Antimicrobial resistance determinants and future control

Quantifying uncertainty about future antimicrobial resistance: Comparing structured expert judgment and statistical forecasting methods

The increase of multidrug resistance and resistance to last-line antibiotics is a major global public health threat. Although surveillance programs provide useful current and historical information on the scale of the problem, the future emergence and spread of antibiotic resistance is uncertain, and quantifying this uncertainty is crucial for guiding decisions about investment in antibiotics and resistance control strategies. Mathematical and statistical models capable of projecting future rates are challenged by the paucity of data and the complexity of the emergence and spread of resistance, but experts have relevant knowledge. We use the Classical Model of structured expert judgment to elicit projections with uncertainty bounds of resistance rates through 2026 for nine pathogen-antibiotic pairs in four European countries and empirically validate the assessments against data on a set of calibration questions. The performance-weighted combination of experts in France, Spain, and the United Kingdom projected that resistance for five pairs on the World Health Organization’s priority pathogens list (E. coli and K. pneumoniae resistant to third-generation cephalosporins and carbapenems and MRSA) would remain below 50% in 2026. In Italy, although upper bounds of 90% credible ranges exceed 50% resistance for some pairs, the medians suggest Italy will sustain or improve its current rates. We compare these expert projections to statistical forecasts based on historical data from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results from the statistical models differ from each other and from the judgmental forecasts in many cases. The judgmental forecasts include information from the experts about the impact of current and future shifts in infection control, antibiotic usage, and other factors that cannot be easily captured in statistical forecasts, demonstrating the potential of structured expert judgment as a tool for better understanding the uncertainty about future antibiotic resistance.

Preliminary assessment of the suitability of commonly used antiseptics in the elimination of bacteria in bathing water

The use of antiseptics for the removal of bacteria in water has become pertinent given that most hand dug wells, boreholes, and surface waters are already contaminated in their in situ condition before being used. But, the efficacy of these skin disinfectants (antiseptics) is usually not well spelt out for the aforementioned purpose, and usage may yield no good report. This study assessed the suitability of use of two widely used antiseptics in Nigeria (Dettol and Izal) on Bacillus spp., Escherichia coli and Klebsiella spp., in eliminating bacteria in bathing water. The water which were tested at four different concentrations (0.4 ml, 0.8 ml, 1.2 ml, and 1.6 ml) and at six different contact times (0, 5, 10, 15, 30, and 60 min, respectively) within which bathing is meant to take place after antiseptics were applied. Overall, One hundred and Forty-four (144) samples were analyzed, and based on our null hypothesis of no bacteria should be found in bathing water after disinfection, results showed that both antiseptics were not efficient in bacteria removal. However, the multivariable logistic regression model conducted revealed that both antiseptics were more active in destroying Klebsiella spp. than any other bacteria investigated with Izal showing more dominance (OR = 31.21; p < 0.05). The study further revealed that Izal is 3.6 times more likely to destroy bacteria than Dettol (p < 0.05), with more of the elimination occurring at contact time greater than 5 min (OR = 1.504; p = 0.043). Therefore, it is suggested that disinfectants and antiseptics of high motility and sufficient potency in a wide range of bacteria spectrum should be produced to meet the needs of consumers resulting in a better bathing water quality.

Toxicity and Safety Study of D-PLEX100 in a Sternal Surgical Defect in New Zealand White Rabbits

Bacterial infections are a common complication after surgical procedures. Therefore, local delivery of antibiotics has been developed, including the use of biodegradable polymers. A newly developed product for prevention of surgical site infections is a polymer-lipid encapsulation matrix loaded with doxycycline, named D-PLEX₁₀₀ (D-PLEX). We evaluated the toxicity and safety of D-PLEX using a sternal surgical defect model in rabbits. D-PLEX was tested with three different concentrations of doxycycline in comparison to sham-operated control after administration into the sternal surgical defect and on the ventral side of the sternum in New Zealand White (NZW) rabbits, following 15 months of exposure. No mortality or abnormal clinical findings were attributed to D-PLEX, and clinical pathology assays were normal. Histological examinations revealed no treatment-related adverse findings in any of the examined tissues, including the osseous and surrounding soft tissues. It has been shown that D-PLEX gradually degraded until complete disappearance after 9 months, and mainly during the first 3 months, in parallel to normal bone formation. In addition, the administration of D-PLEX did not affect sternal bone strength. This study adds to the growing data on preclinical safety studies utilizing biodegradable materials and provides information on the expected normal reaction to biodegradable materials in the sternum of NZW rabbits.

Quality of Community Pharmacy Practice in Antibiotic Self-Medication Encounters: A Simulated Patient Study in Upper Egypt

Antibiotic misuse, either by patients or healthcare professionals, is one of the major contributing factors to antimicrobial resistance. In many Middle Eastern countries including Egypt, there are no strict regulations regarding antibiotic dispensing by community pharmacies. In this study, we examined antibiotic dispensing patterns in Egyptian community pharmacies. About 150 community pharmacies were randomly chosen using convenience sampling from the five most populous urban districts of Minia Governorate in Egypt. Two simulated patient (SP) scenarios of viral respiratory tract infection requiring no antibiotic treatment were used to assess the actual antibiotics dispensing practice of. Face-to-face interviews were then conducted to assess the intended dispensing practice. Descriptive statistics were calculated to report the main study outcomes. In 238 visits of both scenarios, 98.3% of service providers dispensed amoxicillin. Although stated otherwise in interviews, most pharmacy providers (63%) dispensed amoxicillin without collecting relevant information from presenting SPs. Findings showed high rates of antibiotic misuse in community pharmacies. Discrepancies between interviews and patient simulation results also suggest a practice‒knowledge gap. Corrective actions, whether legislation, enforcement, education, or awareness campaigns about antibiotic misuse, are urgently needed to improve antibiotic dispensing practices in Egyptian community pharmacies.

Knowledge, practices and attitudes on antibiotics use in Cameroon: Self-medication and prescription survey among children, adolescents and adults in private pharmacies

Benefits of antibiotics are threatened by the self-medication, people's lack of knowledge and inappropriate use of antibiotics, especially in developing countries. This study was designed to determine knowledge; attitudes and practices toward antibiotics use in an urban community, and evaluate the factors that are associated with antibiotic use. Between January and March 2015, a cross sectional and prospective study was conducted in all pharmacies within the Douala IV health district, Cameroon. Anonymous interviews including both open and closed ended questions were conducted in participants selected by convenience sampling Descriptive and logistic regression analysis were performed using StataSE11 software (version 11 SE) and R software (version 3.1.1) in data analysis. Overall 402 (33.7%) of 1,192 customers purchased antibiotics and of these, 47% bought antibiotics without a prescription. 60.7% of purchased antibiotics was for adult 'patients and around 60% of parents carried out self-medication on their children. The vast majority reported that all microbes can be treated with antibiotics (88.3%). The belief that antibiotics are appropriate for bacterial infections was more common among those with a higher level education (OR = 4.03, 95%CI:1.89-8.57, p<0.0001) and among public/private servants (OR = 2.47, 95%CI:1.21-5.08, p = 0.013). Physicians provide less explanations about antibiotics are and their potential side effects than the pharmacy auxiliaries (OR = 0.205, 95%CI = 0.09-0.46, p<0.0001), but more than pharmacists (OR = 3.692, 95%CI:1.44-9.25, p = 0.005). Indications on antibiotics use were 7 times more given to customers with a prescription compared to those without a prescription (OR = 7.37, 95% CI = 2.13-25.43, p = 0.002). Adult male (OR = 2.32, 95%CI:1.24-4.34, p = 0.009) and higher education (OR = 2.05, 95%CI:1.08-3.89, p = 0.027) were significantly associated with self-medication. Misuse, little "practical knowledge" and high self-medication confirm the unsatisfactory prescription and dispensing practices of the antibiotics in our country. These results highlight the important of the development and implementation appropriate guidelines for the responsible use of antibiotics for health care providers and health education targeting community members themselves.

The distribution of antibiotic use and its association with antibiotic resistance

Antibiotic use is a primary driver of antibiotic resistance. However, antibiotic use can be distributed in different ways in a population, and the association between the distribution of use and antibiotic resistance has not been explored. Here, we tested the hypothesis that repeated use of antibiotics has a stronger association with population-wide antibiotic resistance than broadly-distributed, low-intensity use. First, we characterized the distribution of outpatient antibiotic use across US states, finding that antibiotic use is uneven and that repeated use of antibiotics makes up a minority of antibiotic use. Second, we compared antibiotic use with resistance for 72 pathogen-antibiotic combinations across states. Finally, having partitioned total use into extensive and intensive margins, we found that intense use had a weaker association with resistance than extensive use. If the use-resistance relationship is causal, these results suggest that reducing total use and selection intensity will require reducing broadly distributed, low-intensity use.

Investigation of prescribing behavior at outpatient settings of governmental hospitals in eastern Ethiopia: an overall evaluation beyond World Health Organization core prescribing indicators

Background

Rational prescribing remains an important component of rational drug use. The World Health Organization (WHO) standardized and validated core prescribing indicators for evaluating prescribing pattern of drugs. The prescribing practice has been shown to deviate from national and WHO guidelines in Ethiopia. The aim of this study was; therefore, to investigate the overall prescribing behavior of four governmental hospitals: Hiwot Fana Specialized University Hospital (HFSUH), Federal Harar Police Hospital (FHPH), Jugel Hospital (JH) and Southeast Command III Hospital (SECIIIH), Harar, eastern Ethiopia.

Methods

Hospital based retrospective cross-sectional study was employed to evaluate outpatient prescriptions dispensed from January 1 – December 31, 2016. A total of 2400 prescriptions (600 from each hospital) were assessed. A combination of prescription completeness and prescribing indicator forms were used to collect the data.

Result

From a total of 2400 prescriptions reviewed, only HFSUH and FHPH were using standard prescription at prevalence of 92.5 and 99.8%, respectively. Name and weight of the patient were the most and the least commonly recorded information, respectively. A total of 5217 drugs were prescribed with an average number of drugs per encounter to be 2.17 (±0.39) and the highest value (2.60) was observed at FHPH. The frequency of administration was the most commonly written component (85.0%) with an average of 1.85 per prescription. Among all prescriptions analyzed, the percentage of encounters with antimicrobials and injectables prescribed were 66.9 and 26.5%, respectively. The prevalence of drugs prescribed with generic name and from essential drug list were 4644 (89.01%) and 4613 (88.42%), respectively. Among health professional related information, dispenser name was the least documented in all hospitals with the prevalence being 3.9%.

Conclusion

JH and SECIIIH were not using standard prescriptions at all during the review period. Besides, some important components of the prescription such as age, sex and diagnosis were not properly recorded or missed at all in the selected hospitals. The tendency of prescribing drugs with dose and dosage form was very poor. Overall, none of the core prescribing indicators was in line with the WHO standards. These and other related problems should be investigated in-depth to find out the underlying problems for which interventional strategies can be designed to reverse this worrying practice.

Antimicrobial resistance and outcomes of community-onset bacterial bloodstream infections in patients with type 2 diabetes

OBJECTIVES

Antimicrobial resistance of bacterial pathogens in the diabetic population with infection is seldom investigated. This study evaluated the antimicrobial resistance and outcomes of community-onset bloodstream infections (CO-BSIs) in patients with diabetes.

METHODS

From 2007-2014, 1271 monomicrobial CO-BSIs and 178 polymicrobial CO-BSIs were identified in patients with type 2 diabetes from three teaching hospitals in Taiwan. Antimicrobial-resistant strains of the ten most prevalent bacterial pathogens in monomicrobial CO-BSIs were recorded and were defined according to individual drug resistance. The 30-day mortality rate and factors associated with outcome were analysed.

RESULTS

Antimicrobial-resistant strains were found in 33.7% (379/1125) of monomicrobial CO-BSIs involving the 10 most prevalent pathogens. The leading pathogens in these monomicrobial CO-BSIs were Staphylococcus spp. (33.8%; 430/1271), Escherichia coli (20.9%; 266/1271) and Klebsiella spp. (9.6%; 122/1271); antimicrobial-resistant strains accounted for 61.9%, 18.4% and 10.7% of each, respectively. A higher overall 30-day mortality rate was observed for patients infected by antimicrobial-resistant strains compared with antimicrobial-susceptible strains (9.5% vs. 5.5%; P=0.011, log-rank test). A lower serum albumin level was a predictor of mortality after adjusting for antimicrobial-resistant strains and C-reactive protein level.

CONCLUSIONS

Antimicrobial-resistant bacterial pathogens pose a serious threat to diabetic patients with CO-BSIs owing to a higher risk of mortality.

Promoting quality use of medicines in South-East Asia: reports from country situational analyses

BACKGROUND

Irrational use of medicines is widespread in the South-East Asia Region (SEAR), where policy implementation to encourage quality use of medicines (QUM) is often low. The aim was to determine whether public-sector QUM is better in SEAR countries implementing essential medicines (EM) policies than in those not implementing them.

METHODS

Data on six QUM indicators and 25 EM policies were extracted from situational analysis reports of 20 country (2-week) visits made during 2010-2015. The average difference (as percent) for the QUM indicators between countries implementing versus not implementing specific policies was calculated. Policies associated with better (> 1%) QUM were included in regression of a composite QUM score versus total number of policies implemented.

RESULTS

Twenty-two policies were associated with better (> 1%) QUM. Twelve policies were associated with 3.6-9.5% significantly better use (p < 0.05), namely: standard treatment guidelines; formulary; a government unit to promote QUM; continuing health worker education on prescribing by government; limiting over-the-counter (OTC) availability of systemic antibiotics; disallowing public-sector prescriber revenue from medicines sales; not charging fees at the point of care; monitoring advertisements of OTC medicines; public education on QUM; and a good drug supply system. There was significant correlation between the number of policies implemented out of 22 and the composite QUM score (r = 0.71, r² = 0.50, p < 0.05).

CONCLUSIONS

Country situational analyses allowed rapid data collection that showed EM policies are associated with better QUM. SEAR countries should implement all such policies.

Is Antimicrobial Resistance a Bigger Problem in Tertiary Care Hospitals Than in Small Community Hospitals in the United States?

Large tertiary care hospitals (TCHs) are thought to have higher antimicrobial resistance (AMR) rates when compared to small community hospitals (SCHs) as they provide care to patients with higher disease severity. However, we found no systematic differences in AMR rates between TCHs and SCHs in the United States.

T4-like Escherichia coli phages from the environment carry blaCTX-M

The resistance determinant bla_CTX-M has many variants and has been the most commonly reported gene in clinical isolates of extended spectrum beta-lactamase producing Escherichia coli. Phages have been speculated as potential reservoirs of resistance genes and efficient vehicles for horizontal gene transfer. The objective of the study was to determine the prevalence and characterize bacteriophages that harbour the resistance determinant bla_CTX-M . Escherichia coli specific bacteriophages were isolated from 15 samples including soil and water across Mangaluru, India using bacterial hosts that were sensitive to β-lactams. Phenotypic and genotypic characterization based on plaque morphology, host range, restriction fragment length polymorphism (RFLP), presence of bla_CTX-M and electron microscopy was performed. Of 36 phages isolated, seven were positive for Group 1 of bla_CTX-M . Based on host range and RFLP pattern, the seven phages were classified into four distinct groups, each harbouring a variant of bla_CTX-M . Five phages were T4-like Myoviridae by electron microscopy which was further confirmed by polymerase chain reaction (PCR) for T4 specific gp14. Generalized transduction of the CTX-M gene from these phages was also observed. The high prevalence (20%) of this gene bla_CTX-M in the phage pool confirms the significant role of Myoviridae members, specifically T4-like phages in the dissemination of this resistance gene.

SIGNIFICANCE AND IMPACT OF THE STUDY

The CTX-M gene that confers resistance to Beta-lactam class of drugs is widespread and diverse. Understanding mechanisms of antimicrobial resistance transfer is a key to devise methods for controlling it. Few studies indicate that bacteriophages are involved in the transfer of this gene but the type of phages involved and the degree of involvement remains to be explored. Our work has been able to identify the class of phages and the magnitude of involvement in the dissemination of this gene.

Potentiation of antibiotic activity by Passiflora cincinnata Mast. front of strains Staphylococcus aureus and Escherichia coli

The development of new drugs from plants is an interesting alternative approach to overcoming microbial resistance. Passiflora cincinnata shows resistance to diseases and pests and a higher concentration of chemical components that may be useful in the pharmaceutical industry. We investigated the potential antimicrobial and antibiotic-modifying activity of hydroalcoholic extracts of leaves, stems, bark, pulp and seeds of P. cincinnata. The extracts were prepared by homogenization of material in 50% ethanol. Minimum inhibitory concentration (MIC) was determined by the broth dilution method, and the bacterial strains tested were Staphylococcus aureus and Escherichia coli. Antibiotic-modifying activity was evaluated against the strains S. aureus 03 and E. coli 08, using a subinhibitory concentration of extract. The antibiotics tested were: amikacin, gentamicin, ampicillin, potassium benzylpenicillin and oxacillin. The extracts did not show antimicrobial activity of clinical relevance, where the MIC was equal to or greater than 1024 μg/mL. S. aureus showed 13 events, while E. coli showed only 4 events. Among these events, 14 involved synergistic activity, potentiating the effect of the antibiotics, and only 3 events demonstrated antagonistic activity toward ampicillin. Hydroalcoholic extracts are potential antimicrobial agents when combined with conventional drugs little utilized in in vivo treatment.

Bacterial profile of ocular infections: a systematic review

BACKGROUND

Bacteria are the major contributor of ocular infections worldwide. Ocular infections, if left untreated, can damage the structures of the eye with possible blindness and visual impairments. This work was aimed to review the bacterial profile of ocular infections.

METHODS

Literature search was made in different electronic databases; the review was systematically made to get concrete findings.

RESULTS

As far as this review, Staphylococcus aureus, Coagulase negative Staphylococci, Streptococcus pneumoniae and Pseudomonas aeruginosa are the leading isolates in ocular infections. Frequent pathogens of the respective clinical diagnose include Staphylococci, Streptococcus pyogenes and Pseudomonas aeruginosa in blepharitis; Staphylococci, Streptococus pneumoniae, Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli in Conjunctivitis; Staphylococci, P. aeruginosa and E. coli in dacryocystitis; Coagulase negative Staphylococci, Pseudomonas aeruginosa and Staphylococcus aureus in keratitis; Streptococcus viridians, Streptococcus pneumoniae and Coagulase negative Staphylococci in endophthalmitis diagnoses. Endogenous endophthalmitis is associated with Klebsiella pneumoniae whereas Coagulase negative Staphylococci and Bacillus spp. are common causes of post-operative and post-traumatic endophthalmitis. However, the predominant pathogens may not be exactly same in all areas of the world, in the United States for instance, Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae are the major causes of conjunctivitis.

CONCLUSION

Gram positive bacteria are the major contributor of bacterial ocular infections. The distribution and proportion of bacterial isolates among clinical diagnoses varied but without exclusive anatomical restriction. To mitigate the burden of bacterial ocular infections, physicians should regard on risk reduction and comply with etiologic approach of diagnosis.

Antimicrobial resistance in the next 30 years, humankind, bugs and drugs: a visionary approach

PURPOSE

To describe the current standards of care and major recent advances with regard to antimicrobial resistance (AMR) and to give a prospective overview for the next 30 years in this field.

METHODS

Review of medical literature and expert opinion were used in the development of this review.

RESULTS

There is undoubtedly a large clinical and public health burden associated with AMR in ICU, but it is challenging to quantify the associated excess morbidity and mortality. In the last decade, antibiotic stewardship and infection prevention and control have been unable to prevent the rapid spread of resistant Gram-negative bacteria (GNB), in particular carbapenem-resistant Pseudomonas aeruginosa (and other non-fermenting GNB), extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacteriaceae (CRE). The situation appears more optimistic currently for Gram-positive, where Staphylococcus aureus, and particularly methicillin-resistant S. aureus (MRSA), remains a cardinal cause of healthcare-associated infections worldwide. Recent advancements in laboratory techniques allow for a rapid identification of the infecting pathogen and antibiotic susceptibility testing. Their impact can be particularly relevant in settings with prevalence of MDR, since they may guide fine-tuning of empirically selected regimen, facilitate de-escalation of unnecessary antimicrobials, and support infection control decisions. Currently, antibiotics are the primary anti-infective solution for patients with known or suspected MDR bacteria in intensive care. Numerous incentives have been provided to encourage researchers to work on alternative strategies to reverse this trend and to provide a means to treat these pathogens. Although some promising antibiotics currently in phase 2 and 3 of development will soon be licensed and utilized in ICU, the continuous development of an alternative generation of compounds is extremely important. There are currently several promising avenues available to fight antibiotic resistance, such as faecal microbiota, and phage therapy.

Antimicrobial resistance in Africa: a systematic review

BACKGROUND

Antimicrobial resistance (AMR) is widely acknowledged as a global problem, yet in many parts of the world its magnitude is still not well understood. This review, using a public health focused approach, aimed to understand and describe the current status of AMR in Africa in relation to common causes of infections and drugs recommended in WHO treatment guidelines.

METHODS

PubMed, EMBASE and other relevant databases were searched for recent articles (2013-2016) in accordance with the PRISMA guidelines. Article retrieval and screening were done using a structured search string and strict inclusion/exclusion criteria. Median and interquartile ranges of percent resistance were calculated for each antibiotic-bacterium combination.

RESULTS

AMR data was not available for 42.6% of the countries in the African continent. A total of 144 articles were included in the final analysis. 13 Gram negative and 5 Gram positive bacteria were tested against 37 different antibiotics. Penicillin resistance in Streptococcus pneumoniae was reported in 14/144studies (median resistance (MR): 26.7%). Further 18/53 (34.0%) of Haemophilus influenza isolates were resistant to amoxicillin. MR of Escherichia coli to amoxicillin, trimethoprim and gentamicin was 88.1%, 80.7% and 29.8% respectively. Ciprofloxacin resistance in Salmonella Typhi was rare. No documented ceftriaxone resistance in Neisseria gonorrhoeae was reported, while the MR for quinolone was 37.5%. Carbapenem resistance was common in Acinetobacter spp. and Pseudomonas aeruginosa but uncommon in Enterobacteriaceae.

CONCLUSION

Our review highlights three important findings. First, recent AMR data is not available for more than 40% of the countries. Second, the level of resistance to commonly prescribed antibiotics was significant. Third, the quality of microbiological data is of serious concern. Our findings underline that to conserve our current arsenal of antibiotics it is imperative to address the gaps in AMR diagnostic standardization and reporting and use available information to optimize treatment guidelines.

Antibiotic use in South East Asia and policies to promote appropriate use: reports from country situational analyses

Kathleen Holloway and colleagues discuss findings from a rapid assessment of antibiotic use and policies undertaken by South East Asian countries to drive further actions to reduce inappropriate use

Antimicrobial resistance: The complex challenge of measurement to inform policy and the public

Didier Wernli and colleagues discuss the role of monitoring in countering antimicrobial resistance.

Beyond conventional antibiotics - New directions for combination products to combat biofilm

Medical device related infections are a significant and growing source of morbidity and mortality. Biofilm formation is a common feature of medical device infections that is not effectively prevented or treated by systemic antibiotics. Antimicrobial medical device combination products provide a pathway for local delivery of antimicrobial therapeutics with the ability to achieve high local concentrations while minimizing systemic side effects. In this review, we present considerations for the design of local antimicrobial delivery systems, which can be facilitated by modeling local pharmacokinetics in the context of the target device application. In addition to the need for local delivery, a critical barrier to progress in the field is the need to incorporate agents effective against biofilm. This article aims to review key properties of antimicrobial peptides that make them well suited to meet the demands of the next generation of antimicrobial medical devices, including broad spectrum activity, rapid and biocidal mechanisms of action, and efficacy against biofilm.

Misconceptions and Malpractices Toward Antibiotic Use in Childhood Upper Respiratory Tract Infections Among a Cohort of Lebanese Parents

Antimicrobial resistance is an emerging global health threat. Misuse and abuse of antibiotics are of particular concern in the pediatric population. Since management of childhood illnesses depends considerably on parents' perceptions, the objectives of this study were to report parents' perspectives and assess their practices toward antibiotics used for upper respiratory tract infections (URTIs) in children. Using a cross-sectional design, anonymous structured questionnaires were completed by 1,037 parents in public and private schools across Lebanon's largest governorate. Descriptive statistics were used to report participants' responses. A multivariate analysis was performed to identify factors affecting knowledge and malpractice related to antibiotic use. Significant misconceptions and malpractices were identified among parents. For instance, 33.9% of parents considered that antibiotics are helpful in treating common cold among children and 36.2% believed antibiotics expedite the recovery of their child with common cold infection. Moreover, there was a lack of knowledge concerning antibiotic coverage, since 37.9% of the respondents believed that antibiotics treat viral infections and 21.5% were neutral toward this question. Around 20% of the participants believed they can reduce the dose of antibiotics if the child gets better. Significant factors associated with poor knowledge and misuses were parents' lower educational and socioeconomic levels. Despite extensive evidence on the limited role of antibiotics in URTIs, parents in Lebanon continue to misuse them. More concerted efforts are needed to improve parents' knowledge and practices with regard to the rational use of antibiotics.

Synergistic effect of Thymbra spicata L. extracts with antibiotics against multidrug- resistant Staphylococcus aureus and Klebsiella pneumoniae strains

OBJECTIVES

To evaluate the in vitro interaction between different extracts of Thymbra spicata L. and certain antimicrobial drugs of different mechanisms, including ampicillin, cefotaxime, amikacin and ciprofloxacin. This study was performed against multidrug-resistant strains of Staphylococcus aureus and Klebsiella pneumoniae.

MATERIALS AND METHODS

Evaluation of antibacterial activity and synergy interaction between plant extracts and antimicrobial agents was carried out using checkerboard microdilution.

RESULTS

Different interactions (synergistic, additive and indifference) were observed between plant crude extracts and used antibiotics depending on the strain. The fractional inhibitory concentration (FIC) index ranged from 0.02 to 1.5 for S. aureus and 0.25 to 2 for K. pneumoniae strains. The best synergistic capacity appeared with cefotaxime against S. aureus strains, where the activity of cefotaxime was increased from 8- to 128-fold.

CONCLUSION

These results may indicate that T. spicata extracts potentiates the antimicrobial action of antibiotics, suggesting a possible utilization of this herb in combination therapy against emerging multidrug-resistance S. aureus and K. pneumoniae.

Prevention and control of health care-associated infections in Iran: A qualitative study to explore challenges and barriers

BACKGROUND

Globally, the health and economic burden posed by health care-associated infections (HAIs) remains wide and severe. To curb the burden associated with HAIs, countries, including Iran, aim at HAI prevention and control. This study explores the challenges faced by the Iranian health system in addressing the issues associated with the prevention and control of HAIs.

METHODS

A qualitative research method was adopted in exploring the phenomenon. We used the purposive sampling approach in reaching 24 key informants at the national and subnational levels. The thematic framework analysis was conducted for analyzing the interviews.

RESULTS

Five main themes emerged from our study demonstrating the obstacles toward the prevention and control of HAIs. They include governance and stewardship, resources, safety culture, monitoring and surveillance systems, and inappropriate prescription of antibiotics.

CONCLUSIONS

Strengthening of reporting and surveillance systems for HAIs coupled with proper governance and stewardship are crucial in order to improve the health and safety of patients. However, the availability of resources, through an intersectoral approach, is essential to achieve sustained output.

Effects of a computerized provider order entry and a clinical decision support system to improve cefazolin use in surgical prophylaxis: a cost saving analysis

BACKGROUND

Computerized Provider Order Entry (CPOE) and Clinical Decision Support System (CDSS) help practitioners to choose evidence-based decisions, regarding patients' needs. Despite its use in developed countries, in Brazil, the impact of a CPOE/CDSS to improve cefazolin use in surgical prophylaxis was not assessed yet.

OBJECTIVE

We aimed to evaluate the impact of a CDSS to improve the use of prophylactic cefazolin and to assess the cost savings associated to inappropriate prescribing.

METHODS

This is a cross-sectional study that compared two different scenarios: one prior CPOE/CDSS versus after software implementation. We conducted twelve years of data analysis (3 years prior and 9 years after CDSS implementation), where main outcomes from this study included: cefazolin Defined Daily Doses/100 bed-days (DDD), crude costs and product of costs-DDD (cost-DDD/100 bed-days). We applied a Spearman rho non-parametric test to assess the reduction of cefazolin consumption through the years.

RESULTS

In twelve years, 84,383 vials of cefazolin were dispensed and represented 38.89 DDD/100 bed-days or USD 44,722.99. Surgical wards were the largest drug prescribers and comprised >95% of our studied sample. While in 2002, there were 6.31 DDD/100 bed-days, 9 years later there was a reduction to 2.15 (p<0.05). In a scenario without CDSS, the hospital would have consumed 75.72 DDD/100 bed-days, which is equivalent to USD 116 998.07. It is estimated that CDSS provided USD 50,433.39 of cost savings.

CONCLUSION

The implementation of a CPOE/CDSS helped to improve prophylactic cefazolin use by reducing its consumption and estimated direct costs.

Pangenome and immuno-proteomics analysis of Acinetobacter baumannii strains revealed the core peptide vaccine targets

BACKGROUND

Acinetobacter baumannii has emerged as a significant nosocomial pathogen during the last few years, exhibiting resistance to almost all major classes of antibiotics. Alternative treatment options such as vaccines tend to be most promising and cost effective approaches against this resistant pathogen. In the current study, we have explored the pan-genome of A. baumannii followed by immune-proteomics and reverse vaccinology approaches to identify potential core vaccine targets.

RESULTS

The pan-genome of all available A. baumannii strains (30 complete genomes) is estimated to contain 7,606 gene families and the core genome consists of 2,445 gene families (~32 % of the pan-genome). Phylogenetic tree, comparative genomic and proteomic analysis revealed both intra- and inter genomic similarities and evolutionary relationships. Among the conserved core genome, thirteen proteins, including P pilus assembly protein, pili assembly chaperone, AdeK, PonA, OmpA, general secretion pathway protein D, FhuE receptor, Type VI secretion system OmpA/MotB, TonB dependent siderophore receptor, general secretion pathway protein D, outer membrane protein, peptidoglycan associated lipoprotein and peptidyl-prolyl cis-trans isomerase are identified as highly antigenic. Epitope mapping of the target proteins revealed the presence of antigenic surface exposed 9-mer T-cell epitopes. Protein-protein interaction and functional annotation have shown their involvement in significant biological and molecular processes. The pipeline is validated by predicting already known immunogenic targets against Gram negative pathogen Helicobacter pylori as a positive control.

CONCLUSION

The study, based upon combinatorial approach of pan-genomics, core genomics, proteomics and reverse vaccinology led us to find out potential vaccine candidates against A. baumannii. The comprehensive analysis of all the completely sequenced genomes revealed thirteen putative antigens which could elicit substantial immune response. The integration of computational vaccinology strategies would facilitate in tackling the rapid dissemination of resistant A.baumannii strains. The scarcity of effective antibiotics and the global expansion of sequencing data making this approach desirable in the development of effective vaccines against A. baumannii and other bacterial pathogens.

Nonprescription Antimicrobial Use in a Primary Care Population in the United States

Community antimicrobial resistance rates are high in communities with frequent use of nonprescription antibiotics. Studies addressing nonprescription antibiotic use in the United States have been restricted to Latin American immigrants. We estimated the prevalence of nonprescription antibiotic use in the previous 12 months as well as intended use (intention to use antibiotics without a prescription) and storage of antibiotics and examined patient characteristics associated with nonprescription use in a random sample of adults. We selected private and public primary care clinics that serve ethnically and socioeconomically diverse patients. Within the clinics, we used race/ethnicity-stratified systematic random sampling to choose a random sample of primary care patients. We used a self-administered standardized questionnaire on antibiotic use. Multivariate regression analysis was used to identify independent predictors of nonprescription use. The response rate was 94%. Of 400 respondents, 20 (5%) reported nonprescription use of systemic antibiotics in the last 12 months, 102 (25.4%) reported intended use, and 57 (14.2%) stored antibiotics at home. These rates were similar across race/ethnicity groups. Sources of antibiotics used without prescriptions or stored for future use were stores or pharmacies in the United States, "leftover" antibiotics from previous prescriptions, antibiotics obtained abroad, or antibiotics obtained from a relative or friend. Respiratory symptoms were common reasons for the use of nonprescription antibiotics. In multivariate analyses, public clinic patients, those with less education, and younger patients were more likely to endorse intended use. The problem of nonprescription use is not confined to Latino communities. Community antimicrobial stewardship must include a focus on nonprescription antibiotics.

Antimicrobial agents - optimising the ecological balance

BACKGROUND

There is no more challenging a group of pharmaceuticals than antimicrobials. With the antibiotic era came great optimism as countless deaths were prevented from what were previously fatal conditions. Although antimicrobial resistance was quickly identified, the abundance of antibiotics entering the market helped cement attitudes of arrogance as the "battle against pestilence appeared won". Opposite emotions soon followed as many heralded the return of the pre-antibiotic era, suggesting that the "antibiotic pipeline had dried up" and that our existing armament would soon be rendered worthless.

DISCUSSION

In reality, humans overrate their ecological importance. For millions of years there has been a balance between factors promoting bacterial survival and those disturbing it. The first half century of the "antibiotic era" was characterised by a cavalier attitude disturbing the natural balance; however, recent efforts have been made through several mechanisms to respond and re-strengthen the antimicrobial armament. Such mechanisms include a variety of incentives, educational efforts and negotiations. Today, there are many more "man-made" factors that will determine a new balance or state of ecological harmony.

CONCLUSION

Antibiotics are not a panacea nor will they ever be inutile. New resistance mechanisms will be identified and new antibiotics will be discovered, but most importantly, we must optimise our application of these extraordinary "biological tools"; therein lays our greatest challenge - creating a society that understands and respects the determinants of the effectiveness of antibiotics.

Antimicrobial drug prescribing patterns for community-acquired pneumonia in hospitalized patients: A retrospective pilot study from New Delhi, India

OBJECTIVE

The objective of this study was to determine patterns and frequency of antimicrobial drug use among hospitalized patients with community-acquired pneumonia (CAP).

METHODOLOGY

A retrospective 5 years (April 2007-March 2012) detailed medical record review of patients diagnosed with CAP and discharged to home from Non-Intensive Care Unit respiratory medicine wards of two public hospitals in Delhi.

RESULTS

A total of 261 medical records were analyzed. Over the 5 years, 82.0% (2007-08), 78.6% (2008-09), 59.5% (2009-10), 64.7% (2010-11), and 67.8% (2011-12) patients were prescribed two antimicrobials. In the last two study years, the proportion of patients receiving three antimicrobials increased (from 2.0% to 26.5% and 28.8%), while the proportion receiving monotherapy decreased (from 16.0% to 8.8% and 3.4%). In accordance with guidelines, beta-lactams and macrolides were the two most frequently prescribed antimicrobials (34.1%). However, newer generation beta-lactams were prescribed. A total of 37 patients were prescribed beta-lactam-tazobactam combination preparations. Overall, beta-lactams constituted more than 40% of prescriptions while macrolides were the second most prescribed class. Cephalosporin prescriptions significantly increased (P < 0.01) and penicillin prescriptions significantly decreased over study periods. The prescription of fluoroquinolones also decreased (21.5-6.0%, P < 0.01) and aminoglycoside prescription ranged from 9.7% to 16.4%, over 5 years. Reasons for prescribing three antimicrobials, use of aminoglycosides, or higher-end/reserve antibiotics were not mentioned in the medical records. There were no hospital-specific guidelines for doctors to follow in the treatment of CAP.

CONCLUSIONS

These findings suggest the need for implementing antimicrobial treatment guidelines. Adequate documentation and monitoring of antibiotic use for feedback are also lacking. An antimicrobial stewardship program may offer the most comprehensive solution for appropriate use of antimicrobials.

Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial

BACKGROUND

Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England.

METHODS

In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed.

FINDINGS

Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126.98 (95% CI 125.68-128.27) in the feedback intervention group and 131.25 (130.33-132.16) in the control group, a difference of 4.27 (3.3%; incidence rate ratio [IRR] 0.967 [95% CI 0.957-0.977]; p<0.0001), representing an estimated 73,406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135.00 [95% CI 133.77-136.22] in the patient-focused intervention group and 133.98 [133.06-134.90] in the control group; IRR for difference between groups 1.01, 95% CI 1.00-1.02; p=0.105).

INTERPRETATION

Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes.

FUNDING

Public Health England.

The Impact of WHO Essential Medicines Policies on Inappropriate Use of Antibiotics

BACKGROUND

Inappropriate overuse of antibiotics contributes to antimicrobial resistance (AMR), yet policy implementation to reduce inappropriate antibiotic use is poor in low and middle-income countries.

AIMS

To determine whether public sector inappropriate antibiotic use is lower in countries reporting implementation of selected essential medicines policies.

MATERIALS AND METHODS

Results from independently conducted antibiotic use surveys in countries that did, and did not report implementation of policies to reduce inappropriate antibiotic prescribing, were compared. Survey data on four validated indicators of inappropriate antibiotic use and 16 self-reported policy implementation variables from WHO databases were extracted. The average difference for indicators between countries reporting versus not reporting implementation of specific policies was calculated. For 16 selected policies we regressed the four antibiotic use variables on the numbers of policies the countries reported implementing.

RESULTS

Data were available for 55 countries. Of 16 policies studied, four (having a national Ministry of Health unit on promoting rational use of medicines, a national drug information centre and provincial and hospital drugs and therapeutics committees) were associated with statistically significant reductions in antibiotic use of ≥20% in upper respiratory infection (URTI). A national strategy to contain antibiotic resistance was associated with a 30% reduction in use of antibiotics in acute diarrheal illness. Policies seemed to be associated with greater effects in antibiotic use for URTI and diarrhea compared with antibiotic use in all patients. There were negative correlations between the numbers of policies reported implemented and the percentage of acute diarrhoea cases treated with antibiotics (r = -0.484, p = 0.007) and the percentage of URTI cases treated with antibiotics (r = -0.472, p = 0.005). Major study limitations were the reliance on self-reported policy implementation data and antibiotic use data from linited surveys.

CONCLUSIONS

Selected essential medicines policies were associated with lower antibiotic use in low and middle income countries.

Proper use of carbapenems: Role of the infectious disease specialist

OBJECTIVE

One of the objectives of the French national plan on antibiotics is to preserve antibiotic effectiveness. A group of infectious disease specialists of the University hospital of Bordeaux aimed to monitor the prescriptions of broad-spectrum antibiotics. Particular attention was paid to carbapenem (CBP) prescriptions given the increase in betalactamase- and carbapenemase-producing bacteria.

PATIENTS AND METHODS

We carried out a three-step Professional Practice Evaluation (PPE): evaluation of CBP prescriptions made at the hospital between January and June 2013; CBP prescription training for prescribers; and another evaluation of CBP prescriptions between January and June 2014.

RESULTS

Although the number of admissions remained stable between the two evaluation periods, CBP prescriptions decreased by 16%. The mean treatment duration was stable (9.6 days). Physicians asked for the infectious disease specialist's advice for 82% of CBP prescriptions in 2013 and for 83% in 2014. The number of case patients discussed at the multidisciplinary staff meetings for approval of CBP prescriptions increased from 16% in 2013 to 39% in 2014. Antibiotic de-escalation increased by 61% between the two periods.

CONCLUSION

Professional Practice Evaluation, supervised by an infectious disease specialist, is a useful addition to weekly multidisciplinary staff meetings to improve CBP prescription.

Factors Influencing Antibiotic-Prescribing Decisions Among Inpatient Physicians: A Qualitative Investigation

OBJECTIVE

To understand the professional and psychosocial factors that influence physician antibiotic prescribing habits in the inpatient setting.

DESIGN

We conducted semi-structured interviews with 30 inpatient physicians. Interviews consisted of open-ended questions and flexible probes based on participant responses. Interviews were audio recorded, transcribed, de-identified, and reviewed for accuracy and completeness. Data were analyzed using emergent thematic analysis.

SETTING

Two teaching hospitals in Indianapolis, Indiana

PARTICIPANTS

A total of 30 inpatient physicians (10 physicians-in-training, 20 supervising staff) were enrolled in this study.

RESULTS

Participants recognized that antibiotics are overused, and many admitted to prescribing antibiotics even when the clinical evidence of infection was uncertain. Overprescription was largely driven by anxiety about missing an infection, whereas potential adverse effects of antibiotics did not strongly influence decision making. Participants did not routinely disclose potential adverse effects of antibiotics to inpatients. Physicians-in-training were strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians. Participants sometimes questioned their colleagues' antibiotic prescribing decisions, but they frequently avoided providing direct feedback or critique. These physicians cited obstacles of hierarchy, infrequent face-to-face encounters, and the awkwardness of these conversations.

CONCLUSION

A physician-based culture of prescribing antibiotics involves overusing antibiotics and not challenging the decisions of colleagues. The potential adverse effects of antibiotics did not strongly influence decision making in this sample. A better understanding of these factors could be leveraged in future efforts to improve antibiotic prescribing practices in the inpatient setting.

Pattern of Antibiotic Resistance Among Community Derived Isolates of Enterobacteriaceae Using Urine Sample: A Study From Northern India

BACKGROUND

Despite world-wide evidence of increased antibiotic resistance, there is scarce data on antibiotic resistance in community settings. One of the reason being difficulty in collection of biological specimen (traditionally stool) in community from apparently healthy individuals. Hence, finding an alternative specimen that is easier to obtain in a community setting or in large scale surveys for the purpose, is crucial. We conducted this study to explore the feasibility of using urine samples for deriving community based estimates of antibiotic resistance and to estimate the magnitude of resistance among urinary isolates of Escherichia coli and Klebsiella pneumonia against multiple antibiotics in apparently healthy individuals residing in a rural community of Haryana, North India.

MATERIALS AND METHODS

Eligible individuals were apparently healthy, aged 18 years or older. Using the health management information system (HMIS) of Ballabgarh Health Demographic Surveillance System (HDSS), sampling frame was prepared. Potential individuals were identified using simple random sampling. Random urine sample was collected in a sterile container and transported to laboratory under ambient condition. Species identification and antibiotic susceptibility testing for Enterobacteriaceae was done using Clinical Laboratory and Standards Institute (CLSI) 2012 guidelines. Multi-drug resistant (MDR) Enterobacteriaceae, Extended Spectrum Beta Lactamase (ESBL) producing Enterobacteriaceae, and Carbapenem producing Enterobacteriaceae (CRE) were identified from the urine samples.

RESULTS

A total of 433 individuals participated in the study (non-response rate - 13.4%), out of which 58 (13.4%) were positive for Enterobacteriaceae, 8.1% for E. coli and 5.3% for K. pneumoniae. Resistance against penicillin (amoxicillin/ampicillin) for E. coli and K. pneumoniae was 62.8% and 100.0% respectively. Isolates resistant to co-trimoxazole were 5.7% and 0.0% respectively. None of the isolates were resistant to imipenem, and meropenem.

CONCLUSION AND RECOMMENDATIONS

It is feasible to use urine sample to study magnitude of antibiotic resistance in population based surveys. At community level, resistance to amoxicillin was considerable, negligible for co-trimoxazole, and to higher antibiotics including carbapenems.

Prevalence and resistance patterns of commensal S. aureus in community-dwelling GP patients and socio-demographic associations. A cross-sectional study in the framework of the APRES-project in Austria

BACKGROUND

The aim of the present study was to assess the prevalence and resistance of commensal S. aureus in the nasal microbiota of community-dwelling persons in Austria, as well as to identify possible associations with socio-demographic factors. Multi-drug resistance in this population was additionally studied.

METHOD

This cross-sectional study was conducted within the context of the European APRES project. In nine European countries, nasal swabs were collected from 32,206 general practice patients who received care for non-infectious reasons. In Austria, 20 GPs attempted to recruit 200 consecutive patients without infectious diseases, with each patient completing demographic questionnaires as well as providing a nose swab sample. Isolation, identification, and resistance testing of S. aureus were performed. Statistical analyses included subgroup analyses and logistic regression models.

RESULTS

3309 nose swabs and corresponding questionnaires from Austrian subjects were analyzed. S. aureus was identified in 16.6 % (n = 549) of nose swabs, of which 70.1 % were resistant against one or more antibiotics, mainly penicillin. S. aureus carrier status was significantly associated with male sex (OR 1.6; 1.3-2.0), younger age (OR 1.3; 1.0-1.8), living in a rural area (OR 1.4; 1.1-1.7) and working in the healthcare sector (OR 1.5; 1.0-2.1). Multi-drug resistances were identified in 13.7 % (n = 75) of the S. aureus carriers and 1.5 % (n = 8) tested positive for MRSA. The highest resistance rate was observed against penicillin (64.8 %), followed by azithromycin (13.5 %) and erythromycin with 13.3 %.

CONCLUSION

This study describes the prevalence and resistance patterns of commensal S. aureus in community-dwelling persons in Austria and shows that differences exist between socio-demographic groups. Demographic associations have been found for S. aureus carriers but not for carriers of resistant S. aureus strains. Only two thirds of S. aureus strains were found to be resistant against small spectrum penicillin. As it is recognized that one of the corner stones for the containment of antibiotic resistance is the appropriate prescription of antibiotics in the outpatient sector, this finding lends support to the avoidance of prescription of broad-spectrum antibiotics to treat S. aureus infections in the community.

What is infectiveness and how is it involved in infection and immunity?

Proof of the Germ theory of disease and acceptance of Koch’s postulates in the late 1890’s launched the fields of microbial pathogenesis and infectious diseases and provided the conceptual framework that has guided thought and research in these fields. A central tenet that emerged from studies with microbes that fulfilled Koch’s postulates was that microbes that caused disease had characteristics that allowed them to do so, with the corollary that microbes that did not cause disease lacked disease-causing determinants. This observation, which held true for many diseases that were known to cause disease in the late 19^th century, such as toxin-producing and encapsulated bacteria, led to the view that the ability to cause disease rested with microbes and reflected the activity of specific determinants, or virulence factors. With the dawn of the 20^th century, efforts to neutralize virulence factors were under development and ultimately translated into anti-microbial therapy in the form of antibodies targeted to toxins and polysaccharide capsules. However, the 20^th century progressed, antibiotics were identified and developed as therapy for infectious diseases while other medical advances, such as specialized surgeries, intensive care units, intravenous catheters, and cytotoxic chemotherapy became commonplace in resourced nations. An unintended consequence of many of these advances was that they resulted in immune impairment. Similarly, HIV/AIDS, which emerged in the late 1970’s also produced profound immune impairment. Unexpectedly, the prevailing view that microbes were the sole perpetrators of virulence was untenable. Microbes that were rarely if ever associated with disease emerged as major causes of disease in people with impaired immunity. This phenomenon revealed that available explanations for microbial infectiveness and virulence were flawed. In this review, we discuss the question ‘what is infectiveness’ based on the tenets of the Damage-response framework.

Patient Attitudes and Patterns of Self-Medication with Antibiotics – A Cross-Sectional Study in Bulgaria

BACKGROUND: Self-medication with antibiotics is a major concern worldwide because of the high risks of antimicrobial resistance which may result in complicated courses of treatment, increased risk of death and excess costs to the healthcare systems.AIM: The aim was to study the attitudes and self-medication patterns as related to the use of antibiotics among the general Bulgarian population and their determinants.MATERIALS AND METHODS: A questionnaire-based survey was performed among the patients in two randomly selected municipalities. The questionnaire was mailed to 50 randomly selected adult patients by each of the 33 responding GPs thus addressing a total of 1650 participants.RESULTS: A total of 1050 patients completed and returned the questionnaire. The observed self-medication rate was 43%. The women and the younger employees and students tended to have a higher self-medication rate. Fever (22%), sore throat and cough (12.7%) and discomfort when urinating (8.2%) were the most frequent patterns related to the practice of self-medication.CONCLUSION: This analysis reported an extensive use of self-medication with antibiotics in the study population before the changes in the Bulgarian legislation. Younger age and social status (students, employed) were the most important socio-demographic patterns that had probably led towards self-medication with antibiotics.

Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem

Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.

Human enteroviruses are not the cause of neurological impairments in children at the Korle-Bu Teaching Hospital

INTRODUCTION

Convulsions associated with fever and acute onset of unknown aetiology with case fatalities have become a long observed medical condition at the Child Health Department of the Korle-Bu Teaching Hospital. Children admitted to the department with seizures of undetermined origin and fever has been a source of diagnostic confusion. Studies from the Asia Pacific region suggest a link with non-polio enteroviruses. The aim of the study was to investigate the association between non-polio enterovirus and acute encephalopathy causing neurological morbidity in children.

METHODS

One hundred and fifty cerebrospinal fluid (CSF), throat swab and serum samples were collected from participants at the Child Health Department of the Korle-Bu Teaching Hospital for virus isolation and characterization. Samples were cultured on cells and positive culture assayed by microneutralisation. Direct PCR as well as multiplex PCR were used to detect other viral agents present.

RESULTS

Enterovirus isolation rate was approximately 0.67%. Intratypic differentiation by molecular characterization identified a poliovirus from vaccine origin. Further screening by real-time RT-PCR identified the virus as normal Sabin and not vaccine-derive poliovirus. No arbovirus was however detected.

CONCLUSION

Non-polio enteroviruses and chikugunya virus were found not to be the etiologic agent responsible for the convulsion with neurologic morbidity observed in the Ghanaian children. Investigation for other viral agents is recommended.

Success stories of implementation of antimicrobial stewardship: a narrative review

It has been increasingly recognized that antimicrobial stewardship (AMS) has to be a key component of any efforts that aim to mitigate the current global antimicrobial resistance (AMR) crisis. It has also become evident that AMR is a problem that cannot be tackled by single institutions or physicians, but needs concerted actions at regional, national and supra-national levels. However, it is easy to become discouraged, given the problems that are often encountered when implementing AMS. The aim of this review is to highlight some of the success stories of AMS strategies, and to describe the actions that have been taken, the outcomes that have been obtained, and the obstacles that have been met. Although the best approach to effective AMS remains elusive and may vary significantly among settings, these diverse examples from a range of healthcare contexts demonstrate that effective AMS is possible. Such examples will inform others and encourage them to formally evaluate and share their results with the global stewardship community.

PNA-based microbial pathogen identification and resistance marker detection: An accurate, isothermal rapid assay based on genome-specific features

With the rapidly growing availability of the entire genome sequences of microbial pathogens, there is unmet need for increasingly sensitive systems to monitor the gene-specific markers for diagnosis of bacteremia that enables an earlier detection of causative agent and determination of drug resistance. To address these challenges, a novel FISH-type genomic sequence-based molecular technique is proposed that can identify bacteria and simultaneously detect antibiotic resistance markers for rapid and accurate testing of pathogens. The approach is based on a synergistic combination of advanced Peptide Nucleic Acid (PNA)-based technology and signal-enhancing Rolling Circle Amplification (RCA) reaction to achieve a highly specific and sensitive assay. A specific PNA-DNA construct serves as an exceedingly selective and very effective biomarker, while RCA enhances detection sensitivity and provide with a highly multiplexed assay system. Distinct-color fluorescent decorator probes are used to identify about 20-nucleotide-long signature sequences in bacterial genomic DNA and/or key genetic markers of drug resistance in order to identify and characterize various pathogens. The technique's potential and its utility for clinical diagnostics are illustrated by identification of S. aureus with simultaneous discrimination of methicillin-sensitive (MSSA) versus methicillin-resistant (MRSA) strains. Overall these promising results hint to the adoption of PNA-based rapid sensitive detection for diagnosis of other clinically relevant organisms. Thereby, new assay enables significantly earlier administration of appropriate antimicrobial therapy and may, thus have a positive impact on the outcome of the patient.

Detecting differential transmissibilities that affect the size of self-limited outbreaks

Our ability to respond appropriately to infectious diseases is enhanced by identifying differences in the potential for transmitting infection between individuals. Here, we identify epidemiological traits of self-limited infections (i.e. infections with an effective reproduction number satisfying [0 < R eff < 1) that correlate with transmissibility. Our analysis is based on a branching process model that permits statistical comparison of both the strength and heterogeneity of transmission for two distinct types of cases. Our approach provides insight into a variety of scenarios, including the transmission of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in the Arabian peninsula, measles in North America, pre-eradication smallpox in Europe, and human monkeypox in the Democratic Republic of the Congo. When applied to chain size data for MERS-CoV transmission before 2014, our method indicates that despite an apparent trend towards improved control, there is not enough statistical evidence to indicate that R eff has declined with time. Meanwhile, chain size data for measles in the United States and Canada reveal statistically significant geographic variation in R eff, suggesting that the timing and coverage of national vaccination programs, as well as contact tracing procedures, may shape the size distribution of observed infection clusters. Infection source data for smallpox suggests that primary cases transmitted more than secondary cases, and provides a quantitative assessment of the effectiveness of control interventions. Human monkeypox, on the other hand, does not show evidence of differential transmission between animals in contact with humans, primary cases, or secondary cases, which assuages the concern that social mixing can amplify transmission by secondary cases. Lastly, we evaluate surveillance requirements for detecting a change in the human-to-human transmission of monkeypox since the cessation of cross-protective smallpox vaccination. Our studies lay the foundation for future investigations regarding how infection source, vaccination status or other putative transmissibility traits may affect self-limited transmission.

The spread of carbapenemase-producing bacteria in Africa: a systematic review

BACKGROUND

Carbapenems are the last line of defence against ever more prevalent MDR Gram-negative bacteria, but their efficacy is threatened worldwide by bacteria that produce carbapenemase enzymes. The epidemiology of bacteria producing carbapenemases has been described in considerable detail in Europe, North America and Asia; however, little is known about their spread and clinical relevance in Africa.

METHODS

We systematically searched in PubMed, EBSCOhost, Web of Science, Scopus, Elsevier Masson Consulte and African Journals Online, international conference proceedings, published theses and dissertations for studies reporting on carbapenemase-producing bacteria in Africa. We included articles published in English or French up to 28 February 2014. We calculated the prevalence of carbapenemase producers only including studies where the total number of isolates tested was at least 30.

RESULTS

Eighty-three studies were included and analysed. Most studies were conducted in North Africa (74%, 61/83), followed by Southern Africa (12%, 10/83), especially South Africa (90%, 9/10), West Africa (8%, 7/83) and East Africa (6%, 6/83). Carbapenemase-producing bacteria were isolated from humans, the hospital environment and community environmental water samples, but not from animals. The prevalence of carbapenemase-producing isolates in hospital settings ranged from 2.3% to 67.7% in North Africa and from 9% to 60% in sub-Saharan Africa.

CONCLUSIONS

Carbapenemase-producing bacteria have been described in many African countries; however, their prevalence is poorly defined and has not been systematically studied. Antibiotic stewardship and surveillance systems, including molecular detection and genotyping of resistant isolates, should be implemented to monitor and reduce the spread of carbapenemase-producing bacteria.

WHO essential medicines policies and use in developing and transitional countries: an analysis of reported policy implementation and medicines use surveys

BACKGROUND

Suboptimal medicine use is a global public health problem. For 35 years the World Health Organization (WHO) has promoted essential medicines policies to improve quality use of medicines (QUM), but evidence of their effectiveness is lacking, and uptake by countries remains low. Our objective was to determine whether WHO essential medicines policies are associated with better QUM.

METHODS AND FINDINGS

We compared results from independently conducted medicines use surveys in countries that did versus did not report implementation of WHO essential medicines policies. We extracted survey data on ten validated QUM indicators and 36 self-reported policy implementation variables from WHO databases for 2002-2008. We calculated the average difference (as percent) for the QUM indicators between countries reporting versus not reporting implementation of specific policies. Policies associated with positive effects were included in a regression of a composite QUM score on total numbers of implemented policies. Data were available for 56 countries. Twenty-seven policies were associated with better use of at least two percentage points. Eighteen policies were associated with significantly better use (unadjusted p<0.05), of which four were associated with positive differences of 10% or more: undergraduate training of doctors in standard treatment guidelines, undergraduate training of nurses in standard treatment guidelines, the ministry of health having a unit promoting rational use of medicines, and provision of essential medicines free at point of care to all patients. In regression analyses national wealth was positively associated with the composite QUM score and the number of policies reported as being implemented in that country. There was a positive correlation between the number of policies (out of the 27 policies with an effect size of 2% or more) that countries reported implementing and the composite QUM score (r=0.39, 95% CI 0.14 to 0.59, p=0.003). This correlation weakened but remained significant after inclusion of national wealth in multiple linear regression analyses. Multiple policies were more strongly associated with the QUM score in the 28 countries with gross national income per capita below the median value (US$2,333) (r=0.43, 95% CI 0.06 to 0.69, p=0.023) than in the 28 countries with values above the median (r=0.22, 95% CI -0.15 to 0.56, p=0.261). The main limitations of the study are the reliance on self-report of policy implementation and measures of medicine use from small surveys. While the data can be used to explore the association of essential medicines policies with medicine use, they cannot be used to compare or benchmark individual country performance.

CONCLUSIONS

WHO essential medicines policies are associated with improved QUM, particularly in low-income countries. Please see later in the article for the Editors' Summary.

Antimicrobial stewardship in pediatrics: focusing on the challenges clinicians face

Background

Antimicrobial use is very common in hospitalized children. An assessment of clinician’s prevailing knowledge and clinical approach to prescribing antimicrobials is helpful in order to develop the best strategies for successful stewardship programs. The objectives of the study were to determine fundamental knowledge of principles, approach to antimicrobial use through the clinical vignettes and to identify perceived challenges in decreasing antimicrobial use.

Methods

A questionnaire was developed by subject matter experts and pretested to ensure validity. Using a cross-sectional prospective design, the questionnaire was completed anonymously by staff and trainee physicians at a single tertiary care pediatric hospital between late November 2011 and February 2012.

Results

Of 159 eligible physicians, 86 (54.1%) responded, of which 77 (46 staff and 31 trainees) reported regularly prescribing antimicrobials. The majority of physicians had modest knowledge of factors that would increase risk of resistance however, less than 20% had correct knowledge of local resistance patterns for common bacteria. Almost half of physicians correctly answered the clinical vignettes. Over half of trainees and one third of staff relied most on online manuals for information regarding antimicrobials to assist prescription decision-making. Overall, physicians perceived that discontinuing empiric antimicrobials was the most difficult to achieve to decrease antibiotic use.

Conclusions

Our results highlight several challenges that pediatric practioners face with respect to knowledge and approach to antimicrobial prescribing. Pediatric stewardship programs could in this setting focus on discontinuing antimicrobials appropriately and promoting local antibiograms in the proper clinical setting to decrease overall use of antimicrobials.

Antibiotic dispensation by Lebanese pharmacists: a comparison of higher and lower socio-economic levels

INTRODUCTION

Indiscriminate use of antibiotics contributes to a global spread of antimicrobial resistance. Previous studies showed an excessive consumption of antibiotics purchased without medical prescription from community pharmacies, mainly in developing countries. There is a shortage of studies revealing the role of community pharmacists in the overuse of antibiotics. Our objective is to study the dispensing policy of non-medical prescription antibiotics in community pharmacies, assessing the possible influence of the socio-economic level of the area over this practice.

METHODS

A cross-sectional study was conducted between February and May 2011 among 100 pharmacists working in Beirut's pharmacies and its suburbs. Pharmacies were divided into 2 groups according to the socio-economic level of the population living in the pharmacy area. A self-administered questionnaire was filled by pharmacists.

RESULTS

Over-the-counter antibiotic availability existed in both higher and lower socio-economic areas: on the whole, 32% of antibiotics were dispensed without medical prescription, with higher frequency in lower socio-economic areas (p=0.003). Dispensing injectable antibiotics without medical prescription was significantly higher in lower socio-economic areas (p=0.021), as well as dispensing an association of 2 antibiotics without medical prescription (p=0.001). Pharmacists working in lower socio-economic areas recommended more frequent antibiotics to children and the elderly (p<0.001 and p=0.004, respectively).

CONCLUSION

Dispensing antibiotics without medical prescription in Beirut community pharmacies is a common practice, particularly in lower socioeconomic areas. This public health problem should be addressed at the social, educational, and legislative levels.

Lowbury Lecture 2013. Cultural determinants of infection control behaviour: understanding drivers and implementing effective change

Despite dealing with biomedical practices, infection prevention and control (IPC) is essentially a behavioural science. Human behaviour is influenced by various factors, including culture. Hofstede's model of cultural dimensions proposes that national cultures vary along consistent dimensions which can be grouped and scored as specific constructs. Studies have reported that three Hofstede constructs--power distance, uncertainty avoidance, and masculinity--show significant association with several key performance indicators relevant to IPC and antibiotic stewardship. In addition, national meticillin-resistant Staphylococcus aureus (MRSA) levels within Europe correlate well with general quality-of-care indices, including preventive strategies and patient rights. This suggests that IPC may be simply a microcosm of overall quality and safety standards within hospitals and countries. Effective improvement would therefore need to address underlying and embedded core cultural values relevant to patient safety and quality of care. Successful IPC strategies are likely to be those that are compatible with the cultural background where they are implemented. To this end, content analysis of many current IPC improvement tools identifies elements of strong compatibility with cultures that are low in uncertainty avoidance and power distance, and high in individualism and masculinity. However, this cultural combination is largely restricted to Anglo-Saxon countries, where most of the recent improvements in healthcare-associated infection (HCAI) incidence have taken place. There is a paucity of research on IPC behaviour change in different cultural backgrounds, especially countries that score high for power distance and/or uncertainty avoidance. This information is vital to inform IPC campaigns in these countries, which often show high HCAI prevalence.