{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,26]],"date-time":"2025-12-26T22:27:12Z","timestamp":1766788032225},"reference-count":34,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,11,22]],"date-time":"2022-11-22T00:00:00Z","timestamp":1669075200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,11,22]],"date-time":"2022-11-22T00:00:00Z","timestamp":1669075200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Prim. Care"],"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Little is known about the pattern and appropriateness of antibiotic prescriptions in patients with acute respiratory tract infections (ARTIs).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Objective<\/jats:title>\n                <jats:p>Describe the antibiotics used to treat ARTIs in Tunisian primary care offices and emergency departments (EDs), and assess the appropriateness of their use.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>It was a prospective multicenter cross-sectional observational clinical study conducted at 63 primary care offices and 6 EDS during a period of 8\u00a0months. Appropriateness of antibiotic prescription was evaluated by trained physicians using the medication appropriateness index (MAI). The MAI ratings generated a weighted score of 0 to 18 with higher scores indicating low appropriateness. The study was conducted in accordance with the Declaration of Helsinki and national and institutional standards. The study was approved by the Ethics committee of Monastir Medical Faculty.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>From the 12,880 patients screened we included 9886 patients. The mean age was 47.4, and 55.4% were men. The most frequent diagnosis of ARTI was were acute bronchitis (45.3%), COPD exacerbation (16.3%), tonsillitis (14.6%), rhinopharyngitis (12.2%) and sinusitis (11.5%). The most prescribed classes of antibiotics were penicillins (58.3%), fluoroquinolones (17.6%), and macrolides (16.9%). Antibiotic therapy was inappropriate in 75.5% of patients of whom 65.2% had bronchitis. 65% of patients had one or more antibiotic prescribing inappropriateness criteria as assessed by the MAI. The most frequently rated criteria were with expensiveness (75.8%) and\u00a0indication (40%). Amoxicillin-clavulanic acid and levofloxacin were the most inappropriately prescribed antibiotics. History of cardiac ischemia ([OR] 3.66; 95% [CI] 2.17\u201310.26; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), asthma ([OR] 3.29, 95% [CI] 1.77\u20136.13; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001), diabetes ([OR] 2.09, 95% [CI] 1.54\u20132.97; <jats:italic>p<\/jats:italic>\u2009=\u20090.003), history of COPD ([OR] 1.75, 95% [CI] 1.43\u20132.15; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001) and age\u2009&gt;\u200965\u00a0years (Odds Ratio [OR] 1.35, 95% confidence interval [CI] 1.16\u20131.58; <jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001) were associated with a higher likelihood of inappropriate prescribing.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>Our findings indicate a high inappropriate use of antibiotics in ARTIs treated in in primary care and EDs. This was mostly related to antibiotic prescription in acute bronchitis and overuse of expensive broad spectrum antibiotics. Future interventions to improve antibiotic prescribing in primary care and EDs is needed.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Trial registration<\/jats:title>\n                <jats:p>the trial is registered at Clinicaltrials.gov registry (NCT04482231).<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12875-022-01904-7","type":"journal-article","created":{"date-parts":[[2022,11,23]],"date-time":"2022-11-23T07:02:07Z","timestamp":1669186927000},"update-policy":"http:\/\/dx.doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Appropriateness of antibiotic treatment of acute respiratory tract infections in Tunisian primary care and emergency departments: a multicenter cross-sectional study"],"prefix":"10.1186","volume":"23","author":[{"given":"Khaoula","family":"Bel Haj Ali","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adel","family":"Sekma","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Selma","family":"Messous","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Imen","family":"Trabelsi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jalel","family":"Ben Youssef","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hamida","family":"Maghraoui","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rabie","family":"Razgallah","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adel","family":"walha","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamed Habib","family":"Grissa","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kaouthar","family":"Beltaief","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zied","family":"Mezgar","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ahmed","family":"Coubantini","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wahid","family":"Bouida","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamed Amine","family":"Msolli","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Riadh","family":"Boukef","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hamdi","family":"Boubaker","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Semir","family":"Nouira","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2022,11,22]]},"reference":[{"issue":"1","key":"1904_CR1","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1093\/jac\/dkt301","volume":"69","author":"DJ Shapiro","year":"2014","unstructured":"Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007\u201309. J Antimicrob Chemother. 2014;69(1):234\u201340.","journal-title":"J Antimicrob Chemother"},{"issue":"9","key":"1904_CR2","doi-asserted-by":"publisher","first-page":"764","DOI":"10.1136\/bmjqs.2010.049049","volume":"20","author":"N Adriaenssens","year":"2011","unstructured":"Adriaenssens N, Coenen S, Tonkin-Crine S, Verheij TJM, Little P, Goossens H, et al. European Surveillance of Antimicrobial Consumption (ESAC): disease-specific quality indicators for outpatient antibiotic prescribing. BMJ Qual Saf. 2011;20(9):764\u201372.","journal-title":"BMJ Qual Saf"},{"issue":"5","key":"1904_CR3","doi-asserted-by":"publisher","first-page":"930","DOI":"10.1093\/jac\/dki283","volume":"56","author":"AE Akkerman","year":"2005","unstructured":"Akkerman AE, Kuyvenhoven MM, van der Wouden JC, Verheij TJM. Determinants of antibiotic overprescribing in respiratory tract infections in general practice. J Antimicrob Chemother. 2005;56(5):930\u20136.","journal-title":"J Antimicrob Chemother"},{"issue":"10","key":"1904_CR4","doi-asserted-by":"publisher","first-page":"e006245","DOI":"10.1136\/bmjopen-2014-006245","volume":"4","author":"MC Gulliford","year":"2014","unstructured":"Gulliford MC, Dregan A, Moore MV, Ashworth M, van Staa T, McCann G, et al. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open. 2014;4(10):e006245.","journal-title":"BMJ Open"},{"issue":"6","key":"1904_CR5","doi-asserted-by":"publisher","first-page":"757","DOI":"10.1086\/322627","volume":"33","author":"R Gonzales","year":"2001","unstructured":"Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis. 2001;33(6):757\u201362.","journal-title":"Clin Infect Dis"},{"issue":"4","key":"1904_CR6","doi-asserted-by":"publisher","first-page":"273","DOI":"10.1001\/jamainternmed.2013.1984","volume":"173","author":"JA Linder","year":"2013","unstructured":"Linder JA. Antibiotic Prescribing for acute respiratory infections\u2013success that\u2019s way off the mark: comment on \u00ab\u202fA cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis\u202f\u00bb. JAMA Intern Med. 2013;173(4):273\u20135.","journal-title":"JAMA Intern Med"},{"issue":"8","key":"1904_CR7","doi-asserted-by":"publisher","first-page":"e00337","DOI":"10.1128\/AAC.00337-18","volume":"62","author":"NR Shively","year":"2018","unstructured":"Shively NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother. 2018;62(8):e00337-e418.","journal-title":"Antimicrob Agents Chemother"},{"issue":"17","key":"1904_CR8","doi-asserted-by":"publisher","first-page":"1864","DOI":"10.1001\/jama.2016.4151","volume":"315","author":"KE Fleming-Dutra","year":"2016","unstructured":"Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010\u20132011. JAMA. 2016;315(17):1864\u201373.","journal-title":"JAMA"},{"issue":"3","key":"1904_CR9","doi-asserted-by":"publisher","first-page":"1451","DOI":"10.1128\/AAC.02039-13","volume":"58","author":"JP Donnelly","year":"2014","unstructured":"Donnelly JP, Baddley JW, Wang HE. Antibiotic utilization for acute respiratory tract infections in U.S. emergency departments. Antimicrob Agents Chemother. 2014;58(3):1451\u20137.","journal-title":"Antimicrob Agents Chemother."},{"key":"1904_CR10","doi-asserted-by":"publisher","first-page":"388","DOI":"10.1111\/j.1939-7445.2011.00114.x","volume":"25","author":"K Kaier","year":"2012","unstructured":"Kaier K. Economic modeling of the persistence of antimicrobial resistance. Nat Res Model. 2012;25:388\u2013402.","journal-title":"Nat Res Model"},{"issue":"10","key":"1904_CR11","doi-asserted-by":"publisher","first-page":"973","DOI":"10.1111\/1469-0691.12798","volume":"20","author":"S Gandra","year":"2014","unstructured":"Gandra S, Barter DM, Laxminarayan R. Economic burden of antibiotic resistance: how much do we really know? Clin Microbiol Infect. 2014;20(10):973\u201380.","journal-title":"Clin Microbiol Infect"},{"key":"1904_CR12","doi-asserted-by":"publisher","first-page":"b2242","DOI":"10.1136\/bmj.b2242","volume":"338","author":"CC Butler","year":"2009","unstructured":"Butler CC, Hood K, Verheij T, Little P, Melbye H, Nuttall J, et al. Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries. BMJ. 2009;338:b2242.","journal-title":"BMJ"},{"issue":"1","key":"1904_CR13","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1080\/02813432.2017.1288680","volume":"35","author":"M Tyrstrup","year":"2017","unstructured":"Tyrstrup M, van der Velden A, Engstrom S, Goderis G, Molstad S, Verheij T, et al. Antibiotic prescribing in relation to diagnoses and consultation rates in Belgium, the Netherlands and Sweden: use of European quality indicators. Scand J Prim Health Care. 2017;35(1):10\u20138.","journal-title":"Scand J Prim Health Care"},{"issue":"2","key":"1904_CR14","doi-asserted-by":"publisher","first-page":"e0171284","DOI":"10.1371\/journal.pone.0171284","volume":"12","author":"M Ewen","year":"2017","unstructured":"Ewen M, Zweekhorst M, Regeer B, Laing R. Baseline assessment of WHO\u2019s target for both availability and affordability of essential medicines to treat non-communicable diseases. PLoS ONE. 2017;12(2):e0171284.","journal-title":"PLoS ONE"},{"issue":"10","key":"1904_CR15","doi-asserted-by":"publisher","first-page":"1045","DOI":"10.1016\/0895-4356(92)90144-C","volume":"45","author":"JT Hanlon","year":"1992","unstructured":"Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045\u201351.","journal-title":"J Clin Epidemiol"},{"issue":"11","key":"1904_CR16","doi-asserted-by":"publisher","first-page":"893","DOI":"10.1007\/s40266-013-0118-4","volume":"30","author":"JT Hanlon","year":"2013","unstructured":"Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging. 2013;30(11):893\u2013900.","journal-title":"Drugs Aging"},{"key":"1904_CR17","doi-asserted-by":"publisher","first-page":"a437","DOI":"10.1136\/bmj.a437","volume":"337","author":"T Tan","year":"2008","unstructured":"Tan T, Little P, Stokes T. Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ. 2008;337:a437.","journal-title":"BMJ"},{"key":"1904_CR18","unstructured":"NICE guideline: Chronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115). Last updated\u00a026 July 2019. Available at: https:\/\/www.nice.org.uk\/guidance\/ng115\/resources\/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245."},{"issue":"2","key":"1904_CR19","doi-asserted-by":"publisher","first-page":"316","DOI":"10.3390\/antibiotics2020316","volume":"2","author":"A van der Velden","year":"2013","unstructured":"van der Velden A, Duerden MG, Bell J, Oxford JS, Altiner A, Kozlov R, et al. Prescriber and Patient Responsibilities in Treatment of Acute Respiratory Tract Infections \u2014 Essential for Conservation of Antibiotics. Antibiotics (Basel). 2013;2(2):316\u201327.","journal-title":"Antibiotics (Basel)"},{"issue":"4","key":"1904_CR20","doi-asserted-by":"publisher","first-page":"269","DOI":"10.3109\/02813432.2015.1114349","volume":"33","author":"N R\u00fan Sigur\u00f0ard\u00f3ttir","year":"2015","unstructured":"R\u00fan Sigur\u00f0ard\u00f3ttir N, Nielsen ABS, Munck A, Bjerrum L. Appropriateness of antibiotic prescribing for upper respiratory tract infections in general practice: Comparison between Denmark and Iceland. Scand J Prim Health Care. 2015;33(4):269\u201374.","journal-title":"Scand J Prim Health Care"},{"issue":"1","key":"1904_CR21","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1093\/jac\/dkw370","volume":"72","author":"G Cordoba","year":"2017","unstructured":"Cordoba G, Caballero L, Sandholdt H, Arteaga F, Olinisky M, Ruschel LF, et al. Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America. J Antimicrob Chemother. 2017;72(1):305\u201310.","journal-title":"J Antimicrob Chemother"},{"key":"1904_CR22","doi-asserted-by":"publisher","first-page":"g5493","DOI":"10.1136\/bmj.g5493","volume":"349","author":"CJ Currie","year":"2014","unstructured":"Currie CJ, Berni E, Jenkins-Jones S, Poole CD, Ouwens M, Driessen S, et al. Antibiotic treatment failure in four common infections in UK primary care 1991\u20132012: longitudinal analysis. BMJ. 2014;349:g5493.","journal-title":"BMJ"},{"issue":"3","key":"1904_CR23","doi-asserted-by":"publisher","first-page":"359","DOI":"10.1007\/s00228-015-1997-6","volume":"72","author":"Y Wu","year":"2016","unstructured":"Wu Y, Yang C, Xi H, Zhang Y, Zhou Z, Hu Y. Prescription of antibacterial agents for acute upper respiratory tract infections in Beijing, 2010\u20132012. Eur J Clin Pharmacol mars. 2016;72(3):359\u201364.","journal-title":"Eur J Clin Pharmacol mars"},{"issue":"4","key":"1904_CR24","doi-asserted-by":"publisher","first-page":"402","DOI":"10.1093\/fampra\/cmy094","volume":"36","author":"Y Teratani","year":"2019","unstructured":"Teratani Y, Hagiya H, Koyama T, Adachi M, Ohshima A, Zamami Y, et al. Pattern of antibiotic prescriptions for outpatients with acute respiratory tract infections in Japan, 2013\u201315: a retrospective observational study. Fam Pract. 2019;36(4):402\u20139.","journal-title":"Fam Pract"},{"issue":"6","key":"1904_CR25","doi-asserted-by":"publisher","first-page":"1176","DOI":"10.1111\/j.1365-2753.2010.01495.x","volume":"17","author":"SY Hong","year":"2011","unstructured":"Hong SY, Taur Y, Jordan MR, Wanke C. Antimicrobial prescribing in the USA for adult acute pharyngitis in relation to treatment guidelines. J Eval Clin Pract. 2011;17(6):1176\u201383.","journal-title":"J Eval Clin Pract"},{"issue":"9","key":"1904_CR26","doi-asserted-by":"publisher","first-page":"764","DOI":"10.1136\/bmjqs.2010.049049","volume":"20","author":"N Adriaenssens","year":"2011","unstructured":"Adriaenssens N, Coenen S, Tonkin-Crine S, Verheij TJM, Little P, Goossens H, et al. European Surveillance of Antimicrobial Consumption (ESAC): disease-specific quality indicators for outpatient antibiotic prescribing. BMJ Qual Saf. 2011;20(9):764\u201372.","journal-title":"BMJ Qual Saf"},{"key":"1904_CR27","doi-asserted-by":"publisher","first-page":"16","DOI":"10.1016\/j.ijid.2016.09.013","volume":"52","author":"S Shamsuddin","year":"2016","unstructured":"Shamsuddin S, Akkawi ME, Zaidi STR, Ming LC, Manan MM. Antimicrobial drug use in primary healthcare clinics: a retrospective evaluation. Int J Infect Dis. 2016;52:16\u201322.","journal-title":"Int J Infect Dis"},{"key":"1904_CR28","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1016\/j.ijid.2016.12.004","volume":"55","author":"AA Butt","year":"2017","unstructured":"Butt AA, Navasero CS, Thomas B, Marri SA, Katheeri HA, Thani AA, et al. Antibiotic prescription patterns for upper respiratory tract infections in the outpatient Qatari population in the private sector. Int J Infect Dis. 2017;55:20\u20133.","journal-title":"Int J Infect Dis"},{"issue":"4","key":"1904_CR29","first-page":"401","volume":"32","author":"ARJ Dekker","year":"2015","unstructured":"Dekker ARJ, Verheij TJM, van der Velden AW. Inappropriate antibiotic prescription for respiratory tract indications: most prominent in adult patients. Fam Pract. 2015;32(4):401\u20137.","journal-title":"Fam Pract"},{"issue":"5","key":"1904_CR30","first-page":"349","volume":"38","author":"JM Gill","year":"2006","unstructured":"Gill JM, Fleischut P, Haas S, Pellini B, Crawford A, Nash DB. Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study. Fam Med. 2006;38(5):349\u201354.","journal-title":"Fam Med"},{"key":"1904_CR31","unstructured":"World Health Organization. Regional Office for the Eastern Mediterranean.\u00a0(2010).\u00a0Tunisia: Medicine prices, availability, affordability and price components.\u00a0https:\/\/apps.who.int\/iris\/handle\/10665\/116638"},{"issue":"3","key":"1904_CR32","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1002\/jhm.2495","volume":"11","author":"D Livorsi","year":"2016","unstructured":"Livorsi D, Comer AR, Matthias MS, Perencevich EN, Bair MJ. Barriers to guideline-concordant antibiotic use among inpatient physicians: A case vignette qualitative study. J Hosp Med. 2016;11(3):174\u201380.","journal-title":"J Hosp Med"},{"issue":"5","key":"1904_CR33","doi-asserted-by":"publisher","first-page":"543","DOI":"10.1177\/106002809703100503","volume":"31","author":"LS Fitzgerald","year":"1997","unstructured":"Fitzgerald LS, Hanlon JT, Shelton PS, Landsman PB, Schmader KE, Pulliam CC, et al. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother. 1997;31(5):543\u20138.","journal-title":"Ann Pharmacother"},{"issue":"10","key":"1904_CR34","doi-asserted-by":"publisher","first-page":"769","DOI":"10.1007\/s00228-005-0963-0","volume":"61","author":"L Bregnh\u00f8j","year":"2005","unstructured":"Bregnh\u00f8j L, Thirstrup S, Kristensen MB, Sonne J. Reliability of a modified medication appropriateness index in primary care. Eur J Clin Pharmacol. 2005;61(10):769\u201373.","journal-title":"Eur J Clin Pharmacol"}],"container-title":["BMC Primary Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12875-022-01904-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12875-022-01904-7\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12875-022-01904-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,11,23]],"date-time":"2022-11-23T07:03:09Z","timestamp":1669186989000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcfampract.biomedcentral.com\/articles\/10.1186\/s12875-022-01904-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,11,22]]},"references-count":34,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["1904"],"URL":"https:\/\/doi.org\/10.1186\/s12875-022-01904-7","relation":{},"ISSN":["2731-4553"],"issn-type":[{"value":"2731-4553","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,11,22]]},"assertion":[{"value":"28 October 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 July 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 November 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was conducted in accordance with the 'Declaration of Helsinki' as a statement of ethical principles for medical research involving human subjects, including the study of identifiable human substances and data. This study was approved by the Institutional Review Board of Monastir and Sousse Universities. And all included patients provided their written informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"295"}}