics are consumed, particularly in Latin America where there has been an alarming increase in AMR in recent decades. Hispanics are twice more likely to believe antibiotics are helpful to treat respiratory viral infections than other ethnic groups. Furthermore, while most countries in Latin America have passed laws that regulate sales of antimicrobials, dispensing of antibiotics without a prescription remains a challenge in the region. Most countries in Latin America are still in early phases of developing or implementing action plans to combat AMR. Evidence and experience from other regions have shown that education can effectively reduce unnecessary antibiotic use in ambulatory settings. We propose to develop and implement mobile-based digital education targeting key individuals (prescribers, pharmacists, and patients) and key aspects of antibiotic use (e.g. patients’ perceptions about antibiotics and providers’ approach to patients’ expectations). 

Our solution serves the community. This project aims to improve knowledge of and perceptions towards antibiotics in the ambualtory setting targeting physicians, pharmacists, and patients (the three key players in antibiotic use). Several studies have shown educational programs are effective in improving antibiotic use (PMID: 31516125; 36139965; 3574019). However, there is limited data coming from Latin America. Antibiotic consumption is usually higher in younger children, older adults, and in women. However, adverse events related to antibiotics (such as a severe form of colitis due to Clostridiides difficile, gastrointestinal symptoms requiring emergency room visits) can happen after just one dose or one treatment course. Therefore, this program would benefit individuals of all ages. As >50% of all outpatient antibiotic prescriptions are given for 5 conditions (otitis media, sinusitis, bronchitis, pharyngitis, and nonspecific upper respiratory tract infection [common cold]) we will focus our education on those syndromes. The intervention will also serve ambulatory physicians who after the education will likely feel more comofrtable and be more efficient in dealing with common scenarios that traditionally have led to inappropriate antibitoic prescribing including patients' demand for antibiotics. 

The work developed for this project will be shared with regional health organizations and/or public health authorities with an interest in the material. Additionally, we plan to write a manuscript for peer-review. Mobile-based digital information is well accepted in communities.  While the material will be developed in Spanish (the language spoken by 60% of the population in Central and South America), it could be translated to Portuguese and French (although not within the scope of the current proposal). 

Several studies have shown educational programs are effective in improving antibiotic use (PMID: 31516125; 36139965; 3574019). In a recent study led by the research team (data not yet published), most physicians participating in a survey from various countries in Latin America including Argentina, stated they were pressured to prescribe antibiotics by patients and/or their families, highlighting the need to implement strategies to address patients demand for antibiotics. In another study also by the research team (PMID: 37406044) in which physicians were interviewed about their perceived barriers to improve antibiotic prescribing revealed a need for effective educational resources as healthcare professionals in Latin America have limited access to training opportunities (no protected time for continuing medical education, training courses have to be paid out of pocket) or available resources are not in their primary language. We expect the intervention will result in a reduction in antibiotic prescriptions for conditions that normally do not benefit from them (upper respiratory infections, cough, diarrhea).

We will collaborate with city public health authorities, and local thought leaders in the medical and pharmacy communities to develop, implement and disseminate the educational program. We will work with subject matter experts (including behavioral scientists) to develop educational material such as short videos, podcasts, and algorithms for physicians, pharmacists, and patients. Development of digital education, data collection forms, and quizzes will ocur during year 1. We will seek feedback from physicians, pharmacists, and patients from Latin America (not participating on the study) to ensure information is clear and relevant. Education will be disseminated in years 2 and 3 (see Figure 4 and Table for timeline). Patient education will be performed through ambulatory clinics and other public and retail spaces such as schools, banks, community centers, and pharmacies. 

We will measure the impact of the intervention on antibiotic use and antimicrobial resistance before and after the intervention. Additionally, we will assess stakeholders’ (physicians, pharmacists, and community) knowledge, perceptions, and attitudes approach to antibiotics

• Impact on antibiotic use:
  • Overall antibiotic consumption of selected antibiotics commonly used for ambulatory conditions
    • Narrow-spectrum to broad-spectrum antibiotic ratio among those antibiotics
  • Number of visits with a diagnosis that does not require antibiotic treatment with an antibiotic prescription/visits with a diagnosis that does not require antibiotic treatment
• Impact on AMR:
  • Antibiotic susceptibility among urine enterobacterales isolates (there are 5 microbiology laboratories in town; we chose urine isolates as the most feasible specimen to obtain data on) including percent susceptible to amoxicillin, third generation cephalosporins, fluoroquinolones, and trimethoprim-sulfamethoxazole
• Impact on knowledge and attitudes towards antibiotics:
  • Electronic survey to assess physicians and pharmacists’ knowledge on antibiotics for common ambulatory conditions that may trigger antibiotic use and AMR before and after educational modules
  • Electronic survey to assess patients’ knowledge and approach to antibiotics

This is a much-needed intervention that has not been implemented due to lack of funding opportunities to support community-based antibiotic stewardship projects in the region (funding opportunities for antibiotic stewardship have focused on hospital settings). With funds, we could support improvements to the functionality of PROAnet app including adding tools (e.g., including training material, adding validated knowledge self-administered quizzes, improving search function, etc), as well as developing effective educational material including short videos, podcasts, checklists and algorithms to make appropriate antibiotic decisions, scripts to facilitate physicians and pharmacists conversation with patients around lack of benefit of antibiotics in certain conditions. 

There is an urgent need to implement strategies to improve antibiotic use in communities in Latin America, a region with alarming increases in AMR.  Even though most (80-90%) antibiotics are prescribed  in the ambulatory setting, the majority of antibiotic stewardship activities and funding opportunities have focused on the inpatient setting. We propose to develop effective role-specific digital education to improve prescriebrs, pharmacists, and patients knowledge on antibiotics. Given that inappropriate antibitoic use is multifactorial we will develop material that addresses both technical and behavioral aspects related to antibiotic use. This solution was thought based on prior literature and experience shown the impact of such interventions and the research team's understanding of local needs and practices which are shared across the Latin American region.

It would be beneficial to discuss the solution with experts in phone-based applications to ensure the proposed material would not alter the funcationality of the exisitng app.