Van sluimerende antimicrobiële resistentie tot de globale COVID-19-pandemie: versterking van het beheer van infectieziekten in de ambulante zorg

Background: Acute infections are common in ambulatory care and most do not require antibiotic treatment. Nevertheless, antibiotics are frequently prescribed due to the complex interplay between the knowledge and attitudes of both patients and prescribers, as well as external pressures. In particular, children are often inappropriately prescribed antibiotics, partly due to the more pronounced uncertainty in distinguishing serious from nonserious infections. Antibiotic overuse leads to adverse events, increased rates of patient reattendance, and the development of antimicrobial resistance (AMR), a major public health threat. The COVID-19 pandemic, as an acute health crisis, shifted research priorities. This doctoral project aimed to study and strengthen the management of infectious diseases in ambulatory care, by advancing the long-known priority of antimicrobial stewardship and by addressing the emergent challenge of persistent symptoms after COVID-19. Methods: In part I, we investigated antibiotic use in children presenting to ambulatory care, focusing on Belgium, high-income countries, and the determinants of inappropriate prescribing. In part II, we evaluated the impact of the pandemic on antibiotic use and investigated management strategies for patients with persistent symptoms after COVID-19. In part III, we examined the needs, feasibility, and user engagement of clinical decision support systems (CDSS) aimed at improving infectious disease management in ambulatory care. Results: Antibiotic use in Belgian children has decreased between 2010 and 2019 (-35.5% in the number of dispensed packages). In high-income countries, antibiotic prescribing rates for children remain high, especially for acute otitis media (AOM; 85.6%). Determinants of inappropriate prescribing include diagnosis of AOM, diagnosis of respiratory infection (RTI), general practitioner (GP) as prescriber, older children, and rural area. Antibiotic use in Belgian children sharply declined during the COVID-19 pandemic and gradually returned to pre-pandemic levels afterwards. Based on evidence of very low certainty, physical training, breathing exercises, olfactory training, and multidisciplinary treatment may be effective rehabilitation therapies for patients with persistent symptoms after COVID-19. This evidence, together with stakeholder opinion, was incorporated in the first Belgian guideline on the follow-up and rehabilitation of these patients. Ambulatory care physicians expect a CDSS for infectious disease management that is pragmatic, minimally time-consuming, and provides clear and concise guidance on diagnostics and treatment. The pilot tool was quick to use (median 23 seconds), rated highly for usability (mean 78.6), and used selectively in uncertain cases. GPs and trainees valued its clarity, but broader engagement may require electronic health record integration and strategies to reach those less inclined to use such tools. Discussion: Antibiotic prescribing may in particular be improved for GPs, in rural areas, and for RTIs and AOM. A CDSS for infectious disease management was perceived to improve knowledge and antimicrobial prescribing behaviour. Next steps should focus on broader implementation of this tool in ambulatory care, together with complementary stewardship interventions; and on evaluating its impact on prescribing volume and appropriateness, patient outcomes, costs, AMR, and long-term behaviour change. A definition of appropriate antibiotic prescribing is needed, and stewardship strategies should be embedded into pandemic response plans to maintain their effectiveness during health crises. Lastly, incorporating real-time evidence on persistent symptoms after COVID-19 into national guidelines ensures a standardised approach to follow-up and rehabilitation strategies in ambulatory care.