In order to change antibiotic prescribing behaviour, we need to understand the prescribing process. The aim of this study was to identify targets for antibiotic stewardship interventions in hospitals through analysis of the antibiotic prescribing process from admission to discharge across five groups of infectious diseases.We conducted a multi-centre, observational cohort study, including patients with lower respiratory tract infections, exacerbation of chronic obstructive pulmonary disease, skin- and soft tissue infections, urinary tract infections or sepsis, admitted to wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway. Data was collected over a 5-month period and included antibiotics prescribed and administered during admission, antibiotics prescribed at discharge, length of antibiotic therapy, indication for treatment and discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, antibiotic allergies, place of initiation of therapy, admittance from an institution, patient demographics and outcome data. Primary outcome measure was antibiotic use throughout the hospital stay, analysed by WHO AWaRe-categories and adherence to guideline. Secondary outcome measures were a) antibiotic prescribing patterns by groups of diagnoses, which were analysed using descriptive statistics and b) non-adherence to the national antibiotic guidelines, analysed using multivariate logistic regression.Through analysis of 1235 patient admissions, we identified five key targets for antibiotic stewardship interventions in our population of hospital inpatients; 1) adherence to guideline on initiation of treatment, as this increases the use of WHO Access-group antibiotics, 2) antibiotic prescribing in the emergency room (ER), as 83.6% of antibiotic therapy was initiated there, 3) understanding prescribing for patients admitted from other institutions, as this was significantly associated with non-adherence to guideline , 4) understanding cultural and contextual drives of antibiotic prescribing, as non-adherent prescribing differed significantly between the sites of initiation of therapy  and 5) length of therapy, as days of antibiotic therapy was similar across a wide range of diagnoses and with prolonged therapy after discharge.Analysing the process of antibiotic prescribing in hospitals with patient-level data identified important targets for antibiotic stewardship interventions in hospitals. Suboptimal use of antibiotics is a key driver of antibiotic resistance . In ordeThis was an observational, multicentre cohort study across the wards of infectious diseases, pulmonary medicine and gastroenterology at three teaching hospitals in Western Norway . The lar1) lower respiratory tract infections (LRTI) 2) exacerbation of Chronic Obstructive Pulmonary Disease (COPD ex) 3) urinary tract infections (UTI) 4) skin- and soft tissue infections (SSTI) and 5) sepsis. Patients were excluded if: a) they were admitted to intervention wards in the post-intervention period; and b) comorbidity and patient outcome data were missing.The cohort included patients recruited to an antibiotic stewardship intervention study and consisted of adult patients discharged from study wards between the 10th of February and the 11th of July 2014 with a hospital stay ≥24 h and ≤ 21 days, receiving antibiotics during admission for an indication within guideline recommendations . If a paData were collected manually from electronic medical records, including admission notes from the emergency room, medical charts, physicians’ clinical notes, discharge letters and laboratory test results. Data included patient demographics, indication for antibiotic treatment, antibiotic use throughout the hospital stay, discharge diagnoses, estimated glomerular filtration rate (eGFR) on admission, length of stay, 30-day readmission, in-hospital and 30-day mortality, comorbidity and admittance from institution. Coded data on discharge diagnoses were retrieved from the hospital administrative system.The primary outcome measure was antibiotic regimens used throughout the hospital stay, grouped by AWaRe-categories and guidelines adherence on initiation of treatment and analysed at initiation of treatment, after first modification of regimen, and at discharge. Secondary outcome measures were antibiotic prescribing patterns by groups of diagnoses and non-adherence to the national antibiotic guidelines, analysed as association with study variables.To assess comorbidity, the Charlson Comorbidity Index (CCI) was calculated based on ICD-10 diagnoses at discharge , 14. CCIThe initial working diagnosis, documented in the electronic medical record for prescribed antibiotics, was used as the principal indication. Patients and treatment regimens were grouped by indications according to Supplement 1, Table Antibiotic regimens could include single or multiple antibiotics. Initially prescribed antibiotic regimens were assessed for adherence according to the Norwegian national antibiotic guidelines, as all hospitals included the national guidelines in their local antibiotic policy. Only first-choice empirical regimen for a given indication was regarded adherent. Assessment of adherence was performed using automated syntax in SPSS for Windows . Indication for treatment was combined with prescribed active substance(s) to generate the adherence variable and adherence was thereafter adjusted manually for patients with kidney failure or antibiotic allergies.Anti-infectives for systemic use (ATC-group J01), metronidazole tablets (ATC code P01AB01) and vancomycin tablets A07AA09) were defined as antibiotics in this study. The prescribed antibiotic regimens were assigned to WHO AWaRe categories  were def. For oveModifications that prescribing physicians made to the first antibiotic regimen were defined in four categories: escalation, de-escalation, change within same level or unchanged. Day 1 was the day antibiotic therapy was initiated. Patients with regimens in the unchanged category were not included in analysis of time to change. Definitions of modifications are given in Table Duration of antibiotic therapy was measured in days from the first to the last day of therapy and reported as: 1) mean total days of treatment, including prescribed treatment after discharge, 2) mean days of in-hospital antibiotic therapy and 3) mean days of therapy after discharge. When antibiotic treatment continued after discharge, the day of discharge was counted as in-hospital therapy. Information about antibiotic therapy after discharge was retrieved from the discharge letter and also reported as percentage of patients where post-discharge antibiotics were described.p-value of less than 0.2 were included in the final model. Only the first four variables were associated with non-adherence in univariate analysis and included in the final multivariate model. P-values below 0.05 were considered statistically significant for all analysis. Stata SE version 15  was used for all statistical analysis, while SPSS for Windows  was used for assessment of adherence.Descriptive statistics were applied to describe the prescription patterns. To examine which factors were associated with non-adherence, we used univariate and multivariate logistic regression. A targeted selection of factors were evaluated for the multivariate logistic regression model: place of antibiotic therapy initiation, indication for treatment, hospital site, admission from institution, accuracy between indication for treatment and discharge infection diagnosis, sex, age group, comorbidity measured by CCI, multiple working diagnoses, antibiotic allergies and eGFR. Variables that in univariate analysis had a During the study period, 1544 patients with available comorbidity and outcome data met the inclusion criteria. Of these patients, 309 were admitted in the post-intervention period at intervention wards and was therefore excluded, leaving 1235 unique patients included in analysis for this study.The characteristics of the patients are given in Table Prescribed antibiotic regimens were adherent to guidelines for 63% of patients Table . Second p < 0.05). Being admitted to hospital B was associated with reduced OR of non-adherence compared to hospital A, with an OR = 0.63, 95% CI , p = 0.004. Patients admitted from an institution had increased risk of receiving non-adherent antibiotic treatment, OR = 1.44, 95% CI , p = 0.029. Other factors tested were not associated with prescriptions being non-adherent to guidelines.The majority 83.6%) of antibiotic prescriptions were initiated in the emergency room, ranging from 64.8% of prescriptions for UTI to 96.8% for sepsis  of antibiotic therapy was 10.6 days, 95% CI 10.3, 10.9)  consisted of only access group antibiotics. Non-adherent empirical regimens however, included several antibiotics from the watch/reserve category, but these regimens were often switched to regimens within the access categories upon first modification of treatment. At discharge, a greater number of regimens were from the access category, both suggestive of clinical microsystems that tried to adhere to guidelines and antibiotic stewardship principles, but also likely related to the restricted availability of oral broad-spectrum antibiotics in Norway.In an American study from 2014, Braykov et al. ranked antibiotics in categories of narrow-spectrum, broad-spectum, extended spectrum and restricted antibiotics . Althougp = 0.001). Other studies report reluctance from other medical teams to change therapy further down the line and together this highlights the need to focus on first-line clinical staff when planning antibiotic stewardship interventions [Initiating empirical antibiotic therapy is a crucial step in the treatment of infections and an important target for antibiotic stewardship interventions, as recently outlined by Tamma et al. in their paper describing the four moments of antibiotic decision making . In our ventions .p = 0.004). It also signals that a thorough understanding of organisational culture with barriers and facilitators for prudent antibiotic prescribing is an important part of planning for antibiotic stewardship interventions.Non-adherence to guidelines was also associated with hospital site and whether patients were admitted from an institution or not. Patients admitted from nursing homes or other institutions may have had treatment prior to hospital admission. A combination of age, frailty, comorbidity and increased fear of resistant bacteria as cause of infection could have caused physicians to prescribe more broad-spectrum antibiotics for these patients. There is however, a need for a more thorough understanding of prescribing practices in this particular group of patients. Studies show that organisational culture influence antibiotic prescribing –22. ThisEmpirical antibiotic regimens were usually modified during admission (61.5%) and oral antibiotics were prescribed for 84.5% of patients. Other studies looking at the process of antibiotic prescribing in hospitals have focused on review of empirical therapy in relation to patient outcome or effect of interventions on prescribing process measures –25. BrayThis study has some limitations. When assessing adherence to guidelines on initiation of treatment, we used the indication for treatment stated in the electronic medical record, and this was usually a working diagnosis on admission. The diagnosis may change with more data and results available. To check whether this constituted a major issue for interpretation of data, we looked at the coherence between indication for treatment and the infection discharge diagnosis (if present) in the discharge letter. The group of diagnoses for which this might be an issue, is sepsis, where accuracy between indication for treatment and discharge diagnosis was low. During the study period, SIRS-criteria were used to screen patients for sepsis. SIRS identify more patients with suspected sepsis than the qSOFA score, which is currently in use. The low accuracy in this group could be due to lack of documentation of sepsis at discharge, with only the original focus of the infection often documented in discharge papers. It is possible that review of therapy took place without modifications to the patient’s antibiotic regimen. Such reviews were not identified during data collection and represents a limitation to this study. We also did not take dosing into consideration when assessing adherence to guidelines and modification of therapy. Appropriateness of antibiotic therapy was not evaluated after initial assessment of adherence to guidelines for empirical antibiotic treatment. It is therefore unknown whether escalation, de-escalation, stop or change was the best option for each individual patient. From the study by Skodvin et al., with patients derived from the same intervention study cohort, we do however know that only 18% of patients had applicable microbiology test results and for only half of these patients , these findings were used to guide therapy .The Nordic countries and the Netherlands are currently in a favourable position regarding antimicrobial resistance and are still able to utilize the most ecologically friendly antibiotics in empirical regimens. Exploring different ways of aggregating and analysing data to understand hospital antibiotic prescribing processes are however important in all countries and institutions, aiming to identify targets for stewardship interventions.Future studies should include assessment of appropriateness of therapy throughout the hospital stay to have a more comprehensive review of prescribing quality at every step of the process. Identifying and studying contributions from other healthcare professionals, like nurses and pharmacist and the team effort in antibiotic stewardship would also be valuable. As patient involvement and empowerment is increasing, the contribution of patients in antibiotic stewardship in hospital settings should also be investigated. Such studies could contribute to the identification of more targets for antibiotic stewardship interventions.Analysis of patient level antibiotic prescribing data and the use of WHO AWaRe to categorise antibiotic regimens throughout the hospital stay, identified relevant targets for antibiotic stewardship interventions in our population of hospital inpatients. Identified targets included 1) adherence to guidelines 2) focus on prescribing physicians in the emergency room 3) understanding prescribing for patients admitted from an institution 4) organisational culture and 5) duration of antibiotic therapy.Additional file 1: Table 1. Grouping of indication for treatment. Table 2. Overview of AWaRe categories with study modifications. Table 3. Evaluation of antimicrobial spectrum and categorization of change.


In order to save resources and reduce the carbon footprint of concrete, the addition of high volumes of supplementary cementitious materials (SCMs) to replace cement is one of the most effective and promising methods. Zeolite powder (ZP), with a high specific surface area, exhibits high pozzolanic reactivity in cement-based materials. This paper investigates the effects of ZP addition used to replace cement at the levels of 20%, 40% and 60% on the strength development and microstructure evolution of concrete, and the nanomechanical properties are analyzed using nanoindentation technique. The results show that the replacement of ZP for cement generally has a dilution effect on the concrete, leading to a detrimental effect on the strength development. However, the 20% ZP replacement for cement slightly enhances the 90-day compressive strength. The pore structure analysis shows that the sample with 20% ZP content has a lower total porosity than the control sample. The hydration of ZP goes against the dilution effect and reduces the total porosity of concrete to compact the microstructure. Nanoindentation investigation of the matrix shows that 20% ZP decreases the content of portlandite but increases the content of high density calcium silicate hydrate (C-S-H). This is beneficial for improving the nanomechanical properties of interface transition zone. However, further increases in the content of ZP (40% and 60%) decrease the total volume of C-S-H and increase the porosity to degrade the microstructure. Portland cement (PC) production is a process with high carbon dioxide emission and energy consumption . Recent Various types of SCMs, including industrial byproducts of fly ash, blast furnace slag and other metallurgical slags, have been used in concrete production for many years ,11,12,133S and formations of portlandite and ettringite, and the pozzolanic reactivity of ZP depended on the exchangeable cation content and crystallinity [2 sequestration to improve carbonation resistance, and observed that ZP effectively compacted the pore structure [ZP is one of the most abundant deposits occurring in areas of recent and ancient volcanism . The fraallinity . Sedić etructure . Xu et atructure  also obsNowadays, the development and application of nanomechanical characterization methods, such as nanoindentation and nanoscratch, show great potential for a better understanding of cement-based materials at the micro-, nano- and even smaller scales, which exhibits direct correlations to the macroscopic mechanical properties of cement-based materials. Some systematic investigations using the nanoindentation technique in cement-based materials have been previously published by Hu et al. , Lee et In this paper, the compressive strength development of concretes containing different amounts of ZP was measured. Meanwhile, the effects of ZP on the microstructure of concrete were tested by using scanning electron microscopy (SEM) and mercury intrusion porosimetry (MIP) methods, and the nanomechanical properties were analyzed using the nanoindentation technique.2 and Al2O3. Both PC and ZP particles have irregular polygonal shapes  method are shown in l shapes . The meal shapes . River sZP was added into concrete as a cement replacement in this study. The content of ZP was in the range of 0–60% by weight of cement. The water to binder ratio and binder to aggregate ratio of each group were kept as constants with the values of 0.30 and 0.40, respectively. The content of polycarboxylic superplasticizer was adjusted to maintain a slump of 150–200 mm. The proportions of the concrete mixtures are shown in The compressive strengths of concretes after 7, 28 and 90 days of curing were measured using an auto-test compression machine , as shown in The fractured samples without coarse aggregate were collected. The core parts of fractured samples were coated with gold and the morphologies of cross section were analyzed by using a Quanta FEG 250 field emission scanning electron microscope (SEM) (FEI). The granular samples with 5.0 ± 0.5 mm diameter were collected for characterizing the pore structure by using the mercury intrusion porosimetry (MIP)  with PoreMaster 60. The detailed steps of the above experiments are described in Reference .iE = 1140 GPa and iv = 0.07 are Young’s modulus and Poisson’s ratio of the indenter used in this experiment. rE is the reduced elastic modulus of the sample and v is the Poisson’s ratio of sample [The nanoindentation technique was carried out to determine the nanomechanical properties of concrete samples containing ZP. To meet nanoindentation measurement requirements , the conf sample .SEM images of the 90-day cured concretes containing different amounts of ZP are shown in Generally speaking, concrete matrix mainly consists of pore, hydration products and unhydrated particles. All nanoindentation results of three representative areas of the cement matrix were merged and the probability densities of the elastic modulus are shown in As shown in The ITZ of concretes containing different amounts of ZP were selected for nanoindentation investigation and the results are shown in This work investigated the strength development and microstructure evolution of cement concretes containing ZP. The nanoindentation characterization was also used to evaluate the effects of ZP addition on the nanomechanical properties of concretes. The following conclusions can be drawn.(1) The replacement of ZP in cement has a dilution effect on the hydration of concrete, resulting in a detrimental effect on strength development. Concretes with ZP addition generally exhibited lower compressive strengths than the control concrete with 100% PC. When the ZP content was 20%, the hydration of ZP went against the dilution effect and slightly enhanced the 90-day compressive strength.(2) After 90 days of curing, the hydration of 20% ZP compacted the microstructure of the matrix. The MIP results showed that the sample with 20% ZP content had a lower total porosity than the pure PC sample. In comparison, some large capillary pores and cracks existed in concretes with higher ZP contents (40% and 60%). This increased the average pore sizes and total porosity of the samples.(3) Nanoindentation investigation showed that the addition of 20% ZP decreased the porosity and the content of CH in the matrix, and also increased the contents of HD C-S-H. The addition of 20% ZP improved the nanomechanical properties of ITZ. However, a further increase in the content of ZP in the matrix mitigated the formation of C-S-H and increased the porosity to degrade the microstructure.


Nussbaum’s capability theory by drawing attention to multiple determinants of wellbeing provides a rich and relevant evaluative space for framing antibiotic resistance. I consider the implications of antibiotic resistance for child development and adult capabilities. There are common risk factors for childhood growth stunting and the spread of infectious diseases in both antibiotic sensitive and resistant forms. The interaction between infectious diseases, antibiotic resistance and growth stunting illustrates a clustering of disadvantage. The control of antibiotic resistance requires wide-ranging cooperative action. Cooperation is predicated on an expectation of equitable access to effective antibiotics. This expectation is confounded by inequality both in access to antibiotics, and in the risk that available antibiotics will be ineffective. Securing child development (and adult capabilities) requires that inequalities both in access to antibiotics and in risk factors for the dissemination and transmission of antibiotic resistance are addressed. Inequality undermines the cooperative activity that is control of infectious diseases and compounds the threat to the securing of capabilities that arises from antibiotic resistance. Yet, new antibiotics and constraints on use of existing antibiotics can never be a solution to the potentiation of infectious disease transmission (in antibiotic sensitive or resistant forms) consequent on poverty, over-crowding, malnutrition, limited educational opportunity, environmental degradation, poor water quality, inadequate sanitation or conflict. Antibiotic resistance has been framed as a problem consequent on the lack of development of new antibiotics and overuse of existing antibiotics. How we frame a problem is important in determining our responses to the problem  or the potential for capabilities (children). One consequence of the use of antibiotics is antibiotic resistance. The rate at which antibiotic resistance develops is a function of usage, time, control measures, and the context of use. The availability of effective treatments for infectious disease is a substantial determinant of health. The interactions between health and the determinants of health are complex and not unidirectional, so for example health both determines and is determined by nutrition, education, and social status. The extent of capability fulfilment can be used to define health, while health is required for the fulfilment of capabilities (Venkatapuran The control of infectious diseases (antibiotic sensitive and resistant) requires fulfilment of multiple entitlements. An entitlement to bodily health requires that an individual is able to have good health, including reproductive health; to be adequately nourished; and to have adequate shelter. The adequacy of shelter is important as a risk factor for the spread of infectious disease, and for damage to child development . The entitlement to affiliation requires that an individual is able to live for and in relation to others, to recognize and show concern for other human beings, and to engage in various forms of social interaction. Bodily integrity requires that an individual can move freely from place to place. These last two entitlements can be breached by restrictions taken to control the spread of infectious disease (antibiotic sensitive or resistant), and by the social consequences of infectious disease, particularly when associated with treatment (antibiotic ) resistance . By contrast antibiotic resistance is more prevalent now in developing countries with high levels of deprivation than in developed countries (WHO Report The use of antibiotics in many developed economies has extended beyond the treatment and prevention of life-threatening human infections to include the mitigation of symptoms of self-limiting disease(s), animal husbandry, fish farming, and to allow us to extend the range of medical and surgical interventions including those with limited health benefits such as some forms of cosmetic surgery. In developed countries antibiotics have become a means to a variety of ends, with varying degrees of relationship with mitigation of harm to human capabilities. Despite this there is evidence that the use of antibiotics in developed countries has stabilised or fallen this century  in 2007. The position from the Indonesian perspective is described in a journal article as follows – ‘Indonesia believes that the world must work in unity against the H5N1 virus infection…. The work must be conducted side by side with mutual trust, transparency and equity as global citizens professionals, taking into consideration the elements of human dignity and solidarity.’ ‘The avian influenza case in Indonesia has demonstrated once again the unresolved imbalance between the affluent ‘high-tech’ countries and poor agriculture-based countries. Countries that are the hardest hit by a disease must also bear the burden of the cost of the vaccine, therapeutics and other products, while the monetary and non-monetary benefits of these products go to the manufacturers that are mostly in the industrialised countries’ . Reasons for rejecting inequalities ‘presuppose some form of relationship or interaction between unequal parties’ and are based on comparing the differences in the situations of individuals  and healthy living conditions. The less wealthy in many countries have less access to high quality medicines, little access to medical advice, or diagnostic facilities, often live under conditions that may facilitate the spread of antibiotic resistant bacteria, may be exposed to resistant bacteria even before exposure to antibiotics, and are more at risk of infection, and of the serious consequences from infection. Securing child development requires control of infectious diseases in treatment sensitive and resistant forms. There is an unequal distribution of childhood burdens and benefits associated with antibiotics and antibiotic resistance both within and between countries. These inequalities contribute to avoidable suffering (preventable infectious disease), differences in status (growth stunting), and potentially domination of vulnerable children by others. Inequalities subvert the achievement of capability thresholds.prima facie claim to access to effective antibiotics then when inequalities exist we can ask if those inequalities can be justified – ‘basic structures need to be justified to all who are asked to accept them’   but rather as an indicator of the care that the agent has to take to avoid causing harm’. Scanlon states that ‘..the cost of avoiding all behaviour that involves risk of harm would be unacceptable. Our idea of ‘reasonable precautions’ defines the level of care that we think can be demanded: a principle that demanded more than this would be too confining, and could reasonably be rejected on that ground’ Scanlon . Scanlon


In Europe, the use of wastes in the cement and construction industry follows the assumptions of sustainability and the idea of circular economy. At present, it is observed that cement plants introduce wastes to the cement in the form of so-called mineral additives. The most often used mineral additives are: fly ash with silica fume, granulated blast furnace slag and silica fume. The use of mineral additives in the cement is related to the fact that the use of the most expensive component of cement—Portland cement clinker—is limited. The purpose of the article is a preliminary evaluation of the suitability of slag from the municipal solid waste incineration plant for its use as a replacement of cement. In this article, slag from the municipal solid waste incineration (MSWI) replaces cement in the quantity of 30%, and presents the content of oxides and elements of slag from the MSWI. The obtained results are compared to the requirements that the crushed and granulated blast furnace slag need to meet to be suitable for use as an additive of type II to the concrete. The conducted analyses confirmed that the tested slag meets the requirements for the granulated blast furnace slag as an additive to the concrete in the following parameters: CaO ≤ 18.0%, SO3 ≤ 2.5% and Cl ≤ 0.1%. At the same time, mechanical features were tested of the designed mortars which consisted of a mixture of Portland cement (CEM I) with 30% of slag admixture. The designed mortar after 28 days of maturing reached a compressive strength of 32.0 MPa, and bending strength of 4.0 MPa. When compared to the milled granulated blast furnace slag (GBFS), the obtained values are slightly lower. Furthermore, the hardened mortars were subject to a leachability test to check the impact on the environment. Test results showed that the aqueous extracts from mixtures with 30% of slag admixtures slightly exceed the limits and do not pose a sufficiant threat to the environment as to eliminate the MSWI slag from economical use. In the past couple of years, we have observed a constant increase of the produced municipal waste. In 2018, 2.5 billion Mg of waste was generated in the EU countries. Municipal waste accounts for about 10% of their total stream. According to the data provided by Eurostat . Rep. Rep5]. Poland does not have any experience in the use of this sort of waste in the construction industry, because in previous years (up to 2016) there were not any significant amounts of these wastes. We only base on Poland’s experience, within an academic register of foreign plants which cannot be transferred to the Polish market. It needs to be noted that the quality of the input stream to the system reflects the output stream. At present, Poland is at the stage of constructing a modern waste management system with the elements of the circular economy. Therefore, we need to conduct tests and broaden our knowledge on the changeability of the input stream in the course of the time depending on the thermal processing and evaluate the impact of the thermal processing on the composition of the secondary materials . Such information will be helpful, if not indispensable, when choosing the best criteria for the safe use of the secondary materials in the construction industry, avoiding any negative impact on the environment. A potential threat when using secondary waste from the thermal degradation of municipal waste for the production of mortar and concrete is the migration of heavy metals to the soil and water environment. High levels of chloride salts and sulfates may prove to be environmentally problematic. The negative effect of salt migration into the environment may be the extinction of living organisms, which can lead to a reduction in species biodiversity . The hig2 can be limited. It needs to be noted that with the production of 1 Mg of cement 1 Mg of CO2 is generated and the participation of the cement industry in the global CO2 emission caused by human being amounts to 5%–8% [The approach presented in this article is ecologically friendly because it aims at the best and safe use of the slag from the MSWI by replacing part of the cement with slag of similar parameters. In this way, the emission of the greenhouse gases in cement plants, mainly emission of COThe thermal degradation installation processes 210 Mg of waste annually. It has two combustion lines that work independently of each other. The boiler has a temperature of 1000 °C, and cleaned exhaust gases are discharged up to a 50 m chimney. The final effect of the process is electricity  and thermal energy . The energy produced is used for the needs of the city .The installation accepts waste with an average calorific value of 7.5 GJ/Mg. These include, among others: residua waste (20 03 01), bulky waste (20 03 07), in addition to waste constituting combustible waste  [Residual municipal waste collected in the city is transported by cars to the installation. The vehicle enters the scale. The mass of collected waste is measured and passes through the radiosensitive gate. The vehicle is directed to the delivery hall. The hall has negative pressure to prevent unpleasant odours from spreading. The waste goes to the bunker, in which the gripper mixtures the waste to avoid self-ignition and to unify the mass in the event of installation shutdown. An independent deodorizing system is installed in the bunker. Pre-prepared waste is ready for thermal treatment with energy recovery. The waste is directed to the hopper using a gripper. Then the feeder is directed to the grate, where they are thermally transformed. The waste gases generated in the process are cleaned . The flu4), which can be found, for example, in the soil, in the direct contact with the concrete. It leads to a chemical reaction with aluminum contained in the cement generating an expansive substance. These phenomena may lead to inciting internal tensile forces and consequently to the occurrence of cracks, in case of excessive concrete resistance [Analysis of the mechanical properties indicates that slag (S) from the MSWI plant is a component that fills microstructure of mortars without pozzolan properties, unlike granulated blast furnace slag (GBFS). When preparing mortars based on MSWI slag, particularly undesirable are reactions between cement and aluminum and zinc found in the wastes. Concrete may swell because of the salts such as sulfurs  are the main reasons for low resistance of the concrete and limit the way of its use. Depending on the composition, concrete strength reaches 2–10 MPa. Slag from MSWI plant shall not be used for the production of reinforced concretes and concretes exposed to permanent humidity over 75%. When the amount of the substance mentioned above is high, mortar/concrete may tend to change volume  under the wet conditions. The reason is usually the content of unburnt coal. Water absorption of the slag-concrete, depending on the type of slag and composition of concrete, equals 15%–25%. Frost resistance is generally satisfactory, under the condition that the slag used does not contain a large amount of unburnt coal (C < 5%), and the concrete resistance is not lower than 5 MPa ,14.Concrete with the additive of slag from the MSWI is used in the building industry almost exclusively for the production of various types of hollow wall bricks and less often for the construction of monolith walls in the first two floors in individually constructed houses. Due to the unfavorable results of experiments, it is no longer used in the monolith wall, and only small wall elements are made of it.To be suitable for use in a responsible way, the slag from the MSWI plant needs to be seasoned and processed. Depending on the original composition and eventual destination, processing of slag may assume various forms  . One of There is a lack of national requirements for the slag of the MSWI as the addition to the cement. For the needs of this article, the discussions were based on the requirements for the milled granulated blast furnace slag (GBFS), used as additive of type II to concrete . The staThe purpose of the article is a preliminary evaluation of the physical, chemical and mechanical properties of the slag from the municipal solid waste incineration plant used as an addition to the mortar and in future in concrete. The volume of the mortar in concrete is about 55%–60%, which allows the assessment of the concrete based on the examination of the properties of the mortar (they do not take into account the influence of the coarse aggregate compact zone).For the tests, Portland cement was used-CEM I 42.5R (further on marked as CEM I) following the requirements of PN-EN 197-1:2002 . The maiThe second material used for tests was slag b which w2. The high content of silica (SiO2 >50%) may be reflected in respective high pozzolana activity. Content of CaO meets the requirements for the crushed, granulated blast furnace slags. (CaO ≤ 18%).At the beginning of the research, a chemical analysis of the tested materials was carried out. Oxides content and concentration of heavy metals in cement and slag from the MSWI were investigated. The obtained results are presented in The composition of the tested mortars is presented in The mortars were prepared following the procedure described in standard EN 197-1:2011  with theConducted tests of heavy metals content in cement CEM I confirmed a high level of most of the trace elements, i.e., Zn > Cr > Cu > Pb > V > Ni > As > Cd > Tl > Hg . Higher The testing procedure is planned and realized in such a way as to determine the characteristics of slag  which are important in the light of its use a partial replacement of cement. Impact on the environment was also taken into consideration.Moisture content in the tested sample of slag was determined in compliance with the standard EN 15934: 2013  and bulkThe slag sample was crushed in a ball mill and underwent physical and chemical analyses. The specific surface was determined according to standard EN 196-6:2019-01  and lossThe concentration of sodium, calcium, potassium, lithium and barium was determined with the flame photometry method—in compliance with the standard EN-ISO 9964-3:1994 .To determine the concentration of heavy metals in the dry mass of samples, an inductively coupled plasma mass spectrometer from Perkin Elmer Company was used. It allows defining elements activated in argon plasma .3/kg (basic test). The elution liquid was distilled water of pH 7.1 [The aqueous extract from the slag was prepared in compliance with the standard PN-EN 12457-2:2006 . From thf pH 7.1  and elecf pH 7.1 . Subsequ42−) was tested with gravitation method with barium chloride, according to the standard PN-ISO 9280:2002 [Analysis of the aqueous extracts from slag and cement mortar included several determinations. Content of organic carbon was determined using analyzer Vario TOC Cube from the company Elementar . The pH 280:2002 .The concentration of potassium, calcium, lithium and barium in aqueous extracts of ashes and mortar was determined with the flame photometry method–in compliance with standard EN-ISO 9964-3:1994 . For theBinding time of the slurry of CEM I 42.5R with the 30% slag was tested in the automatic device of Vicata according to the procedure specified in EN 196-3 .Consistency of the mortars was determined using a flow table method as specified in EN 1015-3 . The morFurther, the air content was measured as per EN 1015-7:1999  by pouriDetermination of the volume changes according to EN 196-3  is conduw) of mortars is calculated on the basis of the following Equation (1):Mass absorbability .Bulk density of tested slag reached 1700 kg/mAmong physical properties which GBFS needs to meet to be acceptable for use as the addition of type II to the concrete, size of specific surface area was defined.2/g, so the slag meets the requirements for GBFS according to the standard.The size of the specific surface area of the tested slag was 3200.0 cmThe undesirable components of the possible mineral additive include an excessive amount of compounds of sulfur, chloride and unburnt coal. The high content of the unburnt coal (C > 5%) may increase water demand and decrease frost resistance of mortars or concretes made with these mortars. The concentration of chloride, sulfur and organic coal in the tested slag was below 1.0%. Low content of the above elements  was reflected in a very low leachability.Secondary wastes from MSWI may pose a problem for the environment due to the high content of chloride salts and sulphates. Similar observations can be found in the publication . LeachabThe aqueous extracts from the tested slag have been prepared to measure heavy metals concentration. These included: barium, zinc, copper, lead, cadmium, chrome, cobalt, iron, manganese and nickel. .The leachability level of heavy metals from the tested slag was very low. Only Pb level exceeded about 0.1 mg/kg the permissible value for the waste stored in the landfills for the neutral waste. The concentration of the other metals  did not exceed the permissible values, and in many cases  it was below the detection threshold.Together with the physicochemical tests, mortar with 30% addition of slag from MSWI was designed and produced. The mortars were maturing for 28 days in the laboratory conditions. After that, aqueous extracts were prepared. The leachability of contaminants from the mortar with the addition of the slag could be affected by the form of the mortar (monolith or crushed) which subsequently may influence the environmental nuisance.In case of the monolith form, surface release process and diffusion determine to a large extent, the leachability level. In case of crushed mortar, the leachability level depends on the percolation process. The article presents tests for the leachability of contaminants for both forms of the mortars.The MSWI slag should be tested to check its chemical composition before each use. Slag MSWI was evaluated over a period of two years. The slag composition fluctuates mainly in the scope of CaO and Cr due to the technology used in incineration plants in its valorisation. As a response to comparison requirements in the field of chemical fabric composition, granulated blast furnace slag GBFS can be adopted EN 15167–1: 2007 standard: “Ground granulated blast furnace slag for use in concrete, mortar and grout-Part 1: Definitions, specifications and compliance criteria” [2 reduces the hydraulic activity of the slag. In case of tested MSWI the proportion between CaO, MgO and SiO2 is adequate  when compared to the mortar with 30% of GBFS . HoweverThe water absorption of the 28 days hardened mortar made with the 30% addition of the blast furnace slag reaches a level of 9%. For comparison, the absorbability of the mash with GBSF slag is 7%. In case of Portland cement (CEM I) water absorption falls in the range of 3%–8%. It may be stated that the addition of slag does not significantly affect the water absorption of concrete. It is known that after 90 days, the absorbability of mortar with slag changes, reducing its value .Analysis of the mechanical properties of mortars after 2 and 28 days of hardening indicates that slag (S) from MSWI plant is a component that fills microstructure of mortars without pozzolan properties, unlike GBFS. The reason for this is the lack of the vitreous phase in case of MSWI slag.4), which can be found, for example, in the soil, in the direct contact with the concrete. It leads to a chemical reaction with aluminum contained in the cement generating an expansive substance. These phenomena may lead to inciting internal tensile forces and consequently to the occurrence of cracks, in case of excessive concrete resistance [In case of MSWI slag particularly undesirable are reactions between cement and aluminum and zinc found in the wastes. Concrete may swell because of the salts such as sulfurs  are the main reasons for low resistance of the concrete and limit the way of its use. Depending on the composition, concrete strength reaches 2–10 MPa. Slag from MSWI plant shall not be used for the production of reinforced concretes and concretes exposed to permanent humidity over 75%. When the amount of the substance mentioned above is high, mortar/concrete may tend to change volume  under the wet conditions. The reason is usually the content of unburnt coal. Water absorption of the hearth slag concrete, depending on the type of slag and composition of concrete, equals 15%–25%. Frost resistance of hearth slag concrete is generally satisfactory, under the condition that the slag used does not contain a large amount of unburnt coal (C < 5%), and the concrete resistance is not lower than 5 MPa .Concrete with the additive of slag from MSWI is used in the building industry almost exclusively for the production of various types of wall hollow bricks and less often for the construction of monolith walls at 1–2 floor in the individually constructed houses. Due to the unfavorable results of experiments, it is no longer used in the monolith wall, and only small wall elements are made of it.To be suitable for use, the slag from MSWI plant in a responsible way, it needs to be seasoned and processed. Depending on the original composition and eventual destination, processing of slag may assume various forms  to assure the expected quality of the concrete . One of Slags from MSWI require constant analysis, mainly referring to the chemical compositions. Based on the reports, a correct decision could be taken concerning their possible use, for example, for the production of concretes. A search for concrete with the addition of slag from MSWI plant that is environmentally friendly and that has excellent mechanical properties, suitable volume, and low leachability of contaminants is still ongoing ,43,44,45The leachability of heavy metals from monolithic concrete forms after 28 days of their maturation is presented in The obtained levels of concentration of heavy metals in the aqueous extract were compared to the permissible values for wastes designated to the disposal at the landfills other than hazardous and neutral . It needWithin the course of the conducted tests, also crushed mortar was exposed to the activity of the elusion liquid. The obtained results give a chance for environmentally friendly use of the slag in the construction industry. In many cases, the analyzed matter may constitute the best and the cheapest long term solution in the waste management economy, filling up the gap in the market in respect of the diminishing anthropogenic resources.It is indispensable to legally determine the requirements for the slags from MSWI plants so that they could be used as an additive to the mortar and also in concrete. Mechanical tests showed that the MSWI slag might constitute the partial replacement of cement in mortar and concrete; the requirements of EN 196-3  were fulConducted chemical tests proved that the use of MSWI slag in mortar would not cause any environmental nuisance. Furthermore, many physical and chemical properties of the slag from MSWI are similar to widely used in mortars crushed, granulated blast furnace slag. It must be remembered that the composition of MSWI slag depends on the structure of the municipal wastes directed to the incineration plant. That is why further tests concerning the variability of the chemical content of the slag over time need to be conducted.


Prescribing in dental practice has a relatively small but important contribution to the quantity of antibiotics prescribed in primary care. This study aimed to analyse antibiotic prescribing in dentistry over time (2010–2016) in 4 different Northern European countries and their relative contribution to national outpatients consumption.100,000).This retrospective study evaluated the frequency and number of national antibiotic prescriptions written by dentists in England, Scotland, Norway and Sweden. The consumption of such antibiotics was measured using WHO defined daily doses (DDDs), DDDs per 100,000 inhabitants per day  archived between 2010 and 2016 from the four countries were analysed. The national contribution of Norwegian dentists to the total primary care prescription during this period was 8%. The corresponding figures for Sweden, Scotland and England were 7, 6, and 8%. Dental contribution to National antibiotic use in all four countries has decreased over the study time period for commonly prescribed antibiotics in dentistry, i.e., the beta-lactams (Phenoxymethyl penicillin/Amoxicillin) and metronidazole. There were less numbers of prescriptions by dentists in Norway and Sweden compared to England and Scotland. Marked differences in some classes of antibiotics were noted with Phenoxymethyl penicillin dominating in Sweden/Norway compared to Amoxicillin and Metronidazole in England/Scotland. In England and Scotland, dentists were the largest prescribers of metronidazole in primary care. Clindamycin prescriptions was higher in Norway and Sweden.Noticeable differences exist in prescribing patterns for the management of oral infections. High levels of metronidazole use in England and Scotland also require further analysis. All countries over the study period showed a decrease in total numbers of antibiotics prescribed. Prescribing in dental practice has a relatively small but important contribution to the quantity of antibiotics prescribed in primary care. Dentists prescribe antibiotics to treat acute bacterial intra-oral infections and some cases of chronic periodontitis. The majority of acute dento-alveolar infections should be managed primarily by surgical or local measures to control the source of infection  with professional guidelines re-enforcing this basic tenet of infection source control in dental practice –3. HowevThe trend of antibiotic prescriptions over time is influenced by many factors, such as disease levels, access to dental services, prescribing guidelines, patients’ attitude toward antibiotic prescribing, and incidence of antimicrobial resistance (AMR) , 10. TheThe objective of this study was to compare the national use of antibiotics by dental prescribers in England and Scotland with Norway and Sweden. Report their relative contribution to the total national antibiotic consumption by outpatients, and review differences in prescribing patterns to ascertain whether lessons can be used to inform antimicrobial stewardships policies in the four countries.For the study period 2010–2016, except for England where data was available from 2011, the data on National Health Service (NHS) antibiotic prescriptions written by dentists dispensed in the community was obtained from the NHS Business Service Authority for England and from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland held by NHS National Services Scotland. The data on dental antibiotic use in Norway, was obtained from the Norwegian prescription database (NorPD) , while tThe data obtained on antibiotic use was classified according to the anatomical therapeutic chemical (ATC) classification system, using the WHO defined daily dose (DDD) for each drug . In thisIn the current study, all dental prescriptions dispensed in the community were analysed. In dentistry, the use of antibiotics to treat dental and oral infections usually relies on five groups of antibiotics. These are beta-lactams (primarily Phenoxymethyl penicillin and amoxicillin), macrolides, lincosamides, tetracyclines, and metronidazole. Beta-lactams: Amoxicillin, ATC code J01CA04; Phenoxymethyl penicillin (penicillin V), ATC code J01CE02; Co-amoxiclav (Augmentin), J01CR02, Cefalexin, ATC codes J01DB01 and Cefradine, ATC code J01DB09. Macrolides and Lincosamides: Erythromycin, ATC code J01FA01; Spiramycin, ATC code J01FA02; Clarithromycin, ATC code J01FA09; Azithromycin, ATC code J01FA10; Clindamycin, ATC code J01FF01. Tetracyclines: Doxycycline, ATC code J01AA02; Oxytetracycline, ATC code J01AA06 and Tetracycline, ATC code J01AA07. Metronidazole: Metronidazole, ATC code P01AB01.100,000). The average number of antibiotic prescriptions dispensed in the community per dentist per year in each country was calculated. The proportion (%) of each antibiotic to the total antibiotics dispensed in the community was also calculated.Trends in the consumption of antibiotics were assessed for the study period (2010–2016). The proportion of each antibiotic prescribed compared to the total antibiotic prescription by dentists was calculated. The proportion of antibiotic consumption attributed to dentistry-based prescription to the total national primary care consumption was also calculated. The mid-year populations in England and Scotland for each year were extracted from the office of National Statistics. The population size in Norway and Sweden for each year was obtained from the Statistical Bureau in Norway and Sweden. To better illustrate the consumption of antibiotics by dental prescriptions in the four countries, the data was calculated for each antibiotic prescribed by dentists in each country and expressed as a number of DDD per 100,000 inhabitants per day , by 2016 this had declined to 133 antibiotic prescriptions per year  and had declined to 87 per annum by 2016. Norway had the lowest rates of prescriptions per dentist (peaking at 31 in 2014) with a decline in prescriptions to 26 per year by 2016. Swedish prescribing levels were highest in 2010 (n = 36) and declined to 28 per annum by 2016. The dental contribution to the total of antibiotics prescribed in the community for each Country over the period 2010–16 was 8, 6, 8, and 7% for England, Scotland, Norway and Sweden. The proportion (%) of Phenoxymethyl penicillin and Amoxicillin dispensed in Norway and Sweden versus England and Scotland by dentists to the total antibiotics dispensed in the community by general dental practitioners is presented in Fig. The highest annual rate of antibiotic prescribing per dentist was in England in 2011 (The proportion (%) of Metronidazole and Clindamycin dispensed in Norway and Sweden versus England and Scotland to the total antibiotics dispensed by general dental practitioners is presented in Fig. 100,000 attributed to dental prescriptions in England, Scotland, Norway and Sweden in every year from 2010 to 2016 are presented in Table 100,000 attributed to dental prescriptions in the study period.The DIDThere were marked differences in patterns of consumption of antibiotic attributed to dental prescription between England and Scotland versus Norway and Sweden. In England and Scotland, Amoxicillin, Metronidazole, Erythromycin and Phenoxymethyl penicillin (ordered from highest to lowest) were the top four antibiotics prescribed by dentists. However, in Norway and Sweden, Phenoxymethyl penicillin, Amoxicillin, Clindamycin and then Metronidazole (ordered from highest to lowest) were the top four antibiotics prescribed by dentists.100,000 for Phenoxymethyl penicillin. Sweden had the highest reduction (16%) in DID100,000 of this antibiotic declining to 66.86 in 2016 from 80.37 in 2010. This was followed by Norway (14% reduction) with a DID100,000 of 68.49 in 2010 declining to 58.65 in 2016. In contrast, Phenoxymethyl penicillin was one of the least commonly prescribed antibiotics by dental practitioners in England and Scotland over the study period. For England in 2011 the DID100,000 was 0.94 falling to 0.29 in 2016 and in Scotland a fall from 2.02 in 2010 to 0.68 in 2016.This was the most commonly prescribed antibiotic in Norway and Sweden by dental practitioners. In line with the overall decrease in total antibiotic prescriptions between 2010 and 2016 there was a trend towards decrease in the DID100,000 was in England in 2011 (n = 89.93) declining to 80.93 in 2016. In contrast the Amoxicillin DID100,000 in Scotland rose from 70.28 in 2010 to 82.92 in 2016. Sweden saw a fall in DID100,000 from 10.28 to 6.99 in 2016. Conversely, Norway saw an increase in the DID100,000 between 2010 (n = 7.57) rising to a DID100,000 of 9.52 in 2016.Amoxicillin was prescribed more frequently in England and Scotland than in Norway and Sweden. The highest number of DID100,000 in 2011 of 13.66 for England and in Scotland peaking at a DID100,000 of 11.96 in 2012 and falling to 9.56 in 2016. Both England and Scotland prescribed more Metronidazole than Norway and Sweden. In Norway and Sweden, this was the fourth most frequently prescribed antibiotic . The Metronidazole DID100,000 for Sweden and Norway both showed deceases over the 2010 and 2016 period with Sweden showing a decline in DID100,000 of 3.29 in 2010 to 2.52 in 2016 and Norway’s DID100,000 decreasing from 3.52 in 2010 to 3.39 in 2016.For England and Scotland Metronidazole was the second most frequently prescribed antibiotic, with a DID100,000 in England (n = 6.16) in 2011 and the lowest DID100,000 in Sweden in 2016 of 0.21.In England and Scotland this was the third most commonly prescribed antibiotic but the fifth most commonly prescribed antibiotic in Norway and Sweden . All countries showed a decline in erythromycin prescriptions over the study period with the largest DID100,000 consumption for Clindamycin, with a DID100,000 of 4.03 in 2010 for Norway rising to 4.58 in 2016 and from a DID100,000 of 4.15 in 2010 to 3.02 in 2016 for Sweden. In contrast the Clindamycin consumption were lower for England and Scotland varying from a 0.45 DID100,000 in England in 2011 to 0.19 DID100,000 in 2016 for Scotland.Norway and Sweden had the highest DID100,000 levels across the four countries. In contrast, for Norway the DID100,000 for Azithromycin (0.8 in 2016) and Spiramycin (0.1 in 2016) was higher than in the other three countries. The DID100,000 for Augmentin (Co-amoxiclav) prescriptions was significantly higher in England and Scotland in 2016 running at 0.4 and 0.13, respectively.The Tetracycline class of antibiotics were prescribed at approximately the same DIDThe Global Burden of Disease Study 2016 estimated that oral diseases affected half of the world’s population [This is the first study to use National data to assess antibiotic prescription volume and prescription patterns for dental infections in four northern European countries. A total of 27,076,599 prescriptions issued by dentists working in England, Scotland, Norway and Sweden over the period 2010–2016 were analysed in this study. Prescriptions for dental infections accounted on average for 6–8% of the total prescriptions in Primary care from these countries. An important caveat of this data is that in the UK it probably underestimates the actual number of antibiotic prescriptions since the data source does not capture private prescriptions, and the number of patients receiving private treatment is estimated to be around 33% in the UK .100,000 and number of prescriptions per dentists in Norway are still the lowest for all antibiotics, except Clindamycin, compared to England, Scotland and Sweden. The significantly lower prescribing rates in other Northern European countries compared to the UK is a pattern observed in other Specialties [All countries show a decline in antibiotic prescriptions since the start of the analysis period indicating that stewardship initiatives in these countries are having an overall downward effect on prescription volumes. From 2010 to 2016, Sweden dentists reduced their total number of prescriptions by 19% followed by England 18%, Scotland 13% and then Norway by 4%. Although the least reduction of the total number of prescriptions was in Norway, however, the DIDcialties . Lower pOne of the more marked differences in the antibiotic prescribing patterns between the UK and Northern Scandinavian countries is the selection of Amoxicillin over Phenoxymethyl penicillin. In the UK the British National Formulary highlights either Amoxicillin (500 mg every 8 h in adults for 5 days) or Metronidazole (400 mg every 8 hourly in adults for 3–7 days) . The dos100,000 for Norway and Sweden is at least 10 times less than that of England and Scotland. Similar pattern is also found in other European countries where DID100,000 attributed to dental prescription of Amoxicillin in Belgium is approximately 10 times higher than that of Norway and Sweden [C. difficile infection. It is unclear why there is a higher prescription rate for this antibiotic in Norway and Sweden.The narrower spectrum Phenoxymethyl penicillin are more widely prescribed in Norway and Sweden whilst the broader spectrum Amoxicillin is largely prescribed in England and Scotland. The Amoxicillin DIDd Sweden . The queThe majority of oral penicillins are absorbed, so that they yield peak levels 1–2 h after ingestion with approximately 60 and 75% absorption following oral administration for Phenoxymethyl penicillin and Amoxicillin, respectively . PenicilPhenoxymethyl penicillin and Amoxicillin belong to the time-dependent killing agents, with a target to maintain concentrations greater than the MIC for greater than or equal to 75% of the dosing interval). Phenoxymethyl penicillin, are most active against non-ß-lactamase producing Gram-positive bacteria , anaerobes and selected Gram-negative cocci. Gram positive bacteria inhibited by natural pencillins in general are more susceptible to Phenoxymethyl penicillin than to semisynthetic pencillins like Amoxicillin , 29. Typ90 data). This is illustrated by reports of resistance rates for Amoxicillin ranging from 9 to 54% of common isolates from acute dental abscesses [Prevotella intermedia. Resistance to macrolides appears to have a higher prevalence in the ‘viridans group streptococci’, anaerobic streptococci and Prevotella species [90 of 2 mg/L for 15 strains of penicillin resistant anaerobic streptococci, with all the remaining isolates (649) having a clindamycin MIC90 less than 0.5 mg/L. Similar low levels of clindamycin resistance have been found in the UK and elsewhere [Antibiotic resistance in microbes recovered from the acute dental abscess has been reported to be increasing (with the exception of Metronidazole) in some populations studied over the last few decades –35. Carebscesses . However species –38. The lsewhere , 39.Differences in the prescribing patterns of Metronidazole are also markedly different between the UK and Northern Scandinavian countries. In England and Scotland prescription of Metronidazole in accounts for approximately 52–57% of all Metronidazole prescribed in primary care , 41. In The high levels of use of Metronidazole for the management of dental infections in England and Scotland is of concern in the context of potential increase in Metronidazole resistance in anaerobic bacteria populations . This isThe prescribing levels of the macrolides (clarithromycin/erythromycin) are as expected for their recommended use as second line agents in patients allergic to penicillins. Spiramycin is an antibiotic belong to the macrolide group of antibiotics. It has a spectrum against aerobic and anaerobic bacteria. This drug is prescribed by dentists in Norway and not by dentists in England, Scotland and Sweden, although Norwegian prescription guidelines do not encourage the use of this drug. The use of spiramycin as an adjunct to mechanical therapy for treatment of periodontal infections is recommended in the Norwegian Pharmaceutical Product Compendium , which might explain the prescription of his drug in Norway.In conclusion, this study has provided an in-sight into prescribing patterns for bacterial intra-oral infections managed by general dental practitioners from England and Scotland with Norway and Sweden. All four countries demonstrated reduction in overall numbers of items dispensed with lower prescribing patterns in Norway and Sweden. Other notable differences in prescribing patterns linked to first line choice of antibiotic between these countries existed with Phenoxymethyl penicillin the preferred choice in Scandinavia. There is some logic in a more widespread adoption of the use of the narrower spectrum Phenoxymethyl penicillin over Amoxicillin in the UK as it probably has a lesser impact on the normal flora without compromising treatment efficacy. Identification of high levels of Spiramycin prescribing in Norway may serve as a trigger for this country to review the prescribing guidance for the use of this antibiotic in managing chronic periodontal disease. Further work is required to understand the high levels of metronidazole prescriptions as this element of healthcare accounts for a significant contribution of selection pressure for the emergence of metronidazole resistance.


To the Editor—The coronavirus disease 2019 (COVID-19) pandemic has adversely impacted nearly all aspects of life since emerging in late 2019. Notably, surges in COVID-19 cases have led to antibiotic overprescribing in the inpatient setting, hampering ongoing antimicrobial stewardship efforts.2 However, patients’ reluctance to seek healthcare during the pandemic, particularly for minor ailments, may lead to unexpected outpatient antimicrobial stewardship gains. Jeffery et al3 reported an inverse relationship between COVID-19 cases and daily counts of emergency department visits in 5 US states between January and April of 2020. Diagnoses were not reported in this study, and the authors concluded that clinicians should reinforce to patients the importance of seeking emergency department care for serious conditions. We have previously reported the results of a systemwide initiative to reduce antibiotic prescribing for ambulatory adults with acute, uncomplicated bronchitis.4 Internally, we continue to track and report these data. Recently, we observed a profound reduction in both the overall number of patients seen and discharged with a primary diagnosis of bronchitis and the number of antibiotic prescriptions written for these encounters  were telemedicine encounters, a higher proportion of total visits than observed in previous months. Thus, a shift toward more telemedicine visits was revealed in our data set.The COVID-19 pandemic, while challenging for so many other aspects of antimicrobial stewardship, has led to an overall net reduction in ambulatory adults seeking care for bronchitis in our health system and to a dramatic reduction in antibiotic prescribing for that condition. Reducing unnecessary, outpatient antibiotic prescribing has long been a difficult challenge for many antimicrobial stewardship programs. Our challenge will be to educate patients and clinicians to maintain these improvements in outpatient, acute bronchitis management as the pandemic is brought under control and outpatient visits return to prepandemic levels.


In 2018, the Japanese medical reimbursement system was revised to introduce a fee for the implementation of an antimicrobial stewardship (AS) fee for pediatric patients. The purpose of this study was to evaluate physicians’ prescription behavior following this revision.We conducted a retrospective observational study from January 1, 2017 to September 30, 2018 of pediatric (< 15 years) outpatients with upper respiratory tract infections (URIs). To assess the pattern of antibiotic prescription for the treatment of pediatric URIs before and after the introduction of the AS fee, we extracted data on pediatric URIs, diagnosed during the study period. Patients were divided based on whether medical facilities claimed AS fees. We defined antibiotic use as the number of antibiotics prescribed, and evaluated the proportion of each class to the total number of antibiotics prescribed. We also recorded the number of medical facilities that each patient visited during the study period.The frequency of antibiotic prescription decreased after AS fee implementation, regardless of whether the facility claimed the AS fee, but tended to be lower in facilities that claimed the fee. Additionally, the frequency of antibiotic prescription decreased in all age groups. Despite the reduced frequency of antibiotic prescription, consultation behavior did not change.The AS fee system, which compensates physicians for limiting antibiotic prescriptions, helped to reduce unnecessary antibiotic prescription and is thus a potentially effective measure against antimicrobial resistance. Antimicrobial resistance (AMR) is a growing global threat because in addition to its appreciable clinical impact, it also has a considerable economic impact , 2. TherA common setting for antibiotic overuse is in the treatment of upper respiratory tract infections (URIs). The majority of URIs are viral , and theA high percentage > 94%) of antimicrobials prescribed are oral antibiotics in Japan . The use4% of antIn response to the current situation in Japan, the Japanese government developed the Manual of Antimicrobial Stewardship based on the national action plan on AMR in 2017 , and as In Japan, citizens have unrestricted access to medical care due to the public insurance system. A recent survey reported that 30.1% of patients want to be prescribed antibiotics for a common cold . The impWe conducted a retrospective observational study from January 1, 2017 to September 30, 2018. Data were obtained from the claims database, IQVIA Claims, which collects data of corporate employees and their family members. This database consists of anonymized inpatient, outpatient and pharmacy claims data on > 2.3 million individuals aged < 75 years from 32 Society-Managed Health Insurance institutions. The data accounts for approximately 5% of the total number of claims. In addition, the database includes patient characteristics , prescription drug information , diagnostic information , treatment procedure , and hospital characteristics .The study was performed in accordance with the Declaration of Helsinki and the study protocol was approved by the Ethics Committee of Kyoto Pharmaceutical University (No. 19–13). As this study used only anonymized claims data, the requirement for the consent was waived according to the requirements of the Japanese Ethical Guidelines for Medical and Health Research Involving Human Subjects .We evaluated pediatric patients aged < 15 years who visited outpatient clinics for treatment of an acute URI or acute tonsillitis, as identified by their respective Japanese disease codes . To assess the antibiotic prescription pattern for the treatment of URIs before and after the AS fee was implemented, we extracted data for pediatric URIs diagnosed during the study period, and divided them according to whether the medical facility had claimed the AS fee  and IBM SPSS Statistics 23 . Most of the results were reported as frequencies and proportions. Pearson’s chi-square test was used to test for statistical significance of the differences in the proportion of children prescribed an antibiotic before and after the introduction of the AS fee. Statistical significance was defined as a Figure The frequency of antibiotic prescription for URIs decreased significantly after the AS fee implementation, regardless of whether the facility claimed the fee Fig. .Fig. 3IThe frequency of antibiotic prescription was lower in facilities that claimed the AS fee than in facilities that did not both before and after AS fee implementation. Additionally, the magnitude of the decrease was similar in facilities that claimed the AS fee  and those that did not claim the AS fee , but there was no marked change in the overall antibiotic prescribing pattern Table .Table 1p < 0.001, Fig. p = 0.06).The frequency of antibiotic prescription for URIs decreased significantly in all age groups after AS fee implementation (After the implementation of the AS fee, the frequency of prescriptions for children with URIs decreased at both facilities that did, and did not claim the AS fee, and the frequency of antibiotics decreased in all age groups. However, there was no marked change in either the frequency of consultations, or in the overall prescribing pattern.In this study, the frequency of prescriptions for children with URIs decreased regardless of the type of facility. It has been reported that educational interventions, awareness-raising activities, feedback on social norms, and restrictions have reduced the frequency of prescriptions , 13, 18.The use of antibiotics in children peaks at the age of one year in Japan . In otheIn October 2017, the estimated number of patients with acute URIs aged < 15 years was 113,500 per day, and the number of pediatric clinics was 19,647 . One cliOur study did not show an increase in multiple consultations after the implementation of the AS fee. The AS fee provides doctors with an incentive not to prescribe antibiotics at the first visit and rewards them when they manage and educate patients without prescribing antibiotics . It is aThis study has some limitations. Firstly, it is not an evaluation of the entire population because it only targeted children and used the claims data from 32 Society-Managed Health Insurance institutions responsible for about 5% of claims; thus, the generalizability of the findings might be limited. However, it provides valuable information for evaluating the effectiveness of the AS fee using claims data. A national database could be used in future studies to broaden the generalizability of the findings. Another limitation is that individual patient outcomes could not be evaluated. The results might have also been influenced by the physician not prescribing antibiotics on the first visit. Additionally, the analysis period was less than a year because the claims database could not yet be obtained when we conducted this study. Our research provides vital information that can be a basis for implementing AS fees in other countries. This methodology that evaluated using claims data might also be valuable in other medical reimbursement systems.In conclusion, although the frequency of antibiotic prescriptions decreased regardless of whether the facility claimed the AS fee, the AS fee helps to limit unnecessary antibiotic prescription without affecting patient behavior. Thus, the AS fee system can be considered an effective strategy against AMR.


In the fresh and hardened state, concretes with partial replacements of Portland cement (CPC30R and OPC40C) by pulverized fly ash in combination with the addition of mineral aggregates and chemical admixtures were studied. The physical, mechanical, and durability properties in terms of slump, density, porosity, compressive strength, and permeability to chloride ions were respectively determined. The microstructural analysis was carried out by scanning electronic microscopy. The results highlight the effect of the addition of expanded clay aggregate on the internal curing of the concrete, which allowed developing the maximum compressive strength at 28 days (61 MPa). Meanwhile, the replacement of fine aggregate by 20% of pumice stone allowed developing the maximum compressive strength (52 MPa) in an OPC-based concrete at 180 days. The effectiveness of internal curing to develop higher strength is attributed to control in the porosity and a high water release at a later age. Finally, the lowest permeability value at 90 days (945 C) was found by the substitutions of fine aggregate by 20% of pumice stone saturated with shrinkage reducing admixture into pores and OPC40C by 15% of pulverized fly ash. It might be due to impeded diffusion of chloride ions into cement paste in the vicinity of pulverized fly ash, where the pozzolanic reaction has occurred. The proposed internal curing technology can be considered a real alternative to achieve the expected performance of a high-performance concrete since a concrete with a compressive strength range from 45 to 67 MPa, density range from 2130 to 2310 kg/m Nowadays, reinforced concrete structures are susceptible to chemical attack caused by some elements from the environment. These elements mainly include chloride ions and sulfates. For years, concrete specialists have been trying to increase the service life of the concrete, avoiding the penetration of these harmful agents. To accomplish this tough task, many researchers have focused their efforts on the development of less permeable concrete with low water/cement ratios. In this regard, the use not only of certain chemical admixtures but also supplementary cementitious materials (SCMs) such as pulverized fly ash (PFA) as a synthetic pozzolanic material has contributed to the development of a denser cementitious matrix; thus a less permeable concrete by porosity reduction. The substantial improvement in the properties of the concretes due to the particular addition of chemical admixtures and SCMs have made the concrete, being classified as high-performance concrete (HPC) .Thanks to the high strength-durability performance on structural service under harsh conditions, HPC has been extensively used and investigated around the world ,3,4,5. NFor years, several internal curing methods have been proposed to mitigate autogenous shrinkage and the internal stress that might be induced in HPC ,5,19. MaInternal curing materials can be classified into two categories following the water-absorbing mechanism: substances containing physically adsorbed water and porous materials . At the LWA has been used not only as an internal water source but also as a medium to dose additive mixtures within the concrete without affecting the properties of concretes in the fresh state. Besides, two characteristics in LWA are currently being studied: water absorption and desorption capacity. Recent studies have indicated that the use of large amounts of the LWA eliminates autogenous shrinkage in the concrete. Nonetheless, this implementation causes a decrease in compressive strength. Therefore, some studies have been conducted to evaluate the effect of using a few amounts of lightweight aggregate with an optimum particle size on the cementitious matrix .The technology of porous saturated aggregates with additives consists of the use of solutions introduced as an internal curing medium to increase the durability of the concrete with a higher viscosity than water. The physical principle is based on the Stoke-Einstein equation (Equation 1)):):(1)D0=kdiffuses ,42,43.The IC method using LWA consists in using the same size and fractions as a normal fine limestone aggregate to provide the most efficient supply of internal curing water to the mixtures so that it is covered most of the sites in the paste volume at a maximum level.Although a suitable amount of water is supplied by the saturated LWA, it must be well distributed in the mixture to moisture all of the paste. The required spacing called “the spacing factor” is described as the proximity of the LWA with the paste inside the concrete matrix. This spacing factor has been studied since it influences the internal water desorption. As known, the autogenous shrinkage is in the function of the spacing between LWA and the paste .Moreover, the PS as a curing agent facilitates the internal curing process due to its high porosity and thick porous structure since it allows the absorption of fluids when it is submerged in aqueous solutions. Besides, this aggregate can desorb the solution inside the concrete causing high relative humidity. The PS morphology makes it possible that the water can lodge in the capillary pores of the aggregate. The optimum pore size for storing the internal curing water is approximately 100 nm. If the pores are smaller than 100 nm, the water remains tightly bonded, and it is not available for cement hydration reactions in the hardening process .On the other hand, one of the materials with the highest compressive strength among lightweight aggregates is expanded clay aggregates (leca). Leca is an artificial and manufactured lightweight aggregate. After heating at 1150 °C in a rotary kiln, the clay expanded to about four to five times its original size and took the shape of pellets . Then, tFollowing the above mentioned, it is well recognized that the internal curing technique of presoaked-lightweight aggregates improves the properties of the concrete since it has been proven that the autogenous shrinkage of high-performance concretes decreases with the increase of the induced internal curing water. However, internal curing cannot eliminate the retractions of high-performance concrete ,47,48,49Recently, new techniques have evolved to improve the physical-mechanical performance and durability of structural concrete. One of these techniques includes the combination of mineral aggregates with chemical admixtures to improve high-performance concrete durability since might help to mitigate the diffusion of chloride ions and the penetration of accelerated carbonation ,58,59,60In particular, the resistance to chloride ions penetration is an important matter in concretes applied in marine construction, where there is a high risk of steel corrosion reinforcement concrete induced by chloride ,64,65,66Since the principle and design method of the combined use of mineral aggregates with chemical admixtures are still unclear, the goal of this study is to evaluate the effect of mineral aggregates pumice stone and expanded clay aggregate along to the chemical admixtures superplasticizers and shrinkage reducing additive as internal curing agents to improve the physical, mechanical, and durability properties of high-performance concretes.The raw materials used to elaborate the concretes are commercially available products, such as a CPC30R (Portland composite cement) and OPC40C (ordinary Portland cement) from CEMEX , coarse and fine aggregates from limestone minerals , pulverized fly ash (PFA), pumice stone (PS), and clay aggregates for curing. This clay aggregate is also known as expanded clay (EC).Tetraguard AS20 shrinkage reducing admixture from BASF  was the commercial chemical admixture used in this research to reduce drying shrinkage of concrete and the potential for subsequent cracking. From here this chemical admixture is referred to as SRA.Glenium 3030 NS superplasticizer from BASF was used to produce concrete with high flowability. Glenium 3030 is an admixture based on polycarboxylate chemistry. The dosage is for each cement kilogram, 1% of superplasticizer was added for internal curing concrete.2O and 0.1 wt.% of K2O) since it could be carried out an alkali-aggregate reaction.The chemical analyses results showed a high concentration of calcium in the mineralogical compounds of the ordinary Portland cement. Thus, the calcium concentration is quite enough to generate gels of hydrated calcium silicate with a stoichiometric Ca/Si ratio higher than 3.2 in the hydration process. Additionally, it is important to consider the content of alkalis . As known, it is important to determine the morphology, pore size, and other characteristics of the aggregate since its capacity as an internal curing medium to increase the durability of the concrete depends on these factors. The microstructure of the PS aggregate was analyzed by scanning electron microscopy. The samples were coated with a thin layer of graphite to make the sample conductive as well as to obtain a better resolution in the scanning electron microscope (SEM). The microstructure analysis was performed on a JSM-6490LV electronic microscope  coupled with an INCA-Sight energy dispersive X-ray spectrometer (EDX) from Oxford Instruments .Concrete mixtures were made in two stages. Stage 1 is derived from the results obtained by Trujillo et al. , where fAll concrete mixtures were prepared in a laboratory mixer using the same mixing procedure. For each type of concrete, all the specimens were prepared from the same batch.At a fresh and hardened state, the specimens were kept in the molds under laboratory conditions in a controlled climate chamber at a temperature of 25 ± 1 °C and 60 ± 2% of relative humidity (RH). At the hardened stage, the specimens were kept in their molds for 24 h and protected from moisture exchange. Then the specimens were subsequently unmolded and cured according to the specifications of the ASTM C 531-00  :The properties of fresh concrete were immediately determined after mixing sequence and before concrete specimens casting. The concrete mixing was evaluated as specified by the ASTM C94-17   INCA-Sight from OXFORD was used by the microstructural analysis. This was already stated a few pages back – remove one.The open porosity of hardened concrete at 28, 90, and 180 days of curing were measured with 100 × 50 ± 5 mm cylindrical specimens following the test procedure in the ASTM C642-13   according to the ASTM C1202-12 . Based o3 solution was sprayed onto the fracture surfaces of sliced samples that were split into two sections. The penetrated zone was determined by the change in color on the fracture surfaces to a brownish tone. For each concrete composition, the total charge was measured two times, and the penetration depth from 10 measuring points on each fracture surface.The total charge passed through the sliced specimen in coulombs (C) is referred to 3 to 2400 kg/m3 [3 to 2400 kg/m3. 3). The ICSRA mixture increased its volumetric weight by 8.5% concerning to the IC mixture. It should be mentioned that the volumetric weight in the concrete, where fine aggregate was substituted by the internal curing agents (clay aggregate and pumice stone), only varied approximately 5%.The volumetric weight and the air content in the experimental concrete provide information on the workability, trapped air, and porosity that the concrete may develop in the hardened state. The results show that the concrete elaborated in stage 1 with clay aggregate, registered a volumetric weight ranging from 2100 kg/m00 kg/m3 . MoreoveAs can be observed, at stage 1, the control concrete (R) has a drastic increase in compressive strength from 45 MPa (during the first curing day) to 80 MPa . This strength improvement leads to an increase of about 78% from the initial age (1 day) to the final age (28 days). As expected, the pozzolanic additions from CPC30R contained in the reference concrete (R) lead to the formation of carboaluminates and carbosilicates, which directly influenced to obtain the highest mechanical resistance of all the studied concrete ,86. BesiFollowing a similar behavior, the compressive strength obtained in all concretes tested in stage 2 exceeds the compressive strength of 30 MPa at the first day of age; i.e., it was accomplished the minimum compressive strength indicated by the standard (25 MPa at 28 days) at an earlier age. Then, at 90 days of age, the variation in compressive strength in all concretes evaluated was negligible. In this stage, the highest compressive strength was reached by the R1 concrete (55 MPa at 90 days). Likewise, the lack of an internal curing agent and weak porous medium contributes to achieving this highest strength. Furthermore, in IC2 concrete, which PS replaced 20% of fine aggregate (FA), compressive resistance of 35 and 52 MPa at 14 and 180 days, respectively, was reached. Among the concretes made with the addition of an internal curing agent , the concrete IC2 showed the highest compressive strength at 180 days. A loss of 7% in the strength of IC2 concrete compared to the R1 concrete strength at 28 days can be mainly attributed to a higher porosity in the matrix due to the use of a highly porous curing agent (pumice stone); i.e., a weaker matrix that develops lower strength. In IC2 concrete, it is worth noting the increase in compressive strength from 35 MPa at 14 days to 50 MPa at 28 days. The 42% increase in mechanical resistance indicates that the expected effect of the internal curing agent is being achieved, mainly due to a significant release of water at later ages. The V and ICRSA concretes obtained a compressive strength of 49 MPa at 180 days, which represents an 11% reduction in mechanical resistance compared to the reference concrete. In both, 20% of fine aggregates (FA) were replaced by pumice stone (PS), and a shrinkage reducing admixture was added. The addition of PS in the V concrete was made after the saturation of PS by its immersion into a solution of water with the SRA while in the ICSRA concrete, the PS was saturated in water and then was added into the mixture with the SRA together with the others concrete components. Although different methods were used to add the PS to the mix, the mechanical resistance of both concretes remained practically constant at all ages. In the VFA concrete, where 20% of fine aggregate (FA) were replaced by pumice stone (PS) saturated with shrinkage reducing admixture into pores in addition to 15% of OPC40C by PFA, the lowest compressive strengths were reached with 31 and 45 MPa at 1 and 180 days, respectively. Moreover, VFA concrete developed the lowest compressive strength at 180 days compared to all concretes studied. The average reduction in strength was: R1 concrete (~ 18%), IC2 (~ 13%), ICSRA and V (~ 8%). Certainly, the diminishing in cement concentration by its substitution for PFA in the VFA concrete is the main reason for the strength decrease.As expected, R concrete developed higher compressive strength (80 MPa) at 28 days than R1 concrete (54 MPa). In CPC30R, the pozzolanic was relevant for developing higher mechanical resistance in concrete R (~ 32%). On the other hand, IC2 concrete showed higher compressive strength compared to IC concrete at 28 days (~ 14%). This is due to a better interaction of the PS aggregate in the OPC for IC2 concrete, unlike the PS aggregate in the CPC for concrete IC. This phenomenon can be explained due to the combined effect of desorption of water from the light aggregate and the action of the superplasticizer admixture. The latter causes steric repulsion in the Portland cement particles, which in turn results in hydration of more cement particles, and therefore a higher amount of CSH gel is formed. Internal curing concretes with PS additions based on OPC , showed superior strength at 28 days than that based on CPC (IC concrete). In the same sense, ICFA concrete showed higher compressive strength (50 MPa) than VFA concrete (36 MPa) at 28 days. This higher strength represents an improvement of 28%. The lack of OPC and CPC by its substitution for PFA affects the compressive strength in both concrete. However, the ICFA strength is less affected than the VFA strength since PFA in the ICFA concrete is acting as a filler that contributes to higher strength. Finally, the concrete with expanded clay addition (ECFA concrete) experiments higher strength (61 MPa) than ICFA, and VFA concretes with the addition of pumice stone (50 and 36 MPa) at 28 days. The higher resistance is attributed to the fact that the expanded clay is a less porous curing agent than pumice stone, which led to a denser matrix with higher strength. The higher strength of the ECFA concrete versus ICFA and VFA concretes strength represents an improvement of 18% and 41% respectively.A representative specimen from the ICSRA concrete was taken to be analyzed in a stereoscope to determine the macroscopic effect of the pumice stone in the concrete matrix. A brighter coloration in the periphery area of pumice stone is observed, mainly due to the formation of a CSH-rich gel. This gel is promoted by more exceptional hydration in the region of the aggregate/paste interface. Also, this analysis confirms the homogeneity of all the aggregates in the concrete matrix.Open porosity represents an important parameter since the behavior of concrete against the diffusion of fluids, whether chlorides or carbonation, can be predicted through the percentage obtained. Similar behavior was exhibited in terms of permeability at 90 days by ICFA (1100 C) and ECFA (1150 C) concretes. The VFA, ICFA, ECFA, V (1338 C), and RFA (1500 C) concretes exhibited outstanding performance since their permeability values at 90 days are below 1500 C with almost no penetration. As data, except for the V concrete, the latter group of concretes has the replacement of Portland cement by PFA as a feature. This fact suggests that PFA influenced obtaining low pore connectivity in the cementitious matrix.For concrete V, a reduction in the permeability value from 2600 C (28 days) to 1338 C (90 days), indicates that the internal curing method as a densification medium was effective. R, ICSRA, and IC concrete showed a moderate penetration of chloride ions at 90 days . As mentioned above, in ICSRA and IC concretes, 20% of fine aggregates (FA) were replaced by pumice stone (PS) and a shrinkage reducing admixture was added. Moreover, based on the permeability reduction from 28 days to 90 days, the IC concrete achieved a greater reduction (63%) than the ICSRA concrete (25%). Therefore, the internal curing method on the IC concrete was more effective than the ICSRA concrete.Furthermore, even though R concrete did not develop internal curing, it exhibited moderate permeability due to the formation of a dense matrix. Finally, IC2 and R1 concrete showed the highest permeability values at 90 days (2960 C and 3368 C). A high enough connectivity of the pores in the cementitious matrix could be the cause of the permeability values reached in these concretes. In general, it was possible to observe that the total permeability of chloride ions in concretes with pulverized fly ash (PFA) contents and internal curing, was lower compared to the reference concretes (R and R1). It might be due to impeded diffusion of chloride ions into the cement paste in the vicinity of PFA, where the pozzolanic reaction has occurred.Based on the overall experimental data in the present study, it can be observed that the combined use of pulverized fly ash with curing agents in high-performance concrete can significantly reduce the amount of chloride diffusion.On the other hand, it is well-accepted that SRA improves the water absorption and chloride permeability of concrete due to the reduced surface tension of pore solution, increased viscosity, and refinement of pore structure. However, in the present study, the effect of SRA merely affected the durability property. The effect of superplasticizer on the durability was not clearly understood.High-performance concrete has numerous environmental and societal benefits of structural service under harsh conditions. HPC is characterized by being susceptible to the risk of early-age cracking because of autogenous desiccation and shrinkage. The development of a well-cured system is decisive for high-performance concrete to improve durability. Since the principle and design method of the combined use of mineral aggregates with chemical admixtures are still unclear, the goal of this study was to evaluate the effect of mineral aggregates (pumice stone and clay aggregate) and chemical admixtures (superplasticizers and shrinkage reducing additive) as internal curing agents.In the present research work, an effective internal curing method consisting of the combined effect of substituting Portland cement for mineral aggregates along with chemical admixtures for the manufacture of high-performance concrete was applied.(1)3 were obtained. All these ranges are favorable for the development of structural concretes. The structural efficiencies of these concretes are much higher than the conventional normal density concretes.Structural high-performance concretes with compressive strengths of 45 to 67 MPa and densities of 2130 to 2310 kg/m(2)The adverse effect of internal curing on the mechanical strength of the concrete at early-age was improving at later ages, where acceptable compressive strengths were achieved.(3)A less porous curing agent such as expanded clay (EC) compared to pumice stone (PS) allowed to exhibit the highest mechanical strength at 28 days (61 MPa), due to the development of a denser cementitious matrix (ECFA at stage 1).(4)In IC2 concrete, where 20% fine aggregate (FA) was replaced by pumice stone (PS), the effect of high water release by the internal curing agent allowed to increase the compressive strength from 35 MPa at 14 days to 50 MPa at 28 days, and subsequently achieve the highest compressive strength among the concretes with an internal curing agent at 180 days.(5)The VFA concrete exhibited the lowest permeability value at 90 days (945 C). This concrete included substitutions of fine aggregate by 20% of the PS saturated with shrinkage reducing admixture into pores and substitutions of OPC40C by 15% of PFA. Interestingly, the VFA concrete exhibited the highest porosity at 90 days and 180 days (~ 19% and ~ 16% respectively). The relationship between the porosity in the concrete and the connectivity may affect the chloride penetration. Even if the porosity of concrete is high, chloride penetration may be low when the connectivity of pores is low. Therefore, it was presumed that the VFA concrete developed low connectivity between pores into the matrix.(6)Similar behavior in permeability at 90 days was exhibited by ICFA (1100 C) and ECFA (1150 C), V (1338 C), and RFA (1500 C) concrete. This concrete showed outstanding performance since their permeability values at 90 days are below 1500 C with almost no penetration.(7)The total of chloride ions permeability in internal curing concrete with pulverized fly ash (PFA) were lower than those in the control concrete (R and R1 concrete). It might be due to impeded diffusion of chloride ions into cement paste in the vicinity of PFA, where the pozzolanic reaction has occurred.(8)As known, it is generally believed that SRA improves the water absorption and chloride permeability of concrete due to the reduced surface tension of pore solution, increased viscosity, and refinement of pore structure. However, in the present study, the effect of SRA merely affected the durability property.(9)The effect of superplasticizer on the concrete properties was not clearly understood.Mixtures with partial replacements of CPC30R/OPC40C by pulverized fly ash (PFA) in combination with the addition of pumice stone (PS)/expanded clay (EC) and superplasticizer/shrinkage reducer studied in the fresh and hardened state, allowed to obtain the following conclusions:Considering the overall experimental data in the present study, it can be said that the combined use of pulverized fly ash with curing agents in high-performance concrete can significantly reduce the amount of chloride diffusion. Further research will be conducted along the lines of the present study to evaluated the transmittance charge responsible for migration promotion.