Antimicrobial resistance (AMR) is currently one of the global public health threats. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR. Upper respiratory tract infections (URIs) are one of the most common conditions treated by antibiotics, even if unnecessary as in cases of viral infections and self-limited conditions which represent the most cases of URIs. Investigating physicians’ knowledge, attitudes, and practice regarding antibiotic prescriptions in children with acute URIs may reflect the problem of antibiotic over prescription. This study aims to assess the problem in our community and provide information for further planning of appropriate interventions to optimize antibiotic prescriptions.This is a cross-sectional study for all non-specialized physicians dealing with acute upper respiratory tract infections (URIs) in pediatrics sittings in Assiut district, Egypt. We used a self-administered questionnaire to assess physicians’ knowledge, attitudes, and practice. In addition, four clinical vignettes addressing different URI scenarios were included in the questionnaire to assess the patterns of antibiotic prescriptions in common cases.Our study included 153 physicians whose mean age was 32.2 ± 8.7, most of whom were pediatric residents in different health institutes in Assiut district. They had good knowledge as out of the 17 knowledge questions,the mean number of correct answers was 12.4 ± 2.9. Regarding their attitudes, mean attitude scores for inappropriate antibiotic prescribing were low. However, of those scores, the responsibility of others had the highest score (3.8 ± 0.61). Prescribing practice in special conditions of URIs showed that 80% of participants prescribed antibiotics if fever continued for more than five days and 61.4% if the child had a yellowish or greenish nasal discharge. Among 612 clinical vignettes, 326 contained antibiotic prescriptions (53.3%), and appropriate antibiotic prescriptions represented only 8.3% overall.Physicians dealing with acute URIs in outpatients’ clinics in the Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. Although the percentage of inappropriate prescriptions in clinical vignettes in high, more research is required to investigate the factors of antibiotic inappropriate prescribing practice and non-adherence to guidelines. Also, it is essential to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems. One of the most important medical advancements of the 20th century was the development of antibiotics, which represent the largest class of medications. The development of antibiotics has benefited human society in the fight against microorganisms and saving millions of lives ,2. HowevAntimicrobial resistance is a significant concern for global public health and a major threat to global health security, with an increasing number of resistant bacteria strains identified annually in both human and animal populations in developed and developing countries . Based oPolicymakers, health organizations, and research institutes have advocated for greater control over the distribution and use of antibiotics in society, with a particular focus on antibiotic prescribers and dispensers . DespiteAntibiotics are among the most frequently recommended drugs in pediatric treatment worldwide. Antibiotic overuse is a significant public health issue and crucial in establishing antimicrobial resistance ,10. BesiUpper respiratory tract infections (URIs) are among the leading causes of childhood morbidity. Additionally, it is one of the most common reasons for children seeking health care in outpatient settings, posing an enormous burden on society and the health care system . TherefoIn Egypt, the rationality of antibiotic use in such cases is not well studied. Besides, a few scattered studies were conducted in Egypt on antibiotic prescribing practice among physicians. In 2020, a cross-sectional study was conducted by inviting physicians to evaluate their knowledge, attitudes, and practice regarding antibiotics. In this study, 500 physicians were recruited from across Egypt’s governorates. The study revealed that Egyptian prescribers have considerable knowledge of antibiotics. However, there are low rates of good attitudes and proper practices toward the problem of AMR . FurtherThis cross-sectional study was conducted in Assiut district and targeted physicians dealing with outpatient pediatric cases. The current study is compliant with the "Strengthening the Reporting of Observational Studies in Epidemiology Statement" (STROBE) checklist .Assiut district is the central district of Assiut Governorate, one of the upper Egypt governorates, lying 375 km south of Cairo. Based on the last census in 2017, the population of Assiut district was 974,993 .Outpatient clinics dealing with pediatric cases in Assiut district are distributed among the following centers and hospitals: rural and urban primary health units ; Ministry of Health hospitals ; and Assiut University Hospitals .Inclusion criteria for this study were any non-specialized physicians dealing with outpatients’ pediatric cases having acute URIs at study sites . Physicians who did not work at outpatient clinics and those with a postgraduate degree were excluded.As it is exploratory study and the primary aim was to study the situation of antibiotic prescribing practice, total coverage sampling technique was adopted and all eligible physicians in study area were invited to complete the questionnaire.According to data from the directorate of the Ministry of Health in Assiut and Assiut University Hospital, there were 80 GPs at urban and rural primary health care (PHC) units, 35 pediatric residents, and 8 ENTs at MoHP hospitals. At Assiut University Hospitals, there were 50 pediatric and 9 ENT residents. Thus, the eligible physicians were estimated to be 182 physicians.Data of the present study were collected through a self-administered questionnaire developed and designed by the investigator. For this, a search of primary studies and reviews published in English language was conducted on the PubMed, Medline and Cochrane databases from January 2010 to December 2021 using the following search term strategy: “antimicrobial resistance” OR “antibiotic prescription” AND “perception” OR “attitudes” OR “knowledge” AND “upper respiratory tract infections” AND “pediatrics” OR “Children”. Then evaluation of retrieved papers and tools was performed, and relevant tools was chosen based on our study objectives ,23–25. AThe questionnaire consisted of four parts. First, socio-demographic and professional characteristics; this part includes personal and demographic factors related to physicians. Also, questions about their postgraduate studies, continuous medical education (CME), and factors influencing their prescriptions were included. The second part is knowledge questions; this part includes 17 items and responses selected as yes, no, or do not know. The questions were divided into two groups: knowledge of antibiotics to test the physicians’ background on antibiotics and their use (8 items), and knowledge of antibiotic resistance to test physicians’ knowledge of antibiotic resistance and its causes (9 items). The third part includes attitude questions; 27 items assessed five attitudes aspects according to the Teixeira Antibiotic Prescribing Behavioral Model :Ignorance: a lack of concern for antibiotic resistance resulting from over-prescribing antibiotics (7 items).Responsibility of others: a belief that others  are responsible for the problem of antibiotic resistance (4 items).Indifference: a lack of motivation to change antibiotic prescribing practices (3 items).Complacency: prescribing antibiotics to satisfy patient demands and expectations (8 items).Fear: prescribing antibiotics for fear of losing patients or losing in potential disputes with patients (5 items).The attitude questions were designed according to the five-point Likert scale, having options of "very disagree," "disagree," "neutral," "agree," and "very agree" for the first three aspects . However, for the last two aspects (complacency and fear), the scale having options of "never," "rarely," "sometimes," "often," and "always" was used. Cronbach’s alpha was used to calculate the reliability of attitude scales. The internal consistency  for all attitude scales was 0.80, indicating good consistency.The fourth part includes two types of questions to assess physician practice. First, questions about their choice in specific conditions of upper respiratory tract infections and whether they will prescribe antibiotics "always," "sometimes," or "never" in such cases. Second, they were asked to assess four different clinical vignettes; for each case 7 items were evaluated, they were asked about the suggested diagnosis, if the antibiotic was needed, and if yes, what was the type and duration. They were also asked if they would prescribe injectable or combined antibiotics and if they will ask parents to comeback for follow-up.Each case was assessed to see if it had an inappropriate antibiotic prescription or not based on WHO-aware guidelines, Nelson’s Pediatric Antimicrobial Therapy recommendations, and Assiut University Hospitals antibiotic guidelines –28. In tContent validity of the instrument was evaluated in two different stages in accordance with published guidelines . First iThe study protocol was reviewed and approved by the Institutional Review Board of Faculty of Medicine, Assiut University (IRB no.: 17200370) and registered on clinicaltrials.gov (NCT04127682). A formal permission letter was obtained from the Directorate of the Ministry of Health in Assiut.The questionnaire cover letter informed participants about the purpose of the study, ensured all information would remain confidential and informed them that consent to participate was implied upon their agreement to participate and by signing of cover letter and completing the questionnaire.A pilot study was carried out on 20 physicians before data collection, and their results were not included in the analysis. The pilot aimed to test the reliability of the questionnaire by the test-retest method. It also aimed to estimate the required time for implementing the questionnaire, which was 20–30 minutes. Therefore, an interval of 2 to 4 weeks was allowed to elapse between the first and second administration of the questionnaire.Data were collected from September 2021 to February 2022 as this is the time of year with increased URIs . Two well-trained research assistants from the research office of the Directorate of the Ministry of Health in Assiut helped the researcher to distribute the questionnaires in MoHP hospitals and PHC units and to watch, keep understanding and completeness of data, and answer all the questions asked by the physicians to ensure the accuracy and completeness of data. Aim of the study was explained to physicians and instructions to complete the questionnaire has been given.® Excel 2010 and then transferred to Stata/IC® 16.1 for further data management and analysis. Incomplete questionnaires with more than 50% missing data or incomplete responses to clinical vignettes were excluded from the analysis. Graphic presentations were conducted using Microsoft® Excel 2010.Data were entered in MicrosoftThe frequency and percentage of correct answers were calculated for the knowledge score. For each aspect, the mean score of each participant was calculated and ranged from 1 to 5; the higher the score, the more inappropriate the prescription attitude. Quantitative data were presented as mean ± SD or median (min-max), while categorical data were presented as frequencies and percentages. For comparison of knowledge score according to post-graduate degree enrolment status and between inappropriate prescriptions and appropriate or no prescription cases; students’ t-test was used. To examine the correlation between knowledge and attitude scores Spearman’s correlation was performed. In all statistical tests p-value <0.05 was considered statistically significant.Of 182 eligible physicians, 153 (84.1%) completed the questionnaire and were subjected to the full analysis. Twenty-five physicians were excluded for not being available during data collection time, and four questionnaires were excluded due to incomplete data .The mean age of respondents was 32.2 ± 8.7, and 81.7% were less than 35 years old. The median duration for practice since graduation was four years, and junior doctors in practice for less than one year represented 26% of participants. Females represented 57.5% of respondents. Most study participants work in the university hospital (39.2%); pediatric residents represented the most significant proportion (64.1%), while GPs represented 23.5%. Twenty-four percent of participants did not enroll in any postgraduate degree, while 53.6% enrolled in a pediatric master’s degree. Nearly half of the participants received integrated management of childhood illness (IMCI) training, and 43.1% used IMCI guidelines in their practice. Last year, only 28% of the participants attended continuous medical education events addressing antimicrobial resistance .Nearly eighty-nine percent of participants reported that they rely on their clinical assessment for prescribing antibiotics in cases of upper respiratory tract infections, followed by reported symptoms by the patients or their parents (60%). In contrast, patient expectations were reported to have a minor influence on the decision of antibiotic prescribing in those cases .As regards their knowledge about antibiotics use and resistance, the participants have adequate knowledge as the mean number of correct answers for 17 knowledge questions was 12.4 ± 2.9. The most incorrectly answered questions in the knowledge of antibiotics were second and third, as 61.4% reported that broad-spectrum antibiotics are preferred in treating URT infections, and nearly half of them believe that antibiotics are an effective drug for fever. At the same time, the most incorrectly answered questions in antibiotic-resistant knowledge were the fourth and fifth questions, as 77.8% of participants did not know that antibiotic resistance can spread from animals to humans, and 54.9% did not know that antibiotic resistance can spread from person to person . There wMean attitude scores for inappropriate antibiotic prescribing are illustrated in Prescribing practice in special conditions of URT infections showed that 80% of participants always prescribe antibiotics if fever continues for more than five days, and 61.4% always prescribe antibiotics if the child has yellowish or greenish nasal discharge. On the other hand, 61.4% of participants do not prescribe antibiotics based on caregiver requests .As each participant responded to four clinical vignettes, a total of 612 vignettes were assessed. Among them, 326 contained antibiotic prescriptions (53.3%). Appropriate antibiotic prescriptions represented only8.3% overall. By analysis of difference in knowledge scores between cases which prescribed inappropriate antibiotic (n = 299) and those with appropriate or no antibiotic prescriptions (n = 313), there was no statistically significant difference. The mean total knowledge score in inappropriate prescriptions was 12.3 ± 2.8 while in appropriate prescriptions and non-prescriptions group was 12.6 ± 2.9 .Further analysis of cases revealed that for case one, which is a viral infection and no need for antibiotics, 54 (35.3%) participants prescribed antibiotics. Most of the antibiotics prescribed in these cases were penicillin (70.4%), especially amoxicillin + clavulanic acid, which was the most frequent type used (39.5%). In 14.8% of cases, antibiotics were prescribed as an injection, and 3 participants mentioned that they would prescribe a combined antibiotic in this case. In this case, the mean duration of antibiotic use was 5.8 ± 1.4 days .Regarding the second case, a viral infection case (common cold), no antibiotic was needed; 11 (7.2%) participants were prescribed antibiotics. In this case, penicillin represented the most prescribed antibiotic class (63.6%), especially amoxicillin, which represented (71.4%) of all prescribed penicillin. Only one participant prescribed an injectable antibiotic, while 2 prescribed combined antibiotics. In this case, the mean duration of antibiotic use was 5.6 ± 1.7 days .The other two cases were bacterial infections where antibiotics were indicated. For the third case, otitis media, the most prescribed class was antibiotics and penicillin by 112 (73.2%). Amoxicillin and amoxicillin + clavulanic acid represented the most prescribed penicillin . Also, cephalosporins were prescribed in 17 cases in which ceftriaxone represented 52.9%. Sixteen participants prescribed injectable antibiotics, representing 9.8%, while 11 (9.8%) prescribed combined antibiotics. In this case, the mean duration of antibiotic use was 6.8 ± 2.4 days. Only 15 (13.4%) were appropriate by assessing the appropriateness of prescribed antibiotics .Regarding the fourth case, follicular tonsilitis, 149 (97.4%) prescribed antibiotics, and penicillin was the most prescribed class. Amoxicillin + clavulanic acid represented the most prescribed penicillin (50.4%). Also, cephalosporins were prescribed in 24 cases, in which ceftriaxone represented 45.8% of them. Of the prescribed antibiotics, 101 (67.8%) were injectable, while 49 (32.9%) were combined antibiotics. In this case, the mean duration of antibiotic use was 7.0 ± 2.4 days. Only 12 (8.0%) were appropriate by assessing the appropriateness of prescribed antibiotics .Antimicrobial resistance (AMR) is one of the global threats nowadays. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR . In EgypOveruse and consumption of antibiotics in healthcare are related to physicians’ prescribing behaviors as patients usually comply with their advice even if antibiotics are over-the-counter (OTC) drugs in the country. However, the prescription by the physician is still the main driver for using it . AntibioMost of the recruited physicians in this study were less than 35 years old. This was expected as this study aimed to assess antibiotic prescriptions in GPs and physicians who have not yet specialized or hold a degree. In Egypt’s health system, most medical school graduates enroll in postgraduate studies or fellowship programs to become specialized directly after graduation. This also explains this study’s small proportion of GPs [Previous studies demonstrated that continuous medical education improves antibiotic prescribing behaviors . In the Based on the Teixeira Antibiotic Prescribing Behavioral Model (TAPBM), knowledge and attitudes toward antibiotic use and resistance significantly impact prescribing practice . In the Regarding participant attitudes, the responsibility of others  was the highest attitude score, consistent with the result of a systematic review by Rodrigues et al., in which 35 studies for physician antibiotic prescribing behavior were reviewed. In this review, the responsibility of others was described as influencing antibiotic prescribing in six papers . MoreoveMany studies report patient-related factors affecting antibiotic prescribing behavior. Physicians may feel that specific clinical symptoms frequently connected with prescriptions suggest a bacterial infection or a more severe illness . As repoClinical vignettes are an effective tool to explore antibiotic prescribing patterns for different cases and have been used previously in many studies . In the Among the inappropriate prescriptions in the current study, antibiotics were prescribed for 7% of common cold cases and 35% of viral URT infection cases with a sore throat. This percentage is low compared to other studies conducted in Egypt by examining prescriptions in which antibiotics were prescribed for 53.3% of common cold cases and 96% of viral pharyngitis cases. This difference may be attributed to using case vignettes rather than being like countering real patients, and responses may represent socially desirable answers rather than actual antibiotic prescribing practice . HoweverIn the present study, the antibiotic prescriptions for bacterial cases in which antibiotics are indicated are consistent with other studies. However, the percentage of inappropriate prescriptions was high due to the wrong choice, duration of antibiotics, or use of injectable or combined antibiotics. For otitis media (OM) cases, 73% of participants prescribed antibiotics, and non-prescribing antibiotics here cannot be considered inappropriate as some guidelines recommend delayed prescription or even nonprescription if not complicated. Among those prescriptions, nearly 87% were inappropriate, and most were due to inappropriate duration, as the recommended duration for OM treatment is five days, while in this study, the mean duration was 6.8 ± 2.4.On the other hand, 97% of follicular tonsilitis cases had an antibiotic prescription, and 92% were inappropriate. Hence, the inappropriate type and duration together composed most of the inappropriateness. For those cases, the most prescribed antibiotic was amoxicillin + clavulanic acid (40%). However, guidelines do not recommend the antibiotic of choice as amoxicillin and/or penicillin V, except for penicillin allergy ,28. AlsoAlthough this study is a descriptive and aiming to explore the current practice, but it is obvious that, there is a need to introduce corrective actions to control antibiotic over prescription in such cases. Interventions that attempt to improve antibiotic prescribing tend to be more successful when they combine doctor, patient and public education and when the design is multi-faceted –69. A syOur study relied on physician recall and self-reported practices, which has significant limitations. We did not evaluate the relationship of attitudes to actual antimicrobial prescribing. Therefore, there may have been information bias because of a tendency for respondents to provide answers they believed the researchers wanted to hear, resulting in an underestimation of the prevalence of improper attitudes and prescription behaviors. Other factors influencing physician attitudes regarding antibiotic prescribing, such as pharmaceutical promotion, restricted consultation, dispensing times, and financial incentives, were not investigated. The research was conducted in a single Egyptian district, limiting its generalizability. The four clinical vignettes used to evaluate antibiotic prescriptions were limited to a few features, not actual patients. Furthermore, they did not permit ordering further point-of-care diagnostic testing as would have been appropriate before administering antibiotics.Moreover, we did not measure antibiotic consumption and prescription audit to determine the appropriate use of antibiotics and the efficacy of interventions. Although these limitations, this study is the first evaluation of knowledge, attitudes, and practices reported regarding antibiotic prescriptions for treating acute URTIs in children by pediatricians in Assiut, Egypt. The results of this survey can be used to improve education, antimicrobial surveillance, and antibiotic prescribing patterns among physicians in our setting.Physicians dealing with acute URTIs in outpatients’ clinics in Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. However, the percentage of inappropriate prescriptions for clinical vignettes is high. More research is required to determine the causes of improper antibiotic prescribing and non-compliance with guidelines. Also, it is crucial to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems.


Furthermore, the presence of two cations, Cu and Zn, had an inhibitory effect on the removal of Cd ions. In addition, analysis of the zeta potential revealed the flocculation of polyacrylamide–glutathione. The flocculation mechanism of glutathione is mainly chelation, adsorption bridging, and netting sweeping.In this study, a heavy metal trapping gel with multiple ligand groups was prepared for the first time using response surface methodology. The gel was produced by condensing and grafting glutathione as a grafting monomer onto the main polyacrylamide chain, based on the Mannich reaction mechanism with formaldehyde. FTIR, SEM, TG-DSC, and zeta potentials were used to characterize the gel. The results demonstrated that the gel was morphologically folded and porous, with a net-like structure, which enhanced its net trapping and sweeping abilities, and that glutathione was used to provide sulfhydryl groups to boost the metal trapping ability of polyacrylamide. Coagulation experiments showed that the highest efficiency of the removal of Cd ions from water samples was achieved when the concentration of polyacrylamide–glutathione was 84.48 mgL As the primary source of cadmium pollution, the unregulated disposal of zinc-cadmium smelting waste and cadmium-containing battery waste may pose a substantial risk . It is wTraditional inorganic flocculants effectively remove colloidal substances, suspended particles, and turbidity from water, but it is more difficult to remove dissolved heavy metal ions . In actuAccording to the mechanism of the Mannich reaction ,28, the 4–521 × 104) used in the experiments was synthesized directly in the laboratory using acrylamide polymerization. Acrylamide (99.5%) and reduced glutathione (99% biotech grade) used in the experiments were provided by McLean Biochemical Co. Ltd. . Ammonium persulfate, formaldehyde, manganese sulfate, potassium chloride, hydrochloric acid, sodium hydroxide, and kaolin were provided by Sinopharm Chemical Reagent Co.Ltd. . None of the purchased reagents in this experiment necessitated additional purification (except acrylamide and reduced glutathione). Deionized water was utilized for the preparation and cleaning of every solution.The polyacrylamide  was completely dissolved in 100 mL of deionized water and sealed in a 200 mL three-neck flask by continuous, slow stirring for 20 min. An amount of 0.5 mL of glutathione solution at a concentration of 1 g/mL was prepared and injected into the three-necked flask, which was mechanically stirred at 30 rpm for 2.5–4 h and maintained at a constant temperature of 35 °C. After the reaction, the obtained viscous clear liquid was filtered and transformed into a white granular solid in a vacuum-dried oven at 55 °C. These pellets were identified as polyacrylamide–glutathione and ground into a powder for storage in an airtight container.−1 to 4000 cm−1. A JSM IT500 scanning electron microscope  with an accelerating voltage of 15.0 kV was utilized to observe the surface morphology. On a DTG-60H differential thermal/thermogravimetric simultaneous thermal analyzer (Shimadzu (Beijing) Co., Ltd., Beijing, China) using 40 mL/min of flowing air at a heating rate of 20 °C/min, thermal gravimetric analysis was performed. At 25 °C, the zeta potential was determined using dynamic light scattering (DLS) and a Zeta Nano ZS 90  Co., Ltd., Shanghai, China). In addition, cadmium and other ion concentrations were measured using inductively coupled plasma emission spectrometry  Co. Ltd., Shanghai, China).On a Nicolet 6700 FT-IR spectrometer , FT-IR spectra were recorded with the measured wavenumber interval ranging from 500 cmSimulated and formulated with cadmium sulfate and kaolin, the cadmium-containing water samples used in the coagulation tests were simulated to contain cadmium. Amount of 1.0 mg–20.0 mg of cadmium ions and 600 mg of kaolin were added to 1 L of deionized water, which was then mixed and stored for 30 min. Following this, 800 mL of the suspension was extracted and stored as a kaolin stock solution. The first stage was stirred at 160 r/min for 4 min, the second at 50 r/min for 10 min, and the third stage was left for 40 min. One minute after adding 200 mL of cadmium-containing simulant to the coagulation beaker, 1 to 5 mL of polyacrylamide–glutathione solution was added separately while stirring. Test samples were collected and filtered one centimeter beneath the liquid’s surface through a 5-micron filter. To measure cadmium removal in flocculation tests, the cadmium removal rate, c/c0, was calculated, where c represents the concentration of cadmium ions in real-time and c0 represents the initial concentration.The polyacrylamide–glutathione synthesis is influenced by a variety of external factors. Therefore, screening for these influencing factors is required to examine the relevant optimum parameters. Six single-factor experiments were conducted based on previous research on the graft modification of polyacrylamide-based flocculants . However−1. Based on the available literature and the results of the laboratory synthesis process ,37,38,392OH) in N-hydroxymethyl polyacrylamide occurs [e occurs , which ie occurs .Based on the aforementioned experiments, the following single-factor test conditions were determined to be optimal: the mass ratio of polyacrylamide to glutathione was 15:3, the glutathione grafting reaction time was two hours, the amount of formaldehyde was 1.0 mL/L, and the initial pH of the reaction system was 5.0. In addition, the obtained polyacrylamide-glutathione cadmium ion removal rate was 96.53%. Therefore, it can be said that the optimal conditions for the gel preparation have been attained.Four of the most influential parameters were chosen based on their peak during the experimental period. Due to its lowest value during the interval required to remove approximately 80% of cadmium, the temperature was not significantly influencing among the parameters and was therefore not considered. While the effect of stirring speed was not considered because excessively high rotational speed is destructive to polyacrylamide-glutathione and excessively high energy consumption is impractical for the application, the effect of stirring speed was still not disregarded. In addition, screening factors with significant effects on the design of the response surface methodology were deemed effective in reducing model fitting errors and enhancing the applicability of the results. Four factors were therefore chosen for response surface analysis.Quantifying the effects of these experimental parameters using the response surface method is necessary because the experimental and analytical results cannot be used to determine the relative importance of the experimental parameters affecting the response. The method approximates the relationship between the inputs and outputs of an entire complex system using a hypersurface. Experiments were conducted using the software-derived operating conditions, and a second-order model was fitted to the experimentally obtained data to obtain a quadratic regression equation . The dominant and interaction effects of each effector were investigated to identify the most significant effector and the optimal solution.2), R2adj, and R2pre analyses of these models are presented in Using the software’s Box–Behnken design, a 4-factor, 3-level experimental design and analysis were conducted, with the experimental factors and level values detailed in 2 should be greater than 0.8 for a good-fitting model, and the closer the R2 value is to 1, the better. R2pre and R2adj values should also be close to each other to ensure the model’s predictions are close to those of the actual experiments. From 2 value of the linear model was 0.7643, and the R2adj and R2pre were 0.6541 and 0.2930, and the value of the difference was less than 0.1. This indicates that the linear model has the smallest deviation and a better fit than other models. Furthermore, the final equation in terms of actual factors can also be fitted:Rp-value, the greater the effect of the factor on the response value. For example, the ANOVA results in p-values of items A, B, D, BC, and A2 in the model were <0.05, indicating that they were all significant. The order of significance of the effects of every single factor was reaction time > polyacrylamide/glutathione mass ratio > formaldehyde dosage > pH.ANOVA was performed on the fitted model  to deterThe model’s F-value of 8.53 indicates its significance. There is a 0.02% chance that an F-value of this magnitude could be caused by noise. Values of Prob > F of less than 0.0500 indicate significant model terms. Model terms A, B, and D are significant in this instance. Values exceeding 0.1000 indicate that the model terms are not statistically significant. The F-value for Lack of Fit of 0.94 indicates that the Lack of Fit is not significantly different from the pure.As shown in As seen in After establishing the model to further determine the optimal synthesis factors of polyacrylamide–glutathione, the DesignExpert 9.0 software was utilized to screen for parameter optimization. The results are shown in In this section, a series of characterizations, primarily FTIR, SEM, and DTG, were conducted. The FTIR spectra were primarily used to compare the polyacrylamide prior to synthesis with the polyacrylamide–glutathione after synthesis and to determine if the functional group grafting was successful. EDS was used to analyze the principal elements and characterize the presence of sulfhydryl groups from an elemental perspective, while SEM was used to clarify the microstructure and morphology. Using differential thermal thermogravimetry, the thermal stability of the final reactants was evaluated. The details are listed below.−1, the sharp and weak absorption peak of -COO- was observed at 1544 cm−1, and the characteristic peak of -CH- was observed at 1359 cm−1. These characteristic absorption peaks coincide with the product polyacrylamide and possess the characteristics of the final product. In the polyacrylamide–glutathione FTIR spectra, the characteristic peaks of the aforementioned polyacrylamide appeared at 3430, 2939, 1642, 1537, and 1361 cm−1, respectively. In particular, the characteristic peak of the target sulfhydryl group was located at 2500 cm−1 in the polyacrylamide–glutathione spectrum for this comparative test. Due to the weak absorption intensity of the -SH group and its susceptibility to intermolecular hydrogen bonding, the characteristic absorption peak of the -SH group depicted in SEM was used to compare the surface morphology of polyacrylamide and polyacrylamide–glutathione. It is evident from 2, etc.). This led to a weight loss of approximately 14.7%. Finally, the DSC curve displayed a peak in heat absorption at 268.55 °C. With the increasing temperature, the carbon backbone structure of the polyacrylamide–glutathione was gradually broken by thermal decomposition, resulting in weight loss, which corresponds to the heat absorption peak at 335.17 °C on the DSC curve. From the above analysis, it can be seen that polyacrylamide–glutathione has good thermal stability in the range of 26~200 °C and will not decompose.The polyacrylamide–glutathione sample underwent differential thermal thermogravimetric (TG-DSC) analysis, and the TG-DSC curve depicted in In this section, batch tests were conducted to investigate the performance of cadmium removal under different conditions. Polyacrylamide–glutathione dosing, water turbidity, pH, and cation presence were the four main conditions. Additionally, the influential processes within each condition were analyzed. The flocculation mechanism was also determined by measuring the zeta potential.−1. The effect of polyacrylamide–glutathione concentration (10–50 mg L−1) on cadmium removal was investigated using the experimental coagulation method. −1, the cadmium removal rate reached 99.62%, and as the dosage was increased to 45 and 50 mg L−1, it approached the limit at 99.78% and 99.84%, respectively. The optimal dosage of 40.25 mg L−1 was determined based on the cost of producing polyacrylamide–glutathione and its effectiveness in removing cadmium.The measured dissolved concentration of polyacrylamide–glutathione was 10 mg/mL, and the initial concentration of cadmium ions was 20.0 mg L2) in polyacrylamide–glutathione acquires hydrogen ions, which protonate -NH2 to form -NH3+. The resulting electrostatic repulsion with positively charged cadmium ions is unfavorable for the coordination of the amino group with cadmium ions [2, while a small percentage was complexed with amino groups. In this instance, the cadmium removal rate is high, but the polyacrylamide–glutathione was significantly less effective. In light of the synergistic effect of initial pH on cadmium removal, the optimal initial pH range was determined to be between 7.0 and 9.0.As the pH of the initial solution rose, the cadmium removal rate rose and then fell. Under highly acidic or alkaline conditions, the rate of cadmium removal by polyacrylamide–glutathione was less than 80%. When the initial pH of a solution was less than 5, the amino group  at pH = 4.0, 6.0, and 8.0 were analyzed and determined in this section. The significance of the zeta potential lies in the correlation between its value and the stability of the colloidal dispersion. In addition, the zeta potential quantifies the mutual repulsion or attraction between particles [In order to comprehend the flocculation mechanism of polyacrylamide–glutathione, the zeta potential changes at different polyacrylamide–glutathione concentration levels (10~80 mg Larticles .2 ligands on polyacrylamide–glutathione by cadmium ions is primarily responsible for the flocculation effect. Briefly, adsorption bridging and netting sweeping effects were dominant under acidic conditions, and inhibition of chelation increased with increasing solution acidity; as the pH increased, the chelation effect was combined with adsorption bridging and netting sweeping under neutral and alkaline conditions. The adsorption bridging and netting sweeping were primarily determined by the gel’s polyacrylamide properties. According to the DLVO theory [As depicted in O theory , the smaO theory . AccordiPolyacrylamide-glutathione, a new heavy metal trapping flocculant, was synthesized for the first time in this study to trap the heavy metal cadmium. In addition, the optimal conditions for its synthesis were designed and calculated using response surface methodology. In addition, for the first time, its pertinent characteristics, flocculation mechanism, and application conditions in water bodies were analyzed. The subsequent conclusions were reached:To optimize the synthetic parameters, response surface synthesis tests were conducted and the significant effects of each parameter were determined in the order of reaction time > polyacrylamide/glutathione mass ratio > pH > formaldehyde dosage. The optimal preparation conditions were a reaction time of 2.692, a mass ratio of 11.17:1 between polyacrylamide and glutathione, and a formaldehyde dosage of 0.49 mL/L. The pH of the reaction system was 3.5. The mean cadmium removal rate of the obtained product was 96.67%, and parallel experiments revealed a relative deviation of 1.05% between the actual value of the cadmium ion removal rate and the theoretical prediction of the model.The FTIR and EDS results indicated that the polyacrylamide molecular chain contained new sulfhydryl ligand groups. This suggests that glutathione was successfully grafted to polyacrylamide, as opposed to a simple physical mixture of glutathione and polyacrylamide. SEM reveals that the polyacrylamide–glutathione morphology was multi-folded and porous, with a certain reticulation structure, which enhanced the adsorption of cadmium ions in aqueous media and its sweeping and net trapping abilities. The TG-DSC analysis revealed that polyacrylamide–glutathione was thermally stable between 26 and 200 °C and did not decompose.−1, a dosing amount of 40.25 mg L−1, an initial turbidity of 13.10 NTU, and an initial pH of 8.0. In contrast, the presence of two cations, potassium and aluminum, inhibited the cadmium removal process. The primary mechanism of polyacrylamide–glutathione flocculation was chelation, along with adsorption, bridging, netting, and sweeping. Under acidic conditions, adsorption, bridging, and netting are the primary mechanisms and chelation is partially inhibited, while under neutral and alkaline conditions, all three mechanisms operate simultaneously.Experiments investigating the coagulation revealed that polyacrylamide–glutathione was the most effective at removing cadmium ions from a solution with a cadmium concentration of 20.0 mg L


IgG4‐related disease is characterized by a systemic fibroinflammatory process associated with substantial infiltration by plasma cells with IgG4 in the organs. Our patient presented with pleural effusion, and was diagnosed with IgG4‐related lung disease (IgG4‐RLD) after he received two doses of the Pfizer COVID‐19 vaccine. The patient developed dyspnea and hypoxia 2 weeks after receiving the second dose of the Pfizer COVID‐19 vaccine. CT scan revealed left pleural effusion which was drained. However, the effusion recurred requiring thoracoscopic drainage, placement of an indwelling catheter, and decortication with biopsy. IgG4 serum level was 268 mg/dl and pathology revealed pleural fibrosis, lymphoplasmacytic infiltrates, and increased IgG4‐positive plasma cells with no malignant cells leading to a diagnosis of IgG4‐RLD. Although COVID vaccine‐related IgG4‐RLD is a novel finding, having a high degree of suspicion following vaccination is always important for early diagnosis and effective treatment. We report the case of a patient who presented with pleural effusion, and was diagnosed with IgG4‐related lung disease (IgG4‐RLD) after he received two doses of the Pfizer COVID‐19 vaccine. Although COVID vaccine‐related IgG4‐RLD is a novel finding, having a high degree of suspicion following vaccination is always important for early diagnosis and effective treatment. IgG4‐related disease (IgG‐RD) is a poorly understood inflammatory disease. It is a systemic fibroinflammatory process associated with substantial infiltration by plasma cell with IgG4. Since the COVID era, great effort went into finding a vaccine to decrease the impact of the virus, several companies achieved their goal by finding a vaccine, including the Pfizer vaccine which is a segment of mRNA of the virus wrapped with lipid nanoparticles to activate the immune system.Our patient is a 71‐year‐old male with hypertension, coronary artery disease, prostate cancer and chronic obstructive pulmonary disease with a 50‐pack year smoking history. The patient started being followed in the pulmonology department after a screening chest CT revealed left hilar fullness and peri‐fissural nodules, the largest of which measured 0.4 cm  solid nodular type; (II) round ground‐glass opacity type; (III) alveolar interstitial type; and (IV) broncho‐vascular type. Pleural effusion or nodules is uncommon. Airway involvement is rare, including tracheobronchial stenosis and traction bronchiectasis.The definite diagnosis of IgG4‐RLD relies on histopathological analysis. The key morphological features are dense lymphoplasmacytic infiltrates with collagenised fibrosis and active fibroblastic proliferation.The mainstay treatment for IgG4‐RLD is corticosteroid therapy, and most patients have favourable response in 2 weeks. The usual dose for oral prednisone is between 0.6 and 1 mg/kg/day, and then gradually tapered every 2–4 weeks to maintain a dose of 2.5–5 mg/day and then discontinued within 3 years. For steroid‐refractory patients, immunosuppressants or anti CD20 antibody can be considered.As the worldwide COVID‐19 vaccination continues to accelerate, it is probable to see more autoimmune events. However, due to reporting bias and pre‐existing undiagnosed autoimmune lung disease, true incidence of IgG4‐RLD will be difficult to determine. As multiple doses of vaccines are now being offered, close observation will be needed. Anyone with rapidly progressive lung or pleural disease after COVID 19 vaccine, more aggressive approach for diagnosis is recommended so diseases such as IgG4‐RLD cannot be missed and prompt treatment can be started to mitigate this disease.The authors listed above were involved in taking consent from the patient, writing the manuscript and reviewing the manuscript.None declared.The authors declare that appropriate written informed consent was obtained for the publication of this manuscript and accompanying images.


Background: According to the Centers for Disease Control and Prevention, the single most important factor leading to the development of antibiotic resistance (AMR) is the use of antibiotics. Studies indicate that up to 50% of hospitalized patients receive at least 1 antibiotic, half of which are inappropriate. The outpatient setting accounts for >60% of antibiotic use and over half of these prescriptions are inappropriate. Antibiotic stewardship programs improve appropriate antibiotic use, reduce AMR, decrease complications of antibiotic use, and improve patient outcomes. Building a nursing workforce with necessary AMR and antibiotic stewardship knowledge and skill is critical. Nursing graduates can translate knowledge into practice, promoting the judicious use of antibiotics to keep patients safe from antibiotic harm. Methods: Third-year baccalaureate nursing students enrolled in a fall 2020 health promotion course at an urban university affiliated with an academic medical center participated. Students received a 3-hour lecture on antibiotics, AMR and antibiotic stewardship nursing practices and actively engaged in antibiotic stewardship simulations using standardized patient (SP) encounters. The SP participants were specifically trained for these activities. Simulations included a 30-minute brief before and a 60-minute briefing after the activities. All activities occurred via video conferencing. Case scenarios, developed by the authors, focused on penicillin-allergy delabeling of an adolescent prior to elective surgery and appropriate use of antibiotics in managing pediatric urinary tract infections and acute otitis media (AOM). Before-and-after tests were used to assess the impact on AMR and antibiotic stewardship knowledge. Results: Over a period of 4 days, all enrolled students (n = 165) participated in 1 three-hour virtual simulation session. Using Zoom video conferencing with multiple breakout rooms, the activities were easily managed. During the simulations, students often struggled with reading an antibiogram and applying the concept of “watchful waiting” in AOM management. Significant differences were found in before-and-after test results, with significant improvement in students’ general and specific knowledge and awareness of antibiotics (P < .01). During the debriefing sessions, students reported increased awareness related to their role in advancing the judicious use of antibiotics. Conclusions: Initially, we planned to conduct in-person SP simulations. Due to the COVID-19 pandemic, faculty and students demonstrated remarkable flexibility and resilience as we successfully converted to a virtual format. Virtual lecture and SP simulations, followed by debriefing, was an effective approach to educate baccalaureate nursing students about AMR and their role in antibiotic stewardship. Areas for course content improvement were identified.Funding: NoDisclosures: None


Antibiotic contamination of animal food sources is an important public health problem between animals and humans; milk is an important source of protein for people and one of the foods with antibiotic residues. Antibiotics residues in milk often come from antibiotic treatment of cow mastitis. Through a questionnaire survey study, we found that farmers on most smallholder farms have poor awareness of stewardship and disease management. Some farmers cannot accurately answer the types and usage of antibiotics. Our study also showed that there was a big gap in management between large and smallholder farms in Southwest China, which is the main reason for the prevalence of mastitis in dairy cows and the antibiotic residue rate in bulk tank milk. Our results suggest that dairy farmers need to improve their knowledge of dairy cow diseases and antibiotic use; for non-professional farmers, we recommend listening to the treatment options provided by a professional veterinarian.Bovine mastitis could reduce the milk production and the quality of the bulk tank milk (BTM). Antibiotic treatments through intramammary or parenteral methods are being widely used in dairy farms. A cross-sectional study to investigate for general farm management and pre-test the questionnaire was performed in Southwestern Yunnan province, China. A total of 134 dairy farms were included. Milking cows of each farm were determined for the presence of clinical (CM) and sub-clinical (SCM) mastitis using the California Mastitis Test (CMT). Rates of CM and SCM in studied farms ranged from 2–11%, and 24–69%, respectively. The incidence of antibiotic residues in BTM of all farms was very high . All antibiotic contaminated samples were from smallholder dairy farms. Factors significantly associated with the presence of antibiotic contamination included farm region, antibiotics usage, persons performing mastitis treatment, and rates of CM. Rates of CM were significantly associated with the farm region, cleanliness of udders before milking, and the number of milking cows. Our results emphasize that the risk factors of dairy farm management should be paid attention, which can reduce mastitis prevalence and antibiotic contamination in BTM in Southwestern China. Bovine mastitis is defined as an inflammation of the mammary glands of dairy cows ,2. It caBovine mastitis can lead to a decrease in milk production and early culling of dairy cows . In the Antibiotic residues in milk usually come from the antibiotics used for the treatment of lactating cows ,13. ImprTherefore, controlling antibiotic contamination in milk should be prioritized. Since antibiotics in dairy farms are mostly used for treating bovine mastitis, we should begin by describing the association of high prevalence of bovine mastitis and the presence of antibiotic residues in milk. The levels of antibiotic residues in milk should be reduced when farmers recognize the importance of controlling antibiotic use in their farms through improving management to lower mastitis problems in their farms . The ultIn order to better control and monitor veterinary drug residues in food, the Ministry of Agriculture and Rural Affairs of China (MARA) has issued maximum residue limits (MRLs) for veterinary drugs in food in 2002 and made a revision in 2019. MARA issued regulations for the administration of antibiotics in 2004 and last amended them in 2018. The regulated MRLs for common antibiotics used in veterinary medicine in China include some common veterinary antibiotics in milk, such as β-Lactam, Sulfonamide, Tetracycline, Macrolide, and Aminoglycoside . China eSouthwest China is an underdeveloped area in China, and the per capita income is much lower than that of Eastern and Central China . There iA three-month cross-sectional study was operated in Yunnan, China  was generated through online EpiToolsA stratified random sampling of studied farms was performed based on management system , and farm size  using median number of milking cows, to sample 6 farms consisting of 3 company and 3 community farms. For the CMT criteria, in community farms, when a farmer has <10 cows test all, if a farmer has 10–50 cows test 50%, if a farmer has 50–100 cows test 20%, if a farmer has >100 cows test 10%. For a company, test 10%. A total of 745 samples were obtained.A questionnaire was designed for an interviewer survey to collect farm data. General farm data were collected by face-to-face interviews. These data included farmer’s age, farmer’s name, farmer’s nationality, farmer’s education level and experience, knowledge of the farmer about subclinical mastitis, drugs used in farm, sick animal management, drug knowledge of farmer/worker, and antibiotic testing before selling milk. Management data associated with milking hygiene were collected by observation. These observed data included cleanliness of barn and pipeline milking system, and cleanliness of udders before milking. Udder cleanliness was scored based on the scoring chart described by Munoz . All datEach farm was determined for the numbers of clinical mastitis (CM) cows once per month in order to get an averaged number of CM cows per month. During visits, cows showing clinical signs of mastitis including udder swelling, udder firmness and warmness, and abnormal milk appearance with/without other systemic signs were observed and defined as clinical mastitis cows.All milking cows without any clinical signs on each farm were tested using the California mastitis test (CMT) during milking time to identify subclinical mastitis (SCM) cows. CMT was performed on each selected cow by mixing approximately 2 mL of quarter milk to the same volume of CMT reagent. Quarter milk with observed reaction of a small amount of viscous precipitate at the bottom of the testing plate was considered to be from a mastitis udder. Cows having at least 1 udder producing mastitis milk were defined as cows with subclinical mastitis.Bulk tank milk (BTM) from each farm was collected and tested monthly for a total of 3 times per farm to detect antibiotic residues. For smallholder dairy farms, composite milk samples from all milking cows were mixed to represent a BTM sample for each farm. For large-scale dairy farms, BTM was sampled directly from their cooling tanks. Fifty milliliters of BTM were collected at each visit. BTM samples were stored on ice and transported to the laboratory within 24 h.® SP-NT . Regarding the manual, 0.1 mL of BTM was added into the tube containing spores of Bacillus stearothermophilus, agar medium and bromocresol purple as a pH indicator. The tubes were incubated at 64 ± 2 °C for 3 h. Milk samples were considered positive when color change of the media was not observed. Tubes with color-changed media from purple to yellow were considered negative.Antibiotic residues in BTM were detected using DelvotestPrevalence of CM and SCM at the animal level was calculated (%). Detection rates (%) of antibiotic residues in BTM were calculated for each sampling. Incidence (%) of antibiotic residues in BTM for the 3-month period was calculated as follows:  × 100. Data analysis is described by a popular method in different sampling units, the odds ratio was used to find factor variables associated with statistically significant results. Statistical analysis version 3.0.3 R statistical software program were used to describe the relationship between dairy farm management and milk antibiotic risk factors. Logistic regression and multiple linear regression analyses were conducted using backward stepwise analysis in R statistical program . FactorsIn Yunnan province, the majority of dairy farms were smallholder dairy farms, which were usually grouped together in several dairy communities. A dairy community was composed of a number of smallholder dairy farms, and farmers are both the owners of the farms and farm workers. Most farmers were between 40 to 50 years old. Dairy farmers in this study had relatively low educational level or were uneducated. University graduates accounted for only 2% and worked in the standard farms . About hMost dairy farms (131 farms) purchased their cows from local providers. One farm imported their cows from New Zealand, and another farm imported their cows from Canada . All of Concerning the management of sick animals within the farms, most farmers did not have a system to identify sick and treated animals within the farms (66.41%) . In addiSmallholder dairy farms in dairy communities E and F had the highest prevalence of CM (11%). Lower prevalence of clinical mastitis was observed among large scale dairy farms (2% to 6%) compared to smallholder dairy farms (6% to 11%) . RegardiDetection rates of antibiotic residues in BTM for the 1st, 2nd, and 3rd samplings were 8.95%, 13.43% and 16.42%, respectively . All antAfter logistic regression analysis, 4 variables remained in the final logistic regression model: farm regions A-F, only use penicillin-streptomycin, the person performing mastitis treatment, and rates of clinical mastitis as shown in Some core attributes, for example, farmer productivity, management of sick animals, and treatment, are particularly weak aspects of the dairy production system of smallholder dairy farms in Yunnan. These three attributes not only influence the other attributes but also have long term implications for sustainability. Poor quality of animal management adversely affects milk productivity and hence the cost of milk production and productivity of other inputs. Thus, the formulation and planning of farm management strategies to improve the management of sick animals and animal treatment should be prioritized for the development of the dairy industry in Yunnan. Furthermore, to improve the farmer’s knowledge along scientific lines, development is required in the provisioning of adequate and quality livestock support services ,30.Farmworkers are essential for successful dairy farming. Without a reduction in the drudgery of their work, enhanced control over their financial resources, and their access to information regarding dairy farming, smallholder dairy farms will not be socially sustainable . There iLarge-scale dairy farms are very different from smallholder dairy farms in terms of their management, their clear vision of farming objectives, and their readiness to adopt new innovations to improve their farm management. This may be because large-scale dairy farms usually have at least one well-educated worker to lead and to design and control the productivity of the farm. Moreover, in large-scale dairy farms, the application of digital controls in monitoring the production of the entire farm and, potentially, a specific herd (mainly including reproduction and milking performance) offers the basic data for dairy herd improvement (DHI) ,33. ThisThe prevalence of clinical and subclinical mastitis in dairy farms in this study was quite high and was similar to that in several previous studies in China. For example, the prevalence of SCM in West China was 54.3% and the udder quarter basis was 54.3% . In SoutA higher prevalence of clinical and subclinical mastitis was observed in smallholder dairy farms compared to large-scale dairy farms. Based on our data, most smallholder dairy farmers did not have a system in place to identify sick and treated animals within the farms. Many sick cows and healthy cows can make contact with each other, and may consequently affect the spread of mastitis pathogens among cows in the farms . Moreove® SP, Triphenyltetrazolium chloride (TTC) method and Copan test. One study detected 40.8% antibiotic residue in pasteurized milk from Iran [Many studies had surveyed antibiotic residues in milk in different regions of the world using different methods, such as Delvotestrom Iran . A Serbirom Iran . A studyrom Iran . Anotherrom Iran . We repoStaphylococcus aureus isolated from Chinese patients in surveyed hospitals in 2009 were methicillin-resistant (MRSA) which was an increase from 40% in 2000 [Streptococcus pneumonia isolated from Chinese patients also showed a high rate, up to 70%, of resistance to macrolides [Escherichia coli are resistant to quinolones, which is the highest rate in the world [Antimicrobial-resistant bacteria are proliferating around the world . China i in 2000 . In addicrolides . Moreovehe world . These eThe current study hypothesized that farms with high rates of clinical mastitis can contribute to the high use of antibiotic treatment for mastitis, which consequently is associated with increased antibiotic contamination in BTM. From the analysis of our data set, this hypothesis was confirmed. We found that farms with high rates of clinical mastitis are prone to having antibiotics contaminating their BTM.®, none of the BTM of large-scale dairy farms was found to be contaminated with antibiotics. Only the BTM of smallholder dairy farms was found to be contaminated with antibiotics. We could not provide any evidence to explain this finding in the present study. However, the low rate of antibiotic residues in milk from large-scale dairy farms may be related to the low levels of bovine mastitis on dairy farms, which indicates a low chance of using antibiotics for treatment as previously described and found in this study [Different farm management systems seemed to influence the rates of antibiotic contamination in BTM. In the present study, using Delvotestis study ,50,51. TOther management factors related to antibiotic use on farms were also found to be associated with the presence of antibiotics in BTM in Yunnan. From both observation and interviewing, it was apparent that some farms had only penicillin/streptomycin in their farms, while some farms had penicillin/streptomycin and other antibiotics. The presence of antibiotic products indicates the use of these products on the farm. Farms using different kinds of antibiotics seemed to have a greater likelihood of antibiotic contamination in their BTM, as previously described . MoreoveIn conclusion, the prevalence of both clinical and subclinical mastitis in the studied dairy farms in Yunnan was quite high. Similarly, rates of antibiotic residues in BTM of the selected farms in Yunnan were high. We found a big difference in the management level of dairy farming between the two types of farms: large-scale and smallholder dairy farms, in Yunnan, China, which is one of the significant factors related to both antibiotic residues in BTM and clinical mastitis. Our data set also indicates that farms with higher rates of clinical mastitis and which have farmers performing mastitis treatment are likely to have antibiotic residues in BTM. Therefore, prudent use of antibiotics in dairy farms, under the supervision of veterinarians, should be promoted in Yunnan, China.


While there is growing global concern about the impact of antibiotic residues on emergence and enhancement bacteria’s resistance, toxicity to natural organisms, and, ultimately, public health, a concise picture of measured environmental concentrations of antibiotic occurrence in multiple environmental matrices, particularly in solid matrices  is still elusive, especially for China. In this paper, we present an up-to-date dataset of the distribution of antibiotic occurrence in solid environmental matrices in China, derived from 210 peer-reviewed literature published between 2000 and 2020. We extracted geographical sampling locations and measured concentration associated with antibiotic occurrence reported in English and Chinese original publications, and applied quality-control procedures to remove duplicates and ensure accuracy. The dataset contains 6929 records of geo-referenced occurrences for 135 antibiotics distributed over 391 locations distinguished at four levels of scale i.e., provincial, prefectural, county, and township or finer. The geographical dataset provides an updated map of antibiotic occurrence in solid environmental matrices in China and can be used for further environmental health risk assessment.  Due to the low metabolic rate of humans and livestock, antibiotics are mainly excreted via urine and faeces4, and can migrate to effluent and sludge from domestic wastewater treatment plants (WWTPs), hospitals, and livestock farms either in their original form or in different metabolites5. A large fraction of these residual antibiotics has the potential to enter into solid environmental matrices through wastewater discharge, reclaimed water irrigation, and utilisation of animal manure and WWTP sludge as fertiliser in agriculture7. Contamination by residual antibiotics in municipal sludge10, soil14, and sediments17 has risen serious concerns, especially about antibiotic resistance, on its ultimate harm to public well-being and ecosystem health20. There is an urgent need to disclose the current pattern and environmental fate of antibiotics to better assess the risk of sewage discharge and future agricultural use of sludge products.Since the advent of penicillin in 1929, antibiotics have been widely used as effective disease prevention treatments and animal growth promoters21. Several recent studies have reviewed and compiled the occurrence records of antibiotics in China, with foci on aquatic environment25, soil30, or WWTPs31. There is a lack of a comprehensive and systematic description of the geographic distribution of antibiotic occurrence in the solid environmental matrices in China, especially for municipal sludge, thus far, with Wang et al.32, Lyu et al.2, and Huang et al.6 being notable exceptions. Furthermore, as existing antibiotic-related datasets were on a coarse spatial resolution at the province-2 or basin-level20, a dataset with more detailed geographic information at finer scales would be promising for pinpointing regions at risk and modelling exercises towards environment and health management practices.China has the world’s largest market of antibiotic products and consumes more than 25,000 tons antibiotics each yearThis paper presents an up-to-date dataset of the distribution of antibiotic occurrence in solid environmental matrices in China. The dataset described here comprises 6929 geo-referenced antibiotic occurrence records of 135 antibiotics in sludge, soil and sediments reported in 210 peer-reviewed publications from 2000 to 2020, covering 391 locations across China. The hotspots of antibiotic occurrence records are mainly located in the densely populated and economically prosperous regions of China, such as the Bohai Bay region, Beijing‒Tianjin‒Hebei region, Yangtze River Delta, and Pearl River Delta. Most studies focused on sediment and soil, while a limited number of studies (31 publications) have investigated municipal sludge. The top ten most frequently reported antibiotics are oxytetracycline, tetracycline, ciprofloxacin, sulfadiazine, sulfamethazine, norfloxacin, ofloxacin, sulfamethoxazole, roxithromycin, and enrofloxacin. The median values of antibiotic concentrations in the municipal sludge (15.30 μg/kg) are one to two orders of magnitude higher than that of soil (1.00 μg/kg) and sediments (0.40 μg/kg). In the future research, there is an essential need to strengthen surveillance of antibiotics over a broader geographical region, especially in southwest and northwest China.https://www.webofscience.com/), the Scopus (https://www.scopus.com/), the PubMed (https://pubmed.ncbi.nlm.nih.gov/), and China National Knowledge Infrastructure (CNKI) (http://www.cnki.net/), respectively. A preliminary literature search disclosed that a significant number of antibiotic-related studies in China have been published after 2000. Therefore, we used the timeframe from January 2000 to November 2020. The keywords used for searching were (antibiotic* AND (soil OR sludge* OR biosolid* OR sediment*) AND China) with WOS, (antibiotic AND soil OR sludge OR biosolid OR sediment AND china) with Scopus, ((soil OR sludge OR biosolid OR sediment) AND antibiotic AND China) with PubMed, and (抗生素 * 中国 * (土壤 + 污泥 + 底泥 + 沉积物)) with CNKI. No language restrictions were placed on these searches.Our screening steps and selection criteria for literature review are outlined in Fig. 2O, sulfadiazine, sulfadimidine, sulfamethoxazole, and chloramphenicol in municipal sludge at four sewage treatment plants in the Pearl River Delta33. The earliest article in Chinese was published in 2008, which reported five sulfonamides antibiotics in the soil in the Pearl River Delta34. In recent years, the number of publications of antibiotic occurrences in sludge, soil, and sediments has increased rapidly . We firstly checked through publications to eliminate duplicates. Secondly, abstracts of the remaining publications were examined and we excluded publications which only describe antibiotic resistant bacteria or antibiotic resistance genes not measured antibiotic concentration, or which only focus on human or organism not selected environment matrices. This resulted in 489 papers being selected for full-text review and further extraction of location and concentration information of antibiotic occurrence. Thirdly, having intensively read all the available full-texts, the publications which failed to report details of occurrence data and geographical information were further excluded, and finally, 210 publications were identified to be eligible for extraction. The very first study was published in 2007 in Water Research, and reported the concentration of ofloxacin, norfloxacin, roxithromycin, erythromycin-H36. The measured concentrations presented here were converted to the standardized units (μg/kg or ng/g). Four concentration values of each antibiotic were summarised in the dataset, including the maximum, minimum, mean, and median measured concentrations wherever available. It is worth noting that many studies on pharmaceutical residues in environmental matrices often target hotspots, resulting in measured concentrations outside of normal ranges. To facilitate potential users to distinguish these extreme values, the possible outliers in the concentration records were detected using the Tukey’s test37 and flagged in the dataset. Finally, 6929 records of occurrences of 135 antibiotics were compiled, of which 1397 records occurred in soil, 4948 in sediments, and 584 in municipal sludge. Antibiotics detected in solid environmental matrices were classified into the following categories: sulfonamides , tetracyclines , fluoroquinolones , macrolides , and β-lactams  as well as other . Detailed information on the antibiotics included in this study was listed in Supplementary Table The key information extracted from the literature includes: (i) geographical location associated with antibiotic occurrence in sludge, soil, and sediments , (ii) information on the antibiotics examined , (iii) concentration reported in standardized units , (iv) sampling time, and (v) detection methods. It is common that an article reports several antibiotics at different locations and/or different time, and these records were separated so that each record in our dataset represents an occurrence of an antibiotic in a location reported in a specific time by an author. Concentrations that were reported as “not detected” or “below detection limit” were entered as “ND” , using the similar approach adopted in a recent meta-analysis on the antibiotics found in global lakeset al.38, we determined the latitudinal and longitudinal coordinates using Web APIs (Application Programming Interfaces) to access georeference functions of the most commonly used online location services in China, namely, Baidu Map (https://map.baidu.com/) and Amap (https://www.amap.com/). We searched keywords related to the location of each record, for example, the name of specific geographical objects, administrative regions, or water bodies, and recorded the latitude/longitude information. When only maps of the sampling sites were provided, we approximated rough coordinates through visual interpretation, mapped these records on Baidu Map or Amap, and then adjusted the coordinates according to the geographical characteristics of the original maps. In total number of 389 geographical locations were identified. Based on the level of geographical details, these locations were further classified into four different levels , which could help potential users of this dataset extract proper sections to use. Finally, the distribution of the reported antibiotic occurrence was visualized using ESRI ArcGIS 10.7 .Unless the coordinates of sampling locations were provided, information on the geographical location needed to be extracted from the texts, tables, figures, and supplemental materials of the original publication. Following Zhang .7 Figs. , 5. The 35), each of the rows represents a single record (an occurrence of an antibiotic in a location as reported in a specific year by a reference). The 25 columns of this dataset are explained as follows:sem_type: the type of solid environmental matrices .lon: the longitude of the location of antibiotic occurrence (WGS1984 Datum).lat: the latitude of the location of antibiotic occurrence (WGS1984 Datum).loc_level: the level of geographical details .loc_l1: provincial level information of the location .loc_l2: prefectural level information of the location .loc_l3: county level information of the location .loc_l4: township or finer level information of the location.loc_ref: supplemental geographical information of the location .ABX_cat: the categories of antibiotics .ABX_subcat: full name of antibiotic subcategories.ABX_subcat_abbre: abbreviation of antibiotics subcategories.ABX_subcat_CAS: the CAS  number of antibiotics subcategories.smp_Y: the year of sampling.smp_M: the month of sampling.ABX_conc_max: maximum measured concentration of antibiotics (unit: μg/kg).ABX_conc_min: minimum measured concentration of antibiotics (unit: μg/kg).ABX_conc_mean: mean measured concentration of antibiotics (unit: μg/kg).ABX_conc_median: median measured concentration of antibiotics (unit: μg/kg).ABX_conc_mean_flag: if the mean measured concentration of antibiotics is a possible outlier, flag as 1, otherwise flag as 0.ABX_dtm: abbreviation of analytical method employed (LC-MS/MS (Liquid chromatography-tandem mass spectrometry), HPLC-MS/MS (High performance liquid chromatography-tandem mass spectrometry), UPLC-MS/MS (Ultra performance liquid chromatography-tandem mass spectrometry), RRLC-MS/MS (Rapid Resolution Liquid Chromatography-tandem mass spectrometry), etc.).pub_year: the year of the publication.pub_id: identification number of references.pub_full: references identified for data extraction.In the dataset of distribution of antibiotic occurrence in solid environmental matrices in China  which had not been made identifiable from any online location services. Moreover, some articles only provided fine-level maps of sampling sites without any latitudinal and longitudinal grid, nor any geographical information which could enable visual interpretation. Furthermore, some studies focused on rivers or basins spanning across multiple administrative regions. It thus made it necessary to include the ‘loc_level’ and ‘loc_ref’ fields in the dataset, so that the readers are aware of our confidence in the spatial precision of each record.The spatial distribution of antibiotic occurrence in solid environmental matrices in China was shown in Figs 17. The highest measured concentration of Macrolides was detected in municipal sludge in Wuxi, Jiangsu province, with an average concentration of 6890.95 μg/kg39. The highest measured concentration of Tetracyclines was detected in municipal sludge in Shijiazhuang, Hebei province, with an average concentration of 4063 μg/g40. The highest measured concentration of β-lactams was detected in sediments in the Ba River , with an average concentration of 43.00 μg/kg41. The highest measured concentration of Sulfonamides and Other were both detected in sediments in the Dagu Drainage River (Tianjin), with an average concentration of 4639.05 μg/kg and 5465.95 μg/kg, respectively42.The concentration levels of the six antibiotic subcategories varied with different solid environmental matrices Table . The hig21, the resulting maps of antibiotic occurrence as depicted in Figs. 21, except for the occurrence of antibiotics in soil. According to the research of Chen et al.2, there were no records of antibiotic occurrence in at least 15 provinces including Anhui, Henan, and Guangxi. However, in our dataset, the occurrence of antibiotics in soil has been widely reported, except for Hunan and four provinces in northwest China. Therefore, our study provides a more comprehensive picture of measured environmental concentrations of antibiotic occurrence in solid environmental matrices.Compared our dataset with the existing studiesOur results show that antibiotics are ubiquitously presented in the solid environmental matrices in China. Being aware of the distribution of antibiotics is fundamental to support decision and direct actions to prevent and manage relevant pollutant emissions. The dataset described here could contribute to a more complete picture of the distribution of the reported antibiotic occurrences in the solid environmental matrices in China. The dataset is suitable to be used to investigate the spatio-temporal dynamics of antibiotic distribution at multiple scales. It can also be applied in the environmental and health risk assessment to identify potential sources of pollutants. The dataset has been designed so that potential users  can easily filter or aggregate the dataset for their different investigation purposes.43 or the liquid chromatography fluorescence detection (LC-FLD)44. Most of the recent studies utilized the high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) system48, which is more efficient than only using the parent ions as in LC-MS analysis36.It should be noted that the literature reviewed in this study adopted different methods for antibiotic identification and quantification, which may have introduced background uncertainty. For example, some early detection of antibiotics adopted the liquid chromatography-mass spectrometry (LC-MS)Supplementary Information


Identifying opportunities to safely reduce antibiotic prescribing is necessary for prescribers and antibiotic stewardship teams to minimise unwarranted antibiotic use. We aimed to quantify excess antibiotic use in General Surgery. We retrospectively audited the antibiotic prescribing for patients discharged from the General Surgery specialty in an acute hospital in the south-west of England for one month using an audit tool developed by Public Health England. The appropriateness of prescribing was determined for each patient at three antibiotic decision time-points: at initiation, the pre-72-h antibiotic review, and treatment duration. Two infection specialists and a general surgeon reviewed each patient. Indication and excess days of therapy (DOTs) were calculated at each decision time-point and expressed as a proportion of total DOTs. Eighty-six patients were prescribed 1162 DOTs; 192 (16.5%) excess DOTs were prescribed in 38 patients (44%), with zero excess days identified in the remaining 48 patients (56%). Seventy-five of 192 (39%) excess DOTs occurred at initiation; 55/192 (29%) after the pre-72-h antibiotic review; and 62/192 (32%) due to protracted antibiotic courses. There was concordance between the general surgeon and infection specialist for most apportioned excess DOTs. However, the surgeon apportioned fewer excess DOTs 160/1162 (13.8%). Overall IV antibiotics accounted for 53.4% of total DOTs. Seventy-two of 86 (83.7%) patients received 620 intravenous DOTs; of these, 79 (12.7%) IV DOTS were unnecessary. We have identified excess antibiotic prescribing in General surgery with comparable excess DOTs at all three time-points. Antimicrobial use drives antimicrobial resistance (AMR), a global problem that impacts all countries and all people, regardless of their wealth or status and is expected to result in approximately 10 million deaths each year globally by 2050 if no action is taken .Antibiotic use per occupied bed-day in English hospitals varies by up to 15-fold . AlthougThe Study objectives were (1) to quantify excess antibiotic use in general surgery, measured as excess days of antibiotic therapy (DOTs) at three key time points: at initiation of antibiotics, at the pre-72-h antibiotic review, and course length, and (2) quantify excess IV antibiotic use.Two hundred and fifty patients were discharged from general surgery in August 2021 and were prescribed antibiotics. Of these, 39 (15.5%) patients were excluded because they were either prescribed STAT doses only or did not receive the prescribed antibiotics. Patients receiving STAT doses were excluded as these represented surgical prophylaxis and not assessed within the study. Of the remaining 211 patients, eighty-six (40.8%), with similar number of patients from each of the audit weeks, were audited.Forty of 86 (46.5%) were female with a median age of 56 years (Interquartile Range 41–67 years). The 86 patients received 1162 DOTs with a mean of 13.5 DOTs per patient (range 1–122 days). The mean antibiotic course length per patient was 7.9 days (range 1–56 days). Of 86 infection diagnoses, 70 (86%) were surgical infections; see After the first round of review , 223 of 1162 DOTs (19.2%) were deemed excess. After the second round of review (Consultant Surgeon (MH) and infection team representative (NP) consensus), of the 223 identified excess days; 160 were agreed upon; MH argued from a surgical perspective that 63 DOTs did not represent excess days. On further discussion NP agreed, upon reflection from an infection perspective, that 31 of these 63 DOTs could be considered not to be excess but that 32 of the 63 DOTs did still represent excess DOTs. After these discussions, 192 DOTs of 1162 (16.5%) were deemed excess days with a potential lower estimate of 160/1162 (13.8%); see The 192 excess DOTs were prescribed in 38 patients (44%), with zero excess days identified in the remaining 48 patients (56%). Seventy-five of 192 (39%) DOTs occurred at initiation; 55/192 (29%) at the pre-72 h antibiotic review; and 62/192 (32%) due to protracted antibiotic courses.The 75 excess DOTs which occurred at the initiation of antibiotic therapy were prescribed in 9 of the 86 patients (10.5%). Of these, antibiotics were not indicated from the outset in 4 patients, resulting in 22 excess DOTs and in the remaining 5 patients, antibiotics were indicated at the outset, but excess DOTs were recorded due to other reasons  and resulted in 53 excess DOTs. There was discordance in agreement between infection specialists and surgeon for two patients resulting in 8 excess DOTs .Antibiotics were stopped appropriately for 26 of 86 (30.3%) patients at a pre-72-h antibiotic review. In 50 of 86 (58.1%) patients, antibiotics were appropriately continued beyond the pre-72 h review. The remaining 10 of 86 (11.6%) patients, inappropriate continuation of antibiotic therapy resulted in 55 excess DOTs. In 9 of the 10 cases (90%), patients’ antibiotics were continued beyond the pre-72 h review when they could have been stopped entirely, resulting in 52 excess DOTs. In the remaining patient (10%), the continuation of antibiotics was deemed appropriate but there was a missed opportunity to reduce the number of antibiotic agents being used, resulting in 3 excess DOTs.There was discordance in agreement between infection specialists and surgeon for one patient resulting in 4 excess DOTs .Antibiotics were not indicated past the standard course length for 18 patients and resulted in 61 excess DOTs. Antibiotics were indicated beyond the standard course length for one patient but resulted in 1 excess DOT due to unnecessary prolongation. There was discordance in agreement between infection specialists and surgeon for two patients resulting in 20 excess DOTs .72 of 86 (83.7%) patients received 620 intravenous DOTs; IV antibiotics accounted for 53.4% of total DOTs. Of these, 79 (12.7%) IV DOTS were excessive.16 of 79 (20.3%) excess IV DOTs were on initiation where an antibiotic was appropriate, but the oral route would have been more appropriate (3 patients). Of the 47/79 (59.5%) at the pre-72-h antibiotic review (13 patients), 26 IV DOTs (32.9%) in 4 patients would have been more appropriate via the oral route; the remaining 16/79 (20.3%) was due to protracted course lengths where antibiotics were deemed unnecessary (1 patient).We have used a Public Health England (PHE) developed antibiotic appropriateness assessment tool, with infection specialists and consultant surgeon adjudication to identify that, even in an NHS trust considered a low antibiotic user overall there is still room for improvement as 16.5% of antibiotic prescribing in General Surgery was excess and therefore unnecessary. While excess DOTs occurred evenly across all three timepoints, the greatest proportion occurred at initiation of antibiotics (39%), with similar excess antibiotic DOTs occurring at the pre-72 h review (32%) and antibiotic course length (29%). Overuse of antibiotics for surgical patients has been reported by others ,9. InappAntibiotics were stopped appropriately for almost a third of patients (30.3%) at a pre-72-h antibiotic review. Despite this relatively high stop rate, we estimate this could potentially be increased to 40%, in-line with the pre-72-h antibiotic stop rate achieved by others, and similar to the potential stop rate in medical specialties within the same hospital ,14. InapProtracted course lengths account for a third of excess DOTs. Protracted course lengths put those treated with antibiotics at an increased risk of future resistant infections . AntibioJust over half the DOTs were IV of which 12.7% were found to be unnecessary. Lack of adequate GI absorption may warrant IV therapy in patients undergoing GI surgery, however less than half of patients receiving antibiotics in surgical specialities undergo surgery and therefore the high IV therapy may not be adequately explained by poor GI absorption . DefensiWe have identified opportunities to reduce antibiotic prescribing at all stages of the prescribing process. Empowering clinical pharmacists to challenge antibiotic prescribing in General Surgery, challenging protracted course lengths, and promoting early IV to oral switching may optimise antibiotic prescribing. Peer support and shared decision making may also increase appropriateness of antibiotic of prescribing, but optimising antibiotic prescribing is challenging ,19. IdenDecisions on appropriateness were made on the information available to the prescriber at the time of prescribing using the information recorded in the medical notes and the available electronic sources: pathology, radiology, and observations. Auditors did have sight of subsequent observations and clinical test results, but these were not used to guide auditor decisions at each point of the prescribing process as they were not known to the prescriber at the time. Assessment of appropriateness is potentially subjective and so the determinations of appropriateness were made by two infection specialists until agreement sought, and then discussed with the Consultant Surgeon which adds validity to our findings. The surgeon and infection specialists largely agreed with the apportion of excess DOTs but some disagreement between infection specialists and the consultant surgeon did remain, although only in a small proportion of patients. This is a single centre study that reviewed only a proportion of patients in one month and therefore the results may not be representative of annual prescribing practices within general surgery nor generalisable to other hospitals. This study was conducted in a 750-bed acute secondary care hospital in the south-west of England with an electronic prescribing and medication administration system , Basildon, UK) deployed in all inpatient areas. The study hospital  is a low antibiotic using hospital and ranked in the lowest quintile .NHS ethics approval was not required as the study did not meet the Health Research Authority definition for research or the requirements for NHS Research Ethics Committee approval. Patient data was used in accordance with local NHS hospital policy. In November 2021, pharmacy data analysts used the EPMA system to identify patients who were discharged from the General Surgery specialty in August 2021 and who had received at least one dose of an antibiotic. Patients administered only a single dose or did not receive the prescribed antibiotics were excluded. Patients were grouped by week of discharge from hospital and every third patient discharged that week was included in the study; proving a number of patients that were able to audit with the available resource. Consultants rotate each week which introduces potential for variation in prescribing practices. Weekly sampling was chosen to reduce this potential bias. Junior doctors and antibiotic pharmacists were invited by email to participate in the data collection. Auditors were asked to read the “DEFINING AND MEASURING “APPROPRIATE” ANTIBIOTIC PRESCRIBING—A BRIEFING FOR AUDITORS” document  to ensurThe audit form  facilitaTwo infection specialists, (NP) and , discussed each case in turn and reached consensus on excess antibiotic use. Excess antibiotic use was defined broadly as (1) Prescribing an antibiotic for a patient in the absence of (documented) evidence of signs and symptoms in keeping with a possible bacterial infection or (2) Continuing an antibiotic prescription without on-going evidence of infection (3) Continuing an antibiotic beyond the course length recommended in local or national guidelines, in the absence of a (documented) rationale” (as defined in the “Briefing for Auditors” guide ). ExcessMedian and interquartile range (IQR) were used for age. Days of therapy (DOTs) and antibiotic course lengths were determined for each patient and presented as a mean and a range.This study has identified several opportunities to reduce antibiotic use in General Surgery using an audit tool developed by infection specialists. The greatest opportunity to safely reduce antibiotic use was at the initiation of antibiotic stage, although there were comparable rates across all three time-points in the prescribing process.The use of this tool has demonstrated the need and opportunity for developing further multidisciplinary effort at the time of antimicrobial prescribing decisions in surgery.