Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study

A case of acute myopericarditis associated with Mycoplasma pneumoniae infection in a child

Mycoplasma pneumoniae (M. pneumoniae) primarily causes respiratory tract infections in persons aged 5-20 years. Tracheobronchitis and bronchopneumonia are the most commonly recognized clinical symptoms associated with M. pneumoniae infection. Complications of this infection are unusual; in particular, cardiac involvement is very rare and is generally accompanied by pneumonia. Nonrespiratory illness can therefore involve direct invasion by M. pneumoniae or autoimmune mechanisms, as suggested by the frequency of cross reaction between human antigens and M. pneumoniae. Herein, we report a case of severe acute myopericarditis with pneumonia caused by M. pneumoniae in a healthy young child who presented with fever, lethargy, oliguria and dyspnea. She survived with aggressive therapy including clarithromycin, intravenous immunoglobulin, inotropics, and diuretics. The patient was discharged on the 19th day after admission and followed up 1 month thereafter at the outpatient clinic without sequelae.

Decline in macrolide-resistant Streptococcus pyogenes isolates from French children

We studied the macrolide resistance and serotypes of 585 group A streptococcus (GAS) isolates collected from French children with pharyngitis. Nineteen isolates (3.2%) were erythromycin-resistant and harbored the following resistance genes: 31.6% mef(A), 15.8% erm(A), and 52.6% erm(B). The 19 isolates included 7 different emm types (4, 1, 11, 2, 28, 12, and 77) and 7 corresponding multilocus sequence types. The current fall in macrolide consumption has led to a very low rate of GAS macrolide resistance.

Anti-inflammatory and immunomodulatory properties of azithromycin involved in treatment and prevention of chronic lung allograft rejection

Chronic lung allograft rejection is the single most important cause of death in lung transplant recipients after the first postoperative year, resulting in a 5-year survival rate of approximately 50%, which is far behind that of other solid organ transplantations. Spirometry is routinely used as a clinical marker for assessing pulmonary allograft function and diagnosing chronic lung allograft rejection after lung transplantation (LTx). As such, a progressive obstructive decline in pulmonary allograft function (forced expiratory volume in 1 sec [FEV1]) in absence of all other causes (currently defined as bronchiolitis obliterans syndrome [BOS]) is considered to reflect the evolution of chronic lung allograft rejection. BOS has a 5-year prevalence of approximately 45% and is thought to be the final common endpoint of various alloimmunologic and nonalloimmunologic injuries to the pulmonary allograft, triggering different innate and adaptive immune responses. Most preventive and therapeutic strategies for this complex process have thus far been largely unsuccessful. However, the introduction of the neomacrolide antibiotic azithromycin (AZI) in the field of LTx as of 2003 made it clear that some patients with established BOS might in fact benefit from such therapy due to its various antiinflammatory and immunomodulatory properties, as summarized in this review. Particularly in patients with an increased bronchoalveolar lavage neutrophilia (i.e., 15%-20% or more), AZI treatment could result in an increase in FEV1 of at least 10%. More recently, it has become clear that prophylactic therapy with AZI actually may prevent BOS and improve FEV1 after LTx, most likely through its interactions with the innate immune system. However, one should always be aware of possible adverse effects related to AZI when implementing this drug as prophylactic or long-term treatment. Even so, AZI therapy after LTx can generally be considered as safe.

Overview of strategies for overcoming the challenge of antimicrobial resistance

The discovery of penicillin undoubtedly transformed the management of life-threatening bacterial infections. However, a less comfortable aspect of the antibiotic revolution was that within 10 years, over 80% of patients with acute bronchitis were receiving antibiotics without any evidence of clinical benefit. Antibiotic use inevitably causes collateral damage to the normal human flora and increases the risk of infection with antibiotic-resistant bacteria and Clostridium difficile. The twin aims of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second to provide convincing evidence and information to educate and support professionals and patients to reduce unnecessary use and minimize collateral damage. We review evidence of progress with these aims in Europe and nationally in Scotland.

Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults

BACKGROUND

Community-acquired pneumonia (CAP) is caused by various pathogens, traditionally divided into 'typical' and 'atypical'. Initial antibiotic treatment of CAP is usually empirical, customarily covering both typical and atypical pathogens. To date, no sufficient evidence exists to support this broad coverage, while limiting coverage is bound to reduce toxicity, resistance and expense.

OBJECTIVES

The main objective was to estimate the mortality and proportion with treatment failure using regimens containing atypical antibiotic coverage compared to those that had typical coverage only. Secondary objectives included the assessment of adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012 which includes the Acute Respiratory Infection Group's Specialized Register, MEDLINE (January 1966 to April week 1, 2012) and EMBASE (January 1980 to April 2012).

SELECTION CRITERIA

Randomized controlled trials (RCTs) of adult patients hospitalized due to CAP, comparing antibiotic regimens with atypical coverage (quinolones, macrolides, tetracyclines, chloramphenicol, streptogramins or ketolides) to a regimen without atypical antibiotic coverage.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from included trials. We estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assessed heterogeneity using a Chi(2) test.

MAIN RESULTS

We included 28 trials, encompassing 5939 randomized patients. The atypical antibiotic was administered as monotherapy in all but three studies. Only one study assessed a beta-lactam combined with a macrolide compared to the same beta-lactam. There was no difference in mortality between the atypical arm and the non-atypical arm (RR 1.14; 95% CI 0.84 to 1.55), RR < 1 favors the atypical arm. The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae (L. pneumophilae) and non-significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of (total) adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were less common in the atypical arm (RR 0.70; 95% CI 0.53 to 0.92). Although the trials assessed different antibiotics, no significant heterogeneity was detected in the analyses.

AUTHORS' CONCLUSIONS

No benefit of survival or clinical efficacy was shown with empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta-lactams. Further trials, comparing beta-lactam monotherapy to the same combined with a macrolide, should be performed.

Evaluation of the Do Bugs Need Drugs? program in British Columbia: Can we curb antibiotic prescribing?

OBJECTIVE

Antibiotic resistance is accelerated by the overuse of antibiotics. Do Bugs Need Drugs? is an educational program adapted in British Columbia to target both the public and health care professionals, with the aim of reducing unnecessary prescribing. The current article presents a descriptive evaluation of the impact of the program over the first four years.

METHOD

Program implementation was measured by the amount of educational material distributed and the level of participation in educational sessions. The impact of the program was assessed by measuring changes in knowledge and prescribing habits of participating physicians, and by investigating provincial trends in antibiotic use.

RESULTS

A total of 51,367 children, assisted-living residents and health care professionals have participated in the program since its inception in the fall of 2005. Pre- and postcourse assessments of participating physicians indicated significant improvements in clinical knowledge and appropriate antibiotic treatment of upper respiratory tract infections. Overall rates of antibiotic use in the province have stabilized since 2006. The rates of consumption of fluoroquinolones and macrolides have levelled off since 2005. Utilization rates for acute bronchitis are at the same level as when the program was first implemented, but rates for other acute upper respiratory tract infections of interest have declined.

CONCLUSIONS

The Do Bugs Need Drugs? program significantly improves physician antibiotic prescription decisions and is ecologically associated with desirable change in population antibiotic consumption patterns.

Azithromycin for prevention of exacerbations in non-cystic fibrosis bronchiectasis (EMBRACE): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Azithromycin is a macrolide antibiotic with anti-inflammatory and immunomodulatory properties. We tested the hypothesis that azithromycin would decrease the frequency of exacerbations, increase lung function, and improve health-related quality of life in patients with non-cystic fibrosis bronchiectasis.

METHODS

We undertook a randomised, double-blind, placebo-controlled trial at three centres in New Zealand. Between Feb 12, 2008, and Oct 15, 2009, we enrolled patients who were 18 years or older, had had at least one pulmonary exacerbation requiring antibiotic treatment in the past year, and had a diagnosis of bronchiectasis defined by high-resolution CT scan. We randomly assigned patients to receive 500 mg azithromycin or placebo three times a week for 6 months in a 1:1 ratio, with a permuted block size of six and sequential assignment stratified by centre. Participants, research assistants, and investigators were masked to treatment allocation. The coprimary endpoints were rate of event-based exacerbations in the 6-month treatment period, change in forced expiratory volume in 1 s (FEV(1)) before bronchodilation, and change in total score on St George's respiratory questionnaire (SGRQ). Analyses were by intention to treat. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12607000641493.

FINDINGS

71 patients were in the azithromycin group and 70 in the placebo group. The rate of event-based exacerbations was 0·59 per patient in the azithromycin group and 1·57 per patient in the placebo group in the 6-month treatment period (rate ratio 0·38, 95% CI 0·26-0·54; p<0·0001). Prebronchodilator FEV(1) did not change from baseline in the azithromycin group and decreased by 0·04 L in the placebo group, but the difference was not significant (0·04 L, 95% CI -0·03 to 0·12; p=0·251). Additionally, change in SGRQ total score did not differ between the azithromycin (-5·17 units) and placebo groups (-1·92 units; difference -3·25, 95% CI -7·21 to 0·72; p=0·108).

INTERPRETATION

Azithromycin is a new option for prevention of exacerbations in patients with non-cystic fibrosis bronchiectasis with a history of at least one exacerbation in the past year.

FUNDING

Health Research Council of New Zealand and Auckland District Health Board Charitable Trust.

Macrolide treatment for Mycobacterium abscessus and Mycobacterium massiliense infection and inducible resistance

RATIONALE

Macrolides, such as clarithromycin (CLR) and azithromycin (AZM), are frequently the only oral antibiotics that are active against Mycobacterium abscessus and M. massiliense infections.

OBJECTIVES

To compare the activity of CLR and AZM in experimental models.

METHODS

We compared the treatment efficacies of CLR and AZM and determined the correlation between efficacy and induced erythromycin ribosome methyltransferase gene (erm)(41) expression in experimental models of M. abscessus and M. massiliense infections.

MEASUREMENTS AND MAIN RESULTS

In all tested M. abscessus isolates, a high level of inducible CLR resistance developed (minimal inhibitory concentration [MIC] on Day 3 versus Day 14; P < 0.001). Whereas the AZM MIC increased on Day 14 (P < 0.01 versus Day 3), the level was significantly lower than the CLR MIC on Day 14 (P < 0.001). However, the MICs of CLR and AZM for the M. massiliense isolates did not change. Compared with CLR, AZM presented greater antibiotic activity against M. abscessus in vitro, ex vivo, and in vivo (P < 0.05), whereas both macrolides were comparably effective against M. massiliense. In M. abscessus infection, the level of erm(41) expression was higher after exposure to CLR than after exposure to AZM (P < 0.001). Experiments using an erm(41)-knockout M. abscessus mutant and an M. massiliense transformant expressing M. abscessus erm(41) confirmed that erm(41) was responsible for inducible CLR resistance.

CONCLUSIONS

CLR induces greater erm(41) expression and thus higher macrolide resistance than AZM in M. abscessus infection. AZM may be more effective against M. abscessus, whereas both macrolides appear to be equally effective against M. massiliense.

Impact of recent antibiotics on nasopharyngeal carriage and lower airway infection in Indigenous Australian children with non-cystic fibrosis bronchiectasis

Indigenous Australian children have increased rates of bronchiectasis. Despite a lack of high-level evidence on effectiveness and antibiotic resistance, these children often receive long-term antibiotics. In this study, we determined the impact of recent macrolide (primarily azithromycin) and β-lactam antibiotic use on nasopharyngeal colonisation, lower airway infection (>10(4) CFU/mL of bronchoalveolar lavage fluid culture) and antibiotic resistance in non-typeable Haemophilus influenzae (NTHi), Streptococcus pneumoniae and Moraxella catarrhalis isolates from 104 Indigenous children with radiographically confirmed bronchiectasis. Recent antibiotic use was associated with significantly reduced nasopharyngeal carriage, especially of S. pneumoniae in 39 children who received macrolides [odds ratio (OR)=0.22, 95% confidence interval (CI) 0.08-0.63] and 26 children who received β-lactams (OR=0.07, 95% CI 0.01-0.32), but had no significant effect on lower airway infection involving any of the three pathogens. Children given macrolides were significantly more likely to carry (OR=4.58, 95% CI 1.14-21.7) and be infected by (OR=8.13, 95% CI 1.47-81.3) azithromycin-resistant S. pneumoniae. Children who received β-lactam antibiotics may be more likely to have lower airway infection with β-lactamase-positive ampicillin-resistant NTHi (OR=4.40, 95% CI 0.85-23.9). The risk of lower airway infection by antibiotic-resistant pathogens in children receiving antibiotics is of concern. Clinical trials to determine the overall benefit of long-term antibiotic therapy are underway.

Severity assessment for lower respiratory tract infections: potential use and validity of the CRB-65 in primary care

AIMS

To explore the potential use of the CRB-65 rule (based on Confusion, Respiratory rate, Blood pressure and age >65 years) in adults with lower respiratory tract infection (LRTI) in primary care.

METHODS

Primary care clinicians in 13 European countries recorded antibiotic treatment and clinical features for adults with LRTI. Patients recorded daily symptoms. Multilevel regression models determined the association between an elevated CRB-65 score and prolonged moderately severe symptoms, hospitalisation, and time to recovery. Sensitivity analyses used zero imputation.

RESULTS

Respiratory rate and blood pressure were recorded in 22.7% and 31.9% of patients, respectively. A total of 2,690 patients completed symptom diaries. The CRB-65 could be calculated for 339 (12.6%). A score of >1 was not significantly associated with prolonged moderately severe symptoms (odds ratio (OR) 0.42, 95% CI 0.04 to 4.19) or hospitalisations (OR 3.12, 95% CI 0.16 to 60.24), but was associated with prolonged time to self-reported recovery when using zero imputation (hazard ratio (HR) 0.75, 95% CI 0.64 to 0.88).

CONCLUSIONS

Respiratory rate and blood pressure are infrequently measured in adults with LRTI. We found no evidence to support using the CRB-65 rule in the assessment of LRTI in primary care. However, it is unclear whether it is of value if used only in patients where the primary care clinician suspects pneumonia.

Macrolides vs. quinolones for community-acquired pneumonia: meta-analysis of randomized controlled trials

The relative efficacy, safety and ecological implications of macrolides vs. quinolones in the treatment of community-acquired pneumonia (CAP) are debatable. We performed a systematic review and meta-analysis of randomized controlled trials comparing any macrolide vs. any quinolone for the treatment of CAP among adult inpatients or outpatients, as monotherapy or both in combination with a beta-lactam. We did not limit inclusion by pneumonia severity, publication status, language or date of publication. The primary outcomes assessed were 30-day all-cause mortality and treatment failure. Two authors independently extracted the data. Fixed effect meta-analysis of risk ratios (RRs) with 95% confidence intervals was performed. Sixteen trials (4989 patients) fulfilling inclusion criteria were identified, mostly assessing outpatients with mild to moderate CAP. All-cause mortality was not significantly different for macrolides vs. quinolones, RR 1.03 (0.63-1.68, seven trials), with a low event rate (2%). Treatment failure was significantly lower with quinolones, RR 0.78 (0.67-0.91, 16 trials). The definition of failure used in the primary studies was not clearly representative of patients' benefit. Microbiological failure was lower with quinolones, RR 0.63 (0.49-0.81, 13 trials). All adverse events, adverse events requiring discontinuation and any premature antibiotic discontinuation were significantly more frequent with macrolides, mainly on account of gastrointestinal adverse events. Resistance development was not assessed in the trials. Randomized controlled trials show an advantage of quinolones in the treatment of CAP with regard to clinical cure without need for antibiotic modification at end of treatment and gastrointestinal adverse events. The clinical significance of this advantage is unclear.

Use of a structured panel process to define quality metrics for antimicrobial stewardship programs

INTRODUCTION

Antimicrobial stewardship programs are being implemented in health care to reduce inappropriate antimicrobial use, adverse events, Clostridium difficile infection, and antimicrobial resistance. There is no standardized approach to evaluate the impact of these programs.

OBJECTIVE

To use a structured panel process to define quality improvement metrics for evaluating antimicrobial stewardship programs in hospital settings that also have the potential to be used as part of public reporting efforts.

DESIGN

A multiphase modified Delphi technique.

SETTING

Paper-based survey supplemented with a 1-day consensus meeting.

PARTICIPANTS

A 10-member expert panel from Canada and the United States was assembled to evaluate indicators for relevance, effectiveness, and the potential to aid quality improvement efforts.

RESULTS

There were a total of 5 final metrics selected by the panel: (1) days of therapy per 1000 patient-days; (2) number of patients with specific organisms that are drug resistant; (3) mortality related to antimicrobial-resistant organisms; (4) conservable days of therapy among patients with community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), or sepsis and bloodstream infections (BSI); and (5) unplanned hospital readmission within 30 days after discharge from the hospital in which the most responsible diagnosis was one of CAP, SSTI, sepsis or BSI. The first and second indicators were also identified as useful for accountability purposes, such as public reporting.

CONCLUSION

We have successfully identified 2 measures for public reporting purposes and 5 measures that can be used internally in healthcare settings as quality indicators. These indicators can be implemented across diverse healthcare systems to enable ongoing evaluation of antimicrobial stewardship programs and complement efforts for improved patient safety.

Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial

OBJECTIVE

To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.

DESIGN

Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.

SETTING

68 general practices with about 480,000 patients in Wales, United Kingdom.

PARTICIPANTS

34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.

INTERVENTIONS

Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices' own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.

MAIN OUTCOME MEASURES

Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year's dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.

RESULTS

The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (-0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.

CONCLUSION

The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs. Trial registration ISRCT No 63355948.

Phenotypes and genotypes of erythromycin-resistant Streptococcus pyogenes strains isolated from invasive and non-invasive infections from Mexico and the USA during 1999-2010

OBJECTIVE

To compare the prevalence, phenotypes, and genes responsible for erythromycin resistance among Streptococcus pyogenes isolates from Mexico and the USA.

METHODS

Eighty-nine invasive and 378 non-invasive isolates from Mexico, plus 148 invasive, 21 non-invasive, and five unclassified isolates from the USA were studied. Susceptibilities to penicillin, erythromycin, clindamycin, ceftriaxone, and vancomycin were evaluated according to Clinical and Laboratory Standards Institute (CLSI) standards. Phenotypes of erythromycin resistance were identified by triple disk test, and screening for mefA, ermTR, and ermB genes was carried out by PCR.

RESULTS

All isolates were susceptible to penicillin, ceftriaxone, and vancomycin. Erythromycin resistance was found in 4.9% of Mexican strains and 5.2% of USA strains. Phenotypes in Mexican strains were 95% M and 5% cMLS; in strains from the USA, phenotypes were 33.3% iMLS, 33.3% iMLS-D, and 33.3% M. Erythromycin resistance genes in strains from Mexico were mefA (95%) and ermB (5%); USA strains harbored ermTR (56%), mefA (33%), and none (11%). In Mexico, all erythromycin-resistant strains were non-invasive, whereas 89% of strains from the USA were invasive.

CONCLUSIONS

Erythromycin resistance continues to exist at low levels in both Mexico and the USA, although the genetic mechanisms responsible differ between the two nations. These genetic differences may be related to the invasive character of the S. pyogenes isolated.

Outpatient antibiotic prescribing and nonsusceptible Streptococcus pneumoniae in the United States, 1996-2003

BACKGROUND

Streptococcus pneumoniae infections have become increasingly complicated and costly to treat with the spread of antibiotic resistance. We evaluated the relationship between antibiotic prescribing and nonsusceptibility among invasive pneumococcal disease (IPD) isolates.

METHODS

Outpatient antibiotic prescription data for penicillins, cephalosporins, macrolides, and trimethoprim-sulfamethoxazole were abstracted from the IMS Health Xponent database to calculate the annual number of prescriptions per capita. We analyzed IPD data from 7 of the Centers for Disease Control and Prevention's Active Bacterial Core surveillance sites (population, 18.6 million) for which data were available for the entire time period under study (1996-2003). Logistic regression models were used to assess whether sites with high antibiotic prescribing rates had a high proportion of nonsusceptible and serotype 19A IPD.

RESULTS

Yearly prescribing rates during the period 1996-2003 for children <5 years of age decreased by 37%, from 4.23 to 2.68 prescriptions per capita per year (P < .001), and those for persons ≥5 years of age decreased by 42%, from 0.98 to 0.57 prescriptions per capita per year (P < .001); increases in azithromycin prescribing were noted for both groups. Sites with high rates of antibiotic prescribing had a higher proportion of IPD nonsusceptibility than did low-prescribing sites (P = .003 for penicillin, P < .001 for every other antibiotic class). Cephalosporin and macrolide prescribing were associated with penicillin and multidrug nonsusceptibility and serotype 19A IPD (P < .001).

CONCLUSIONS

In sites where antibiotic prescribing is high, the proportion of nonsusceptible IPD is also high, suggesting that local prescribing practices contribute to local resistance patterns. Cephalosporins and macrolides seem to be selecting for penicillin- and multidrug-resistant pneumococci, as well as serotype 19A IPD. Antibiotic use is a major factor contributing to the spread of antibiotic resistance; strategies to reduce antibiotic resistance should continue to include judicious use of antibiotics.

Blood, tissue, and intracellular concentrations of erythromycin and its metabolite anhydroerythromycin during and after therapy

For macrolides, clinical activity but also the development of bacterial resistance has been attributed to prolonged therapeutic and subtherapeutic concentrations. Although erythromycin is a long-established antimicrobial, concomitant determination of the pharmacokinetics of erythromycin and its metabolites in different compartments is limited. To better characterize the pharmacokinetics of erythromycin and its anhydrometabolite (anhydroerythromycin [AHE]) in different compartments during and after the end of treatment with 500 mg of erythromycin four times daily, concentration-time profiles were determined in plasma, interstitial space of muscle and subcutaneous adipose tissue, and white blood cells (WBCs) at days 1 and 3 of treatment and 2 and 7 days after end of therapy. In WBCs, concentrations of erythromycin exceeded those in plasma approximately 40-fold, while free concentrations in plasma and tissue were comparable. The observed delay of peak concentrations in tissue might be caused by fast initial cellular uptake. Two days after the end of treatment, subinhibitory concentrations were observed in plasma and interstitial space of both soft tissues, while 7 days after the end of treatment, erythromycin was not detectable in any compartment. This relatively short period of subinhibitory concentrations may be advantageous compared to other macrolides. The ratio of erythromycin over AHE on day 1 was highest in plasma (2.81 ± 3.45) and lowest in WBCs (0.27 ± 0.22). While the ratio remained constant between single dose and steady state, after the end of treatment the concentration of AHE declined more slowly than that of the parent compound, indicating the importance of the metabolite for the prolonged drug interaction of erythromycin.

Azithromycin in periodontal treatment: more than an antibiotic

Azithromycin is a macrolide antibiotic used extensively in medicine for the treatment of a wide range of infections such as upper respiratory tract infections, middle ear infections, sexually transmitted infections and trachoma. It is also effective against the most common periodontopathogens. The versatility of the macrolides extends beyond their antibiotic properties as a result of their well-documented immune-modulating/anti-inflammatory effects. Macrolides, including azithromycin, are therefore used to treat diseases not associated with bacteria, such as severe asthma, chronic obstructive pulmonary diseases and, more recently, cystic fibrosis. Azithromycin is concentrated in neutrophils, macrophages and particularly fibroblasts; all of these cells are central players in the pathogenesis of most periodontal diseases. This paper reviews the diverse properties of azithromycin and the clinical periodontal studies of its effects in both the treatment of periodontitis and in resolving drug-related gingival overgrowth. Evidence exists to support the use of a single course of azithromycin in the treatment of advanced periodontal diseases. Azithromycin could have a triple role in the treatment and resolution of periodontal diseases: suppressing periodontopathogens, anti-inflammatory activity and healing through persistence at low levels in macrophages and fibroblasts in periodontal tissues, even after a single course of three tablets. If future periodontal research confirms these properties, it could become a valuable host-modulator in periodontal treatment.

The appropriateness of prescribing antibiotics in the community in Europe: study design

Background

Over 90% of all antibiotics in Europe are prescribed in primary care. It is important that antibiotics are prescribed that are likely to be effective; however, information about antibiotic resistance in the community is incomplete. The aim of our study is to investigate the appropriateness of antibiotic prescribing in primary care in Europe by collecting and combining patterns of antibiotic resistance patterns and antibiotic prescription patterns in primary care. We will also evaluate the appropriateness of national antibiotic prescription guidelines in relation to resistance patterns.

Methods/Design

Antibiotic resistance will be studied in an opportunistic sample from the community in nine European countries. Resistance data will be collected by taking a nose swab of persons (N = 4,000 per country) visiting a primary care practice for a non-infectious disease. Staphylococcus aureus and Streptococcus pneumoniae will be isolated and tested for resistance to a range of antibiotics in one central laboratory. Data on antibiotic prescriptions over the past 5 years will be extracted from the electronic medical records of General Practitioners (GPs). The results of the study will include the prevalence and resistance data of the two species and 5 years of antibiotic prescription data in nine European countries.

The odds of receiving an effective antibiotic in each country will be calculated as a measure for the appropriateness of prescribing. Multilevel analysis will be used to assess the appropriateness of prescribing. Relevant treatment guidelines of the nine participating countries will be evaluated using a standardized instrument and related to the resistance patterns in that country.

Discussion

This study will provide valuable and unique data concerning resistance patterns and prescription behaviour in primary care in nine European countries. It will provide evidence-based recommendations for antibiotic treatment guidelines that take resistance patterns into account which will be useful for both clinicians and policy makers. By improving antibiotic use we can move towards controlling the resistance problem globally.

Description of macrolide-resistant and potential virulent clones of Streptococcus pyogenes causing asymptomatic colonization during 2000-2006 in the Lisbon area

The asymptomatic oropharyngeal colonization rate by Streptococcus pyogenes was 10.7% in children (901 among 8,405 children 0-16 years old) and 3.3% in adults (37 among 1,126 households of children) in the Lisbon area during 2000-2006. Macrolide-resistant S. pyogenes from children (n = 149) was variable with time: 9.8-10.7% in 2000-2002, 28.1% in 2003, 19.6-2.7% in 2004-2005 and 14.6% in 2006. Eight lineages (97.3% of isolates) were identified based on at least 80% similarity of PFGE patterns, T types, emm types and multilocus sequence types (ST). The elevated frequency of macrolide resistance was associated with M phenotype lineages I (emm12/ST36) and V (emm4, emm75/ST39 and a novel emmstMrp6 type) and with one cMLS(B) lineage IV (emm28/ST52) known to be associated with upper respiratory tract and invasive infections. Significant associations (p < 0.05) between emm type/virulence genotype were found, such as emm1/speA (+) ssa (-), emm4/ssa (+) prtF1 (+), emm12/speA (-) ssa (-). The high prevalence (>20%) of speC, prtF1 or ssa was probably caused either by clonal dissemination (speC), or to horizontal gene transfer events (prtF1 and ssa). This report contributes to a better understanding of the molecular epidemiology and evolution of macrolide-resistant S. pyogenes causing symptom-free oropharyngeal colonization. These colonizing strains carry macrolide resistance and virulence genes capable of being transferred to other bacterial species sharing the same niche.

GPs' views in five European countries of interventions to promote prudent antibiotic use

BACKGROUND

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

AIM

To explore GPs' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

DESIGN AND SETTING

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

METHOD

Fifty-two semi-structured interviews explored GPs' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

RESULTS

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

CONCLUSION

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.

A review of the epidemiology, diagnosis and evidence-based management of Mycoplasma genitalium

Mycoplasma genitalium is attracting increasing recognition as an important sexually transmitted pathogen. Presented is a review of the epidemiology, detection, presentation and management of M. genitalium infection. Accumulating evidence suggests that M. genitalium is an important cause of non-gonococcal, non-chlamydial urethritis and cervicitis, and is linked with pelvic inflammatory disease and, possibly, obstetric complications. Although there is no standard detection assay, several nucleic acid amplification tests have >95% sensitivity and specificity for M. genitalium. To date, there is a general lack of established protocols for screening in public health clinics. Patients with urethritis or cervicitis should be screened for M. genitalium and some asymptomatic sub-groups should be screened depending on individual factors and local prevalence. Investigations estimating M. genitalium geographic prevalence document generally low incidence, but some communities exhibit infection frequencies comparable to that of Chlamydia trachomatis. Accumulating evidence supports an extended regimen of azithromycin for treatment of M. genitalium infection, as data suggest that stat 1 g azithromycin may be less effective. Although data are limited, azithromycin-resistant cases documented to date respond to an appropriate fluoroquinolone (e.g. moxifloxacin). Inconsistent clinical recognition of M. genitalium may result in treatment failure and subsequent persistence due to ineffective antibiotics. The contrasting nature of existing literature regarding risks of M. genitalium infection emphasises the need for further carefully controlled studies of this emerging pathogen.

Antimicrobial stewardship: attempting to preserve a strategic resource

Antimicrobials hold a unique place in our drug armamentarium. Unfortunately the increase in resistance among both gram-positive and gram-negative pathogens coupled with a lack of new antimicrobial agents is threatening our ability to treat infections. Antimicrobial use is the driving force behind this rise in resistance and much of this use is suboptimal. Antimicrobial stewardship programs (ASP) have been advocated as a strategy to improve antimicrobial use. The goals of ASP are to improve patient outcomes while minimizing toxicity and selection for resistant strains by assisting in the selection of the correct agent, right dose, and best duration. Two major strategies for ASP exist: restriction/pre-authorization that controls use at the time of ordering and audit and feedback that reviews ordered antimicrobials and makes suggestions for improvement. Both strategies have some limitations, but have been effective at achieving stewardship goals. Other supplemental strategies such as education, clinical prediction rules, biomarkers, clinical decision support software, and institutional guidelines have been effective at improving antimicrobial use. The most effective antimicrobial stewardship programs have employed multiple strategies to impact antimicrobial use. Using these strategies stewardship programs have been able to decrease antimicrobial use, the spread of resistant pathogens, the incidence of C. difficile infection, pharmacy costs, and improved patient outcomes.

Clarithromycin, a cytochrome P450 inhibitor, can reverse mefloquine resistance in Plasmodium yoelii nigeriensis- infected Swiss mice

During the last 2 decades there have been numerous reports of the emergence of mefloquine resistance in Southeast Asia and nearly 50% resistance is reported in Thailand. A World Health Organization report (2001) considers mefloquine as an important component of ACT (artesunate+mefloquine) which is the first line of treatment for the control of uncomplicated/multi-drug resistant (MDR) Plasmodium falciparum malaria. In view of the emergence of resistance towards this drug, it is proposed to develop new drug combinations to prolong the protective life of this drug. Prior studies have suggested that mefloquine resistance can be overcome by a variety of agents such as ketoconazole, cyproheptadine, penfluridol, Icajine and NP30. The present investigation reports that clarithromycin (CLTR), a new macrolide, being a potent inhibitor of Cyt. P450 3A4, can exert significant resistance reversal action against mefloquine resistance of plasmodia. Experiments were carried out to find out the curative dose of CLTR against multi-drug resistant P. yoelii nigeriensis. Mefloquine (MFQ) and clarithromycin (CLTR) combinations have been used for the treatment of this MDR parasite. Different dose combinations of these two drugs were given to the infected mice on day 0 (prophylactic) and day 1 with established infection (therapeutic) to see the combined effect of these combinations against the MDR malaria infection. With a dose of 32 mg/kg MFQ and 225 mg/kg CLTR, 100% cure was observed, while in single drug groups, treated with MFQ or CLTR, the cure was zero and 40% respectively. Therapeutically, MFQ and CLTR combinations 32+300 mg/kg doses cleared the established parasitaemia on day 10. Single treatment with MFQ or CLTR showed considerable suppression of parasitaemia on day 14 but neither was curative. Follow-up of therapeutically treated mice showed enhanced anti-malarial action as reflected by their 100% clearance of parasitaemia. The present study reveals that CLTR is a useful antibiotic to be used as companion drug with mefloquine in order to overcome mefloquine resistance in plasmodia.

Secular trends in antibiotic consumption in the adult population in Emilia-Romagna, Italy, 2003-2009

Antibiotic resistance is closely related to antibiotic use and Italy is a country with high levels of both antibiotic use and antimicrobial resistance. We analysed the trend in antibiotic use in the community among adults (≥15 years) and elderly, in the period 2003-2009, in Emilia-Romagna, Italy, a region with over 4 000 000 inhabitants. Data regarding antibiotic use were obtained from the regional public health system databases. Between 2003 and 2009 the antibiotic consumption increased from 15.4 to 18.7 defined daily doses/1000 inhabitants per day (DID) (+21.4%, p <0.0001). The prescription rate in 2009 was 2.19 prescriptions/1000 inhabitants per day, an increase of 13.8% compared with 2003. The highest increase in antibiotic use was observed among persons aged 20-59 years (+24.7%). The proportion of inhabitants receiving at least one antibiotic treatment was 36.4% in 2003 and 39.7% in 2009, and the proportions receiving at least three antibiotic treatments were 3.5% and 4.2%, respectively. The H1N1 pandemic was associated, in October and November 2009, with a 37-90% increase in antibiotic use among the 15-19-year and 20-59-year age groups compared with 2007 and 2008. No other difference was observed in any other age group. The analysis per antibiotic class showed increases for penicillin + beta-lactamase inhibitor (from 3.6 to 6.3 DID), quinolones (from 2.6 to 3.0 DID) and macrolides (from 3.1 to 3.7 DID), whereas cephalosporin use was stable (1.4 DID). A steady increase in antibiotic use in the adult population has been observed in the Emilia-Romagna: public health interventions are mandatory to counteract this trend.

Access to a polymerase chain reaction assay method targeting 13 respiratory viruses can reduce antibiotics: a randomised, controlled trial

BACKGROUND

Viral respiratory infections are common worldwide and range from completely benign disease to life-threatening illness. Symptoms can be unspecific, and an etiologic diagnosis is rarely established because of a lack of suitable diagnostic tools. Improper use of antibiotics is common in this setting, which is detrimental in light of the development of bacterial resistance. It has been suggested that the use of diagnostic tests could reduce antibiotic prescription rates. The objective of this study was to evaluate whether access to a multiplex polymerase chain reaction (PCR) assay panel for etiologic diagnosis of acute respiratory tract infections (ARTIs) would have an impact on antibiotic prescription rate in primary care clinical settings.

METHODS

Adult patients with symptoms of ARTI were prospectively included. Nasopharyngeal and throat swabs were analysed by using a multiplex real-time PCR method targeting thirteen viruses and two bacteria. Patients were recruited at 12 outpatient units from October 2006 through April 2009, and samples were collected on the day of inclusion (initial visit) and after 10 days (follow-up visit). Patients were randomised in an open-label treatment protocol to receive a rapid or delayed result (on the following day or after eight to twelve days). The primary outcome measure was the antibiotic prescription rate at the initial visit, and the secondary outcome was the total antibiotic prescription rate during the study period.

RESULTS

A total sample of 447 patients was randomised. Forty-one were excluded, leaving 406 patients for analysis. In the group of patients randomised for a rapid result, 4.5% (9 of 202) of patients received antibiotics at the initial visit, compared to 12.3% (25 of 204) (P = 0.005) of patients in the delayed result group. At follow-up, there was no significant difference between the groups: 13.9% (28 of 202) in the rapid result group and 17.2% (35 of 204) in the delayed result group (P = 0.359), respectively.

CONCLUSIONS

Access to a rapid method for etiologic diagnosis of ARTIs may reduce antibiotic prescription rates at the initial visit in an outpatient setting. To sustain this effect, however, it seems necessary to better define how to follow and manage the patient according to the result of the test, which warrants further investigation.

Infectious disease management in primary care: perceptions of GPs

Background

It is important to keep the level of antibiotic prescribing low to contain the development of resistant bacteria. This study was conducted to reveal new knowledge about how GPs think in relation to the prescribing of antibiotics - knowledge that could be used in efforts toward rational treatment of infectious diseases in primary care. The aim was to explore and describe the variations in GPs' perceptions of infectious disease management, with special reference to antibiotic prescribing.

Methods

Twenty GPs working at primary care centres in a county in south-west Sweden were purposively selected based on the strategy of including GPs with different kinds of experience. The GPs were interviewed and perceptions among GPs were analysed by a phenomenographic approach.

Results

Five qualitatively different perceptions of infectious disease management were identified. They were: (A) the GP must help the patient to achieve health and well-being; (B) the management must meet the GP's perceived personal, professional and organisational demands; (C) restrictive antibiotic prescribing is time-consuming; (D) restrictive antibiotic prescribing can protect the effectiveness of antibiotics; and (E) patients benefit personally from restrictive antibiotic prescribing.

Conclusions

Restrictive antibiotic prescribing was considered important in two perceptions, was not an issue as such in two others, and was considered in one perception although the actual prescribing was greatly influenced by the interaction between patient and GP. Accordingly, to encourage restrictive antibiotic prescribing several aspects must be addressed. Furthermore, different GPs need various kinds of support. Infectious disease management in primary care is complex and time-consuming, which must be acknowledged in healthcare organisation and planning.

Antibiotic selection pressure and macrolide resistance in nasopharyngeal Streptococcus pneumoniae: a cluster-randomized clinical trial

BACKGROUND

It is widely thought that widespread antibiotic use selects for community antibiotic resistance, though this has been difficult to prove in the setting of a community-randomized clinical trial. In this study, we used a randomized clinical trial design to assess whether macrolide resistance was higher in communities treated with mass azithromycin for trachoma, compared to untreated control communities.

METHODS AND FINDINGS

In a cluster-randomized trial for trachoma control in Ethiopia, 12 communities were randomized to receive mass azithromycin treatment of children aged 1-10 years at months 0, 3, 6, and 9. Twelve control communities were randomized to receive no antibiotic treatments until the conclusion of the study. Nasopharyngeal swabs were collected from randomly selected children in the treated group at baseline and month 12, and in the control group at month 12. Antibiotic susceptibility testing was performed on Streptococcus pneumoniae isolated from the swabs using Etest strips. In the treated group, the mean prevalence of azithromycin resistance among all monitored children increased from 3.6% (95% confidence interval [CI] 0.8%-8.9%) at baseline, to 46.9% (37.5%-57.5%) at month 12 (p = 0.003). In control communities, azithromycin resistance was 9.2% (95% CI 6.7%-13.3%) at month 12, significantly lower than the treated group (p < 0.0001). Penicillin resistance was identified in 0.8% (95% CI 0%-4.2%) of isolates in the control group at 1 year, and in no isolates in the children-treated group at baseline or 1 year.

CONCLUSIONS

This cluster-randomized clinical trial demonstrated that compared to untreated control communities, nasopharyngeal pneumococcal resistance to macrolides was significantly higher in communities randomized to intensive azithromycin treatment. Mass azithromycin distributions were given more frequently than currently recommended by the World Health Organization's trachoma program. Azithromycin use in this setting did not select for resistance to penicillins, which remain the drug of choice for pneumococcal infections.

TRIAL REGISTRATION

www.ClinicalTrials.gov NCT00322972. Please see later in the article for the Editors' Summary.

Antimicrobial use and indication-based prescribing among general practitioners in Eastern Croatia: comparison with data from the European Surveillance of Antimicrobial Consumption project

AIM

To investigate antibiotic consumption in a sample of physicians from Osijek-Baranja county in Eastern Croatia and to determine the volume of prescribed antimicrobials and assess the appropriateness of prescribing practices.

METHODS

Analysis of routine prescribing data was carried out in 30 primary care practices in both urban and rural communities of eastern Croatia, corresponding to a total population of 48000 patients. Prescribing practices were studied over a period of 3 years, from 2003 to 2005. Both the quantity of antimicrobials and differences and similarities between individual practitioners were analyzed.

RESULTS

Urban and rural practices did not significantly differ in regard to the volume of antimicrobials prescribed. However, significant differences were found between individual physicians. Total consumption was 17.73 defined daily doses per 1000 inhabitants per day or 6456.85 defined daily doses per 1000 inhabitants per year. The 10 most frequently used antimicrobials (93.70% of the total quantity) were amoxicillin, co-amoxiclav, co-trimoxazole, cephalexin, norfloxacin, penicillin V, azithromycin, cefuroxime, doxycycline, and nitrofurantoin. Sore throat was the most frequent reason for prescribing antibiotics.

CONCLUSION

Prescription of medicines in Osijek-Baranja county was characterized by high consumption of broad-spectrum penicillins, combined penicillins, combined sulfonamides and long-acting macrolides (azithromycin), together with disproportionately low use of doxycycline and erythromycin. The use of combined sulfonamides and azithromycin in this part of Croatia was among the highest in Europe. Great differences between prescribers in regard to indication-based prescribing have been found, and future studies should examine the factors behind these heterogeneous practices.

Antimicrobial stewardship: an evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute hospitals

OBJECTIVES

To describe the methodology in developing an antimicrobial self-assessment toolkit (ASAT).

METHODS

The ASAT was developed through a National Pharmacy Reference Group using an evidence-based approach of published information and national reports to identify criteria for inclusion. These were subdivided into domains that addressed: 1) Antimicrobial management within the Trust-structures and lines of responsibility and accountability-high-level notification to the Board. 2) Operational delivery of an antimicrobial strategy-operational standards of good antimicrobial stewardship. 3) Risk assessment for antimicrobial chemotherapy. 4) Clinical governance assurance. 5) Education and training-training needs and delivery of education and training for all who issue, prescribe and administer antimicrobials. 6) Antimicrobial pharmacist-systems in place for ensuring their optimum use. 7) Patients, Carers and the Public-information needs of patients, carers and the public.

RESULTS

A web-based toolkit was developed using information from national reports and guidance on antimicrobial stewardship. The toolkit offers a checklist for hospitals to self-assess their organizations' levels of antimicrobial stewardship.

CONCLUSIONS

The ASAT offers a web-enabled, version-controlled instrument for the assessment of antimicrobial stewardship in acute hospitals. It may offer a sensitive instrument to assess longitudinal progress on antimicrobial stewardship in an individual institution or act as a benchmark with similar organizations. Further work is ongoing to evaluate and further refine the ASAT.

Different patterns of inappropriate antimicrobial use in surgical and medical units at a tertiary care hospital in Switzerland: a prevalence survey

Background

Unnecessary or inappropriate use of antimicrobials is associated with the emergence of antimicrobial resistance, drug toxicity, increased morbidity and health care costs. Antimicrobial use has been reported to be incorrect or not indicated in 9–64% of inpatients. We studied the quality of antimicrobial therapy and prophylaxis in hospitalized patients at a tertiary care hospital to plan interventions to improve the quality of antimicrobial prescription.

Methodology/Principal Findings

Experienced infectious diseases (ID) fellows performed audits of antimicrobial use at regular intervals among all patients—with or without antimicrobials—hospitalized in predefined surgical, medical, haemato-oncological, or intensive care units. Data were collected from medical and nursing patient charts with a standardized questionnaire. Appropriateness of antimicrobial use was evaluated using a modified algorithm developed by Gyssens et al.; the assessment was double-checked by a senior ID specialist.

We evaluated 1577 patients of whom 700 (44.4%) had antimicrobials, receiving a total of 1270 prescriptions. 958 (75.4%) prescriptions were for therapy and 312 (24.6%) for prophylaxis. 37.0% of therapeutic and 16.6% of prophylactic prescriptions were found to be inappropriate. Most frequent characteristics of inappropriate treatments included: No indication (17.5%); incorrect choice of antimicrobials (7.6%); incorrect application of drugs (9.3%); and divergence from institutional guidelines (8%). Characteristics of inappropriate prophylaxes were: No indication (9%); incorrect choice of antimicrobials (1%); duration too long or other inappropriate use (6.7%). Patterns of inappropriate antimicrobial varied widely in the different hospital units; empirical prescriptions were more frequently incorrect than prescriptions based on available microbiological results.

Conclusions/Significance

Audits of individual patient care provide important data to identify local problems in antimicrobial prescription practice. In our study, antimicrobial prescriptions without indication, and divergence from institutional guidelines were frequent errors. Based on these results, we will tailor education, amend institutional guidelines and further develop the infectious diseases consultation service.

Mechanisms of action and clinical application of macrolides as immunomodulatory medications

Macrolides have diverse biological activities and an ability to modulate inflammation and immunity in eukaryotes without affecting homeostatic immunity. These properties have led to their long-term use in treating neutrophil-dominated inflammation in diffuse panbronchiolitis, bronchiectasis, rhinosinusitis, and cystic fibrosis. These immunomodulatory activities appear to be polymodal, but evidence suggests that many of these effects are due to inhibition of extracellular signal-regulated kinase 1/2 (ERK1/2) phosphorylation and nuclear factor kappa B (NF-kappaB) activation. Macrolides accumulate within cells, suggesting that they may associate with receptors or carriers responsible for the regulation of cell cycle and immunity. A concern is that long-term use of macrolides increases the emergence of antimicrobial resistance. Nonantimicrobial macrolides are now in development as potential immunomodulatory therapies.

Optimizing antibiotic prescribing in primary care settings in the UK: findings of a BSAC multi-disciplinary workshop 2009

Several UK resources, including the National Institute for Health and Clinical Excellence (NICE), Clinical Knowledge Summaries, the Infection Specialist Library, the HPA Management of Infection Guide, the Map of Medicine and the Royal College of General Practitioners (RCGP) web site, produce primary care antibiotic prescribing guidance. A BSAC 2009 workshop aimed to discuss how guidance could be best translated into practice using public and professional educational programmes. Workshop participants were asked to consider approaches within the context of a behaviour change model, in which readiness to change is recognized as a product of the individual's perception of the importance of change (the 'why' of change; 'Why should I change my antibiotic prescribing') and their confidence that they can achieve a change (the 'how' of change). Participants concluded that antibiotic education campaigns should be repeated during peak prescribing periods, should be located in pharmacies, clinical waiting areas and schools, and should be reinforced verbally during patient consultations for infections. Patients should receive clear information, ideally reinforced with leaflets, about the likely duration of symptoms, self-care and the likely benefits and harms of antibiotics. Education for clinicians needs to focus on increasing awareness of the importance of antibiotic resistance and providing tools to increase confidence in changing their prescribing. Videos are a useful tool for demonstrating good and poor communication skills and approaches to eliciting and addressing patient concerns and expectations. Well-designed patient information can facilitate consultations. Feedback and audit on antibiotic use to clinicians is essential; this can be facilitated by incentive schemes, especially if clinical records link diagnosis with prescriptions.

The global need for effective antibiotics: challenges and recent advances

The emerging problem of antibiotic resistance is a serious threat to global public health. The situation is aggravated by a substantial decline in the research and development of antibacterial agents. Hence, very few new antibacterial classes are brought to market when older classes lose their efficacy. There has been renewed and growing attention within policy groups to: (i) address the problem; (ii) discuss incentives for the development of urgently needed new treatments; (iii) preserve the efficacy of existing therapeutic options. We briefly review the basic principles of antibiotic resistance, and contrast the increasing resistance to the dwindling antibacterial 'pipeline'. We also highlight some recent policy initiatives aiming to secure the future need of effective antibiotics.

Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices

AIMS

To understand which clinical criteria physicians use to diagnose pneumonia compared to bronchitis and upper respiratory tract infection (URTI).

METHODS

Retrospective chart review of adults diagnosed with pneumonia, bronchitis, or URTI.

RESULTS

Logistic regression analysis identified rales, a temperature > 100 degrees F (37.8 degrees C), chest pain, dyspnoea, rhonchi, heart rate, respiratory rate, and rhinorrhoea, as the best explanation for the variation in diagnosis of pneumonia compared to either of the alternative diagnoses (R2 = 59.3), with rales and a temperature > 100 degrees F explaining 30% of the variation. Rales, chest pain, and a temperature > 100 degrees F best predicted the ordering of a chest x-ray (R2 = 20.0). However, 35% (59/175) of patients diagnosed with pneumonia had a negative chest x-ray. Abnormal breath sounds were the best predictors for prescribing antibiotics (R2 = 38%). A significant number of patients with acute bronchitis (93% excluding sinusitis) and URTI (42%) were given antibiotics.

CONCLUSIONS

The presence of abnormal breath sounds and a temperature > 100 degrees F were the best predictors of a diagnosis of pneumonia.

It's not easy being green: the viridans group streptococci, with a focus on pediatric clinical manifestations

The viridans group streptococci (VGS) are a heterogeneous group of organisms that can be human commensals, colonizing the gastrointestinal and genitourinary tracts in addition to the oral mucosa. VGS are generally considered to be of low pathogenic potential in immunocompetent individuals. However, in certain patient populations, VGS can cause invasive disease, such as endocarditis, intra-abdominal infection, and shock. Within the VGS, the rates and patterns of antimicrobial resistance vary greatly depending upon the species identification and the patient population. In general, Streptococcus mitis group organisms are resistant to more antimicrobial agents than the other VGS species. This review addresses current VGS taxonomy, in addition to the current methodologies being used in clinical microbiology laboratories for identification of VGS. Automated systems struggle overall with species level identification and susceptibility testing for VGS. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification is emerging as a potential alternative for organism identification. A review of recent pediatric-specific data regarding the clinical manifestations of VGS revealed that the Streptococcus anginosus group (SAG) organisms may be important pathogens in pediatric patients and that the VGS may contribute to disease in patients with cystic fibrosis. It also appears that rates of antimicrobial resistance in VGS in pediatric patients are surpassing those of the adult population.

In vitro additive effect of Hyptis martiusii in the resistance to aminoglycosides of methicillin-resistant Staphylococcus aureus

CONTEXT

Bacterial infectious agents represent a risk to populations, where they are responsible for the high morbidity and mortality. In combating these pathogens, our main line of defense is the use of antibiotics. However, the indiscriminate use of these drugs select resistant strains to these same drugs.

OBJECTIVE

In this study the ethanol extract of Hyptis martiusii Benth. (EEHM) (Lamiaceae) was tested for its antimicrobial activity against aminoglycoside multi-resistant Staphylococcus aureus (MRSA).

MATERIALS AND METHODS

In this study, the ethanol extract of H. martiusii was prepared and tested with chlorpromazine for its antimicrobial activity using the microdilution method. Chlorpromazine and the ethanol extract were used alone and also in combination with aminoglycosides against a MRSA strain resistant to these antibiotics to determine the participation of efflux systems in resistance mechanisms. The FIC index was calculated and evaluated by the checkerboard method.

RESULTS

A potentiating effect between this extract and aminoglycosides was demonstrated. Similarly, a potentiating effect of chlorpromazine with kanamycin was detected, indicating the involvement of an efflux system in the resistance to this aminoglycoside. The checkerboard method with combinations of aminoglycosides and EEHM demonstrated additive effect with kanamycin and gentamicin. It is therefore suggested that extracts from H. martiusii could be used as a source of plant-derived natural products with resistance- modifying activity.

CONCLUSION

This is the first report about the modifying antibiotic activity of Hyptis martiusii, constituting a new approach against bacterial resistance to antibiotics as aminoglycosides.

Long-term impacts of antibiotic exposure on the human intestinal microbiota

Although it is known that antibiotics have short-term impacts on the human microbiome, recent evidence demonstrates that the impacts of some antibiotics remain for extended periods of time. In addition, antibiotic-resistant strains can persist in the human host environment in the absence of selective pressure. Both molecular- and cultivation-based approaches have revealed ecological disturbances in the microbiota after antibiotic administration, in particular for specific members of the bacterial community that are susceptible or alternatively resistant to the antibiotic in question. A disturbing consequence of antibiotic treatment has been the long-term persistence of antibiotic resistance genes, for example in the human gut. These data warrant use of prudence in the administration of antibiotics that could aggravate the growing battle with emerging antibiotic-resistant pathogenic strains.

Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenter study

BACKGROUND

Self-medication is an important driver of antimicrobial overuse as well as a worldwide problem. The aim of the present study was to estimate the use of antibiotics, without medical prescription, in a sample of rural population presenting in primary care in southern Greece.

METHODS

The study included data from 1,139 randomly selected adults (545 men/594 women, mean age +/- SD: 56.2 +/- 19.8 years), who visited the 6 rural Health Centres of southern Greece, between November 2009 and January 2010. The eligible participants were sought out on a one-to-one basis and asked to answer an anonymous questionnaire.

RESULTS

Use of antibiotics within the past 12 months was reported by 888 participants (77.9%). 508 individuals (44.6%) reported that they had received antibiotics without medical prescription at least one time. The major source of self-medication was the pharmacy without prescription (76.2%). The antibiotics most frequently used for self-medication were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the most frequent indications for the use of self-medicated antibiotics.

CONCLUSION

In Greece, despite the open and rapid access to primary care services, it appears that a high proportion of rural adult population use antibiotics without medical prescription preferably for fever and common cold.

Prophylactic antibiotic therapy in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) represents a huge epidemiological burden and is associated with a high incidence of morbidity and mortality. The disease is characterized by chronic inflammation and bacterial colonization. Chronic bacterial colonization leads to chronic inflammation and epithelial damage that in turn may increase bacterial colonization and predispose to acute bacterial infection. Acute exacerbations are a major cause of hospitalization and lead to a deterioration in pulmonary function. Antibiotic treatment of acute bacterial exacerbations is a cornerstone of medical treatment. Conversely, the role of antibiotic prophylaxis in COPD in the stable state is controversial. From a theoretical point of view, antibiotic prophylaxis is intriguing as it could break the vicious circle between chronic bacterial colonization, inflammation and epithelial damage; however, evidence is scarce. This paper reviews the literature and focuses on the most recent data shedding light on this fascinating dilemma.

Effects of reducing beta-lactam antibiotic pressure on intestinal colonization of antibiotic-resistant gram-negative bacteria

Background

We determined the effects of two antibiotic policies (predominance of either β-lactam antibiotics or fluroquinolones) on acquisition with third-generation cephalosporin-resistant Enterobacteriaceae (CRE) and fluoroquinolone-resistant CRE (FCRE) in two ICUs, with monitoring of other variables that may influence acquisition.

Methods

After an 8-month baseline period, units were randomized to a predominant β-lactam antibiotic regimen (weekly cycling of ceftriaxone, amoxicillin–clavulanic acid and fluroquinolones) or a fluoroquinolone regimen for 3 months, with cross-over for another 3 months. Acquisition of CRE and FCRE was determined by microbiological surveillance.

Results

During baseline, acquisition rates for CRE and FCRE were 14/1,000 and 2/1,000 patient days at risk, respectively. Cross-transmission of CRE accounted for ≤25% of acquisitions, and CRE acquisition was associated with the use of β-lactam antibiotics (amoxicillin–clavulanic acid in particular). As compared to baseline, β-lactam antibiotic use [in defined daily dose (DDD)/1,000 patient days] was reduced from 854 to 526 (−39%) and 555 (−35%) during both intervention periods. Fluoroquinolone use was increased from 150 and 129 DDD/1,000 patient days in baseline and the β-lactam period to 514 DDD/1,000 patient days (+243%) in the fluoroquinolone period. Reductions in β-lactam use were not associated with reduced CRE acquisition [adjusted HRs were 1.0 (95% CR: 0.5–2.2) and 1.1 (95% CI: 0.5–2.5) during both periods, respectively]. Increased use of fluoroquinolones was associated with increased acquisition of FCRE [adjusted HR 4.1 (95% CI: 1.4–11.9; p < 0.01]. Infection control variables remained comparable during all periods.

Conclusion

A 35–39% reduction of β-lactam exposure was not associated with reduced acquisition of CRE, whereas a 243% increase of fluoroquinolone use increased acquisition of FCRE.