Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention

The Potential of Lactic Acid Bacteria and Dairy By-Products in Controlling Campylobacter jejuni in Poultry

Campylobacter jejuni (C. jejuni) is the primary Campylobacter species and a major cause of foodborne illness associated with poultry products. This review focuses on lactic acid bacteria (LAB), especially Lactobacillus species, and acid whey as a dairy by-product for C. jejuni control in poultry as a sustainable method. LAB strains L. crispatus exhibit a cecal colonization reduction of >90% by competitive exclusion and bacteriocin activity, while L. johnsonii FI9785 decrease bacterial load 4-5 log10. Acid whey, which is abundant in organic acids (e.g., lactic acid) and bioactive peptides (e.g., lactoferrin), reduces C. jejuni viability, decreasing the food product contamination on the carcass for a short time by 40%. LAB antimicrobial function becomes more effective when used with acid whey, although specific farm-related variables require additional optimization. Some of the key strategies include co-encapsulating LAB with acid whey or plant-derived antimicrobials for improving survival, conducting in vivo trials in commercial farm conditions to evaluate scalability, and adding whey into feed (1-2% inclusion) or applying it as a pre-slaughter spray. These strategies enable the antibiotic-free production and circular economy goals through repurposing low-cost acid whey. Future studies should directly compare them with standard antimicrobials to confirm their scalability for poultry safety.

Identifying targets for antibiotic stewardship interventions in pediatric patients in Punjab, Pakistan: point prevalence surveys using AWaRe guidance

Introduction

Surveillance of antibiotic use is crucial for identifying targets for antibiotic stewardship programs (ASPs), particularly in pediatric populations within countries like Pakistan, where antimicrobial resistance (AMR) is escalating. This point prevalence survey (PPS) seeks to assess the patterns of antibiotic use in pediatric patients across Punjab, Pakistan, employing the WHO AWaRe classification to pinpoint targets for intervention and encourage rational antibiotic usage.

Methods

A PPS was conducted across 23 pediatric wards of 14 hospitals in the Punjab Province of Pakistan using the standardized Global-PPS methodology developed by the University of Antwerp. The study included all pediatric inpatients receiving antibiotics at the time of the survey, categorizing antibiotic prescriptions according to the WHO Anatomical Therapeutic Chemical classification and the AWaRe classification system.

Results

Out of 498 pediatric patients, 409 were receiving antibiotics, representing an antibiotic use prevalence of 82.1%. A substantial majority (72.1%) of the prescribed antibiotics fell under the WHO's Watch category, with 25.7% in the Access category and 2.2% in the Reserve group. The predominant diagnoses were respiratory infections, notably pneumonia (32.4%). The most commonly used antibiotics were ceftriaxone (37.2%) and Vancomycin (13.5%). Only 2% of antibiotic uses were supported by culture sensitivity reports, highlighting a reliance on empirical therapy.

Conclusion

The high prevalence of antibiotic use, particularly from the Watch category, and low adherence to culture-based prescriptions underscore the critical need for robust antibiotic stewardship programs in Pakistan. Strengthening these programs could help mitigate AMR and optimize antibiotic use, aligning with global health objectives.

Hospital antimicrobial stewardship funding and resourcing impact on broad-spectrum antibiotic use: a cross-sectional study

Background

Antimicrobial stewardship programs (ASPs) aim to mitigate antimicrobial resistance (AMR) by optimizing antibiotic use including reducing unnecessary broad-spectrum therapy. This study evaluates the impact of ASP funding and resources on the use of broad-spectrum antibiotics in Ontario hospitals.

Methods

We conducted a cross-sectional study of antimicrobial use (AMU) across 63 Ontario hospitals from April 2020 to March 2023. The Ontario ASP Landscape Survey provided data on ASP resourcing and antibiotic utilization. The main outcome was the proportion of all antibiotics that were broad-spectrum, defined as: fluoroquinolones; third-generation cephalosporins; beta-lactam/beta-lactamase inhibitors; carbapenems; clindamycin; and parenteral vancomycin. Secondary outcomes included the proportions of individual antibiotic classes listed above and anti-pseudomonal agents. Statistical analysis involved logistic regression to determine the odds ratio (OR) of the association between ASP funding/resourcing and broad-spectrum antibiotic use.

Results

Among 63 hospitals, 48 reported designated ASP funding/resources. Median broad-spectrum antibiotic use was 52.5%. ASP funding/resources was not associated with overall broad-spectrum antibiotic use (0.97, 95% CI: 0.75-1.25, P = 0.79). However, funding was associated with lower use of fluoroquinolones (OR 0.67, 95% CI: 0.46-0.96, P = 0.03), clindamycin (OR 0.69, 95% CI: 0.47-1.00, P = 0.05), and anti-pseudomonal agents (OR 0.76, 95% CI: 0.59-0.98, P = 0.03).

Conclusion

The presence of designated funding and resources for hospital ASPs is linked to reduced use of specific broad-spectrum antibiotics but not overall broad-spectrum antibiotic use. Enhancing ASP resourcing may be an important factor in limiting targeted antibiotic use, thereby increasing the effectiveness of efforts to mitigate AMR.

Assessing antimicrobial consumption in public and private sectors within the Costa Rican health system: current status and future directions

BACKGROUND

Antimicrobial resistance is a significant global health threat. Therefore, robust surveillance systems for antimicrobial consumption (AMC) are essential to develop public health strategies. However, Latin American countries, including Costa Rica, face challenges in regularly reporting AMC data. This study aims to estimate and analyse the overall AMC in Costa Rica for 2019.

METHODS

This study is a national-level, retrospective, observational, and descriptive analysis of AMC in Costa Rica from 1 January to 31 December 2019. The study followed the World Health Organization (WHO) guidelines for the Surveillance of National AMC. The Anatomical Therapeutic Chemical (ATC) / Defined Daily Doses (DDD) system was used to analyse types of antimicrobials and DDD per 1000 inhabitants per day (DID). Antimicrobial dispensation data from the Costa Rican Social Security Fund (CCSS) represented the public sector, while the private sector data was sourced from IQVIA. The analysis included data from both inpatient and outpatient sectors.

RESULTS

A total AMC of 14.32 DID, of which 12.75 DID was within the public sector and 4.12 DID was within the private sector. Penicillins had the highest consumption nationally and in the public sector, while macrolides and lincosamides predominate in the private sector. According to the WHO-AWaRe (Access-Watch-Reserve) classification, antibiotics predominantly consumed nationally (74.7%) and in the public (83.0%) sectors are categorized under Access, whereas the private (61.0%) sector predominates the Watch category.

CONCLUSION

This study illustrates the importance of enhancing AMC surveillance by integrating data from both the public and private sectors. The findings indicate an excessive use of "Watch" antimicrobials in the private sector. To address this issue, all sectors and regulatory authorities must play an active and supportive role, in the development of effective, multisectoral policies. The methodology employed in this study is applicable to other Latin American countries, and therefore should be utilized for future analysis AMC in this region.

Pharmacokinetic and pharmacodynamic evaluation of the atypical tetracyclines chelocardin and amidochelocardin in murine infection models

IMPORTANCE

There is a strong need to find novel treatment options against urinary tract infections associated with antimicrobial resistance. This study evaluates two atypical tetracyclines, namely chelocardin (CHD) and amidochelocardin (CDCHD), with respect to their pharmacokinetics and pharmacodynamics. We show CHD and CDCHD are cleared at high concentrations in mouse urine. Especially, CDCHD is highly effective in an ascending urinary tract infection model, suggesting further preclinical evaluation.

Exploring drivers and challenges influencing antibiotic prescribing in outpatient settings and possible mitigation strategies in the United Arab Emirates: a qualitative study

Objectives

Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team.

Methods

A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim.

Results

Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies.

Conclusions

Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.

Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study

This study aimed to assess the impact of a prolonged carbapenem use-focused antimicrobial stewardship program (ASP) on antimicrobial consumption and clinical outcomes and to analyze factors affecting adherence to interventions. Patients prescribed carbapenems for ≥ 2 weeks received intervention. Interrupted time-series analysis was performed to compare antimicrobial consumption before and after intervention. Factors associated with non-adherence to intervention were investigated. Of 273 patients who were eligible for intervention, discontinuation or de-escalation was recommended in 256 (94.1%) and intervention was accepted in 136 (53.1%) patients. Before intervention, carbapenem consumption significantly increased to 1.14 days of therapy (DOT)/1000 patient days (PD)/month (P = 0.018). However, it significantly declined by - 2.01 DOT/1000 PD/month without an increase in other antibiotic consumption (P < 0.001). Factors affecting non-adherence to intervention were younger age (odds ratio [OR] = 0.98; 95% confidence interval [CI] 0.96-1.00), solid organ malignancy (OR = 2.53, 95% CI 1.16-5.50), and pneumonia (OR = 2.59, 95% CI 1.08-6.17). However, ASP intervention was not associated with clinical outcomes such as length of hospital stay or mortality. Prolonged carbapenem prescription-focused ASP significantly reduced carbapenem consumption without adverse outcomes. Non-adherence to interventions was attributed more to prescriber-related factors, such as attitude, than patient-related factors including clinical severity.

Comparison of Different Antibiotics and the Risk for Community-Associated Clostridioides difficile Infection: A Case-Control Study

Background

Antibiotics are the greatest risk factor for Clostridioides difficile infection (CDI). Risk for CDI varies across antibiotic types and classes. Optimal prescribing and stewardship recommendations require comparisons of risk across antibiotics. However, many prior studies rely on aggregated antibiotic categories or are underpowered to detect significant differences across antibiotic types. Using a large database of real-world data, we evaluate community-associated CDI risk across individual antibiotic types.

Methods

We conducted a matched case-control study using a large database of insurance claims capturing longitudinal health care encounters and medications. Case patients with community-associated CDI were matched to 5 control patients by age, sex, and enrollment period. Antibiotics prescribed within 30 days before the CDI diagnosis along with other risk factors, including comorbidities, health care exposures, and gastric acid suppression were considered. Conditional logistic regression and a Bayesian analysis were used to compare risk across individual antibiotics. A sensitivity analysis of antibiotic exposure windows between 30 and 180 days was conducted.

Results

We identified 159 404 cases and 797 020 controls. Antibiotics with the greatest risk for CDI included clindamycin and later-generation cephalosporins, and those with the lowest risk included minocycline and doxycycline. We were able to differentiate and order individual antibiotics in terms of their relative level of associated risk for CDI. Risk estimates varied considerably with different exposure windows considered.

Conclusions

We found wide variation in CDI risk within and between classes of antibiotics. These findings ordering the level of associated risk across antibiotics can help inform tradeoffs in antibiotic prescribing decisions and stewardship efforts.

Do or Don't: Results of a Multinational Survey on Antibiotic Prophylaxis in Urodynamics

Antibiotic prophylaxis contributes substantially to the increase in antibiotic resistance rates worldwide. This investigation aims to assess the current standard of practice in using antibiotic prophylaxis for urodynamics (UDS) and identify barriers to guideline adherence. An online survey using a 22-item questionnaire designed according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was circulated among urologists and gynecologists in Austria, Germany, and Switzerland between September 2021 and March 2022. A total of 105 questionnaires were eligible for analysis. Out of 105 completed surveys, most responders (n = 99, 94%) regularly perform dipstick urine analysis prior to urodynamics, but do not perform a urine culture (n = 68, 65%). Ninety-eight (93%) participants refrain from using antibiotic prophylaxis, and sixty-eight (65%) use prophylaxis if complicating factors exist. If asymptomatic bacteriuria is present, approximately 54 (52%) participants omit UDS and reschedule the procedure until antimicrobial susceptibility testing is available. Seventy-eight (78%) participants do not have a standard procedure for antibiotic prophylaxis in their department. Part of the strategy against the development of bacterial resistance is the optimized use of antibiotics, including antibiotic prophylaxis in urodynamics. Establishing a standard procedure is necessary and purposeful to harmonize both aspects in the field of urological diagnostics.

Impact of a Primary Care Antimicrobial Stewardship Program on Bacterial Resistance Control and Ecological Imprint in Urinary Tract Infections

Antimicrobial stewardship programs (ASPs) are a central component in reducing the overprescription of unnecessary antibiotics, with multiple studies showing benefits in the reduction of bacterial resistance. Less commonly, ASPs have been performed in outpatient settings, but there is a lack of available data in these settings. We implemented an ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, compared to the pre-intervention period, a significant reduction in antibiotic prescription occurred, with a reduction in resistance in E. coli urinary isolates. ASP activities also were found to be cost-effective, with a reduction in medication prescription.

Attitudes towards Use of High-Importance Antimicrobials—A Cross-Sectional Study of Australian Veterinarians

The timely implementation of antimicrobial stewardship interventions could delay or prevent the development of higher levels of antimicrobial resistance in the future. In food-producing animals in Australia, high-importance antimicrobials, as rated by the Australian Strategic and Technical Advisory Group (ASTAG), include virginiamycin and third-generation cephalosporins (in individual pigs or cattle). The use of high-importance antimicrobials in companion animals is more widespread and less regulated. There is no national antimicrobial use surveillance system for animals in Australia. Consequently, there is a gap in the knowledge about reasonable use across all sectors of veterinary practice. This study explored attitudes towards the use in veterinary medicine of antimicrobials with high importance to human health, and determined levels of agreement about the introduction of restrictions or other conditions on this use. An online survey was distributed via social media and email from June to December 2020 to veterinarians working in Australia. Of the 278 respondents working in clinical practice, 49% had heard of the ASTAG rating system, and 22% used a traffic light system for antimicrobial importance in their practice. Overall, 61% of participants disagreed that veterinarians should be able to prescribe high-importance antimicrobials without restrictions. If there were to be restrictions, there was most agreement amongst all respondents for only restricting high-importance antimicrobials (73%). There is a need for education, guidance, and practical support for veterinarians for prescribing high-importance antimicrobials alongside any restrictions.

A Non-Restrictive Approach to Fluoroquinolone Stewardship at Two Community Hospitals

Background

Fluoroquinolones are one of the most prescribed antimicrobials in the United States and have been increasingly used in inpatient and outpatient settings to treat various infectious diseases syndromes. Due to the unwanted collateral effects on antibiotic resistance, poor susceptibility rates among Gram-negative pathogens, and adverse effects, fluoroquinolones are often targeted by hospital antimicrobial stewardship programs to prevent overutilization. This study describes the association of nonrestrictive antimicrobial stewardship interventions at 2 nonacademic community hospitals on levofloxacin utilization, prescribing patterns on alternative antibiotics, and Pseudomonas aeruginosa nonsusceptibility rates to levofloxacin.

Methods

Nonrestrictive antimicrobial stewardship interventions included monitoring and reporting of fluoroquinolone susceptibility trends to physician groups, performing medication use evaluations of levofloxacin accompanied with prescriber detailing, daily prospective audit and feedback, implementation of beta-lactam-based institutional guidelines for empiric therapy in various infectious disease syndromes, review and adjustment of electronic medical record order sets containing fluoroquinolones, and intensive prescriber education. No preauthorization of levofloxacin was used during this study period. Antibiotic utilization data were collected for the time periods of August 2015 through January 2021. Correlation between levofloxacin and other broad-spectrum antibiotc use was investigated as well as the impact on Pseudomonas aeruginosa levofloxacin nonsusceptibility rates.

Results

Both hospitals showed an overall downward trend in the prescribing of levofloxacin during the time period of August 2015 to January 2021. There was a significant negative correlation between monthly ceftriaxone and levofloxacin days of therapy for both hospitals (P < .0001). There was a positive correlation between levofloxacin days of therapy and P aeruginosa nonsusceptibility (P < .02 at both hospitals).

Conclusions

Our results demonstrate that a nonrestrictive approach to fluoroquinolone stewardship interventions had a significant impact on reducing levofloxacin utilization, increasing ceftriaxone utilization, and improving P aeruginosa levofloxacin susceptibility.

Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities

INTRODUCTION

Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics.

AREAS COVERED

In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units.

EXPERT OPINION

Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.

Short- and long-term impact of a multifaceted approach targeting fluoroquinolone use in a community hospital: an interrupted time-series analysis

BACKGROUND

While various strategies for antibiotic restrictions have been validated, their impacts are not well described in smaller, non-teaching facilities. Fluoroquinolones are an appropriate target for restriction based on their propensity for overuse and potential for causing "collateral damage."

AIM

Evaluate the impact of a multifaceted approach to decreasing fluoroquinolone use on consumption of fluoroquinolones and alternative antibiotics at a smaller, non-teaching facility.

METHOD

Prospective, interrupted time series analysis conducted at a single 288-bed, non-teaching hospital with 71 adult ICU beds comparing antibiotic consumption measured monthly by defined daily doses per 1000 adjusted patient days (DDD/1000 APD) prior to intervention (January 2011 to August 2014) to short-term (October 2014 to December 2015) and long-term (January 2018 to December 2019) periods following intervention.

RESULTS

An increase in downward trends of fluoroquinolone use was observed from prior to intervention (-0.49 DDD/1000 APD) to the short-term period (-1.13 DDD/1000 APD) and to a greater extent in the long-term period following the intervention (-1.32 DDD/1000 APD). Fluoroquinolone consumption decreased from 100.20 DDD/1000 APD in August 2014 to 73.96 DDD/1000 APD in the short-term and 14.89 DDD/1000 APD in the long-term intervention period. Levofloxacin susceptibility for Pseudomonas aeruginosa increased from 61% to 2014 to 83% in 2018. No deleterious effects on Pseudomonas aeruginosa susceptibilities were observed for alternative antibiotics.

CONCLUSION

A multifaceted approach aimed at decreasing fluoroquinolone use at a community hospital led to a sustained decrease in consumption and a substantial increase in levofloxacin susceptibility to Pseudomonas aeruginosa.

IMPACTS ON PRACTICE

• In smaller community hospitals, implementing pharmacist-driven multifaceted antimicrobial stewardship interventions can produce immediate and sustained impacts on antimicrobial consumption. • Sustained antimicrobial stewardship initiatives targeting fluoroquinolones can lead to improvement in long-term exigencies such as Pseudomonas aeruginosa susceptibility rates without deleterious effects on alternative antibiotics.

The effects of beta-lactam allergy relabeling on antibiotic prescribing practices

BACKGROUND

Beta-lactam antibiotic allergy labels are highly prevalent but rarely indicate an allergic intolerance. These patient-reported allergies lead to broad-spectrum antibiotic use, conferred resistance, increased expense, and adverse effects.

OBJECTIVE

To implement and assess the impact of a history-based clinical guideline that directs antibiotic management and beta-lactam allergy relabeling for patients reporting beta-lactam allergies.

METHODS

Patients with beta-lactam allergy labels were identified by our trained multidisciplinary team in diverse clinical settings. This quality improvement project was conducted to evaluate the safety and impact of the guideline on antibiotic use by comparing prescribing practices before and after guideline implementation.

RESULTS

A total of 79 patients with beta-lactam allergies were identified (penicillins-90%, cephalosporins-10%). After guideline implementation, outcomes of allergy relabeling included the following: (1) complete removal, indicating an unlikely true allergy (27%); (2) updated to detail successfully tolerated beta-lactam courses (48%); or (3) no change made to current label (25%). Beta-lactam antibiotic courses before and after guideline implementation compared with total antibiotic courses: allergy removed (44% vs 70%; P < .001), allergy updated (32% vs 68%; P < .001), and no change (27% vs 41%; P = .08). Compared with before guideline implementation, beta-lactam antibiotics were 3 times more likely to be prescribed after allergy assessment (odds ratio, 3.22; 95% confidence interval, 2.4-4.3; P < .05).

CONCLUSION

The implementation of the beta-lactam allergy clinical guideline resulted in most patients' allergy labels being removed or advantageously updated. These allergy label changes correlated with a substantial increase in the percentage of beta-lactam antibiotics prescribed. After guideline implementation, beta-lactam antibiotics had a 3-fold increased odds of being prescribed independent of allergy label outcome.

Impact of an empiric antimicrobial therapy manual on antimicrobial usage and multidrug resistant organism trends in a large Italian teaching hospital

Aim

To evaluate the changes in antimicrobial consumption and multidrug-resistant microorganism trends after introducing an empiric antimicrobial therapy manual to support antimicrobial stewardship.

Methods

A 4-year prospective interventional study assessed the effect of introducing an empiric antimicrobial therapy manual in medical and surgical wards during two periods: pre-intervention period (January 2015–May 2017) and post-intervention period (June 2017–December 2019). Outcomes included microorganism trends of bloodstream infections (BSI) for Klebsiella pneumoniae carbapenemase-producing bacteria (KPC), extended spectrum beta-lactamase ESBL-E. coli, meticillin-resistant Staphylococcus aureus (MRSA) and Candida albicans. Also, Clostridioides difficile infection (CDI) episodes were included. Rates were normalised per 1000 patient-days (PD). Antimicrobial consumption was assessed as defined daily dose (DDD)/1000 PD in interrupted time series analysis.

Results

In medical wards, we observed a significant decrease in the consumption of piperacillin-tazobactam and a decrease in the trends of tigecycline and vancomycin consumption. In surgical wards, there was a significant decrease in consumption of fluoroquinolones and piperacillin-tazobactam. This decrease was maintained in trend for all the antimicrobials but was significant for tigecycline only. In medical wards, there was a significant reduction of MRSA and C. albicans. In surgical wards, we observed a decrease in MRSA, ESBL-E. coli, C. albicans and CDI. KPC cases decreased by 22.5% in medical wards and 74.3% in surgical wards.

Conclusion

The results suggest that a persuasive educational approach to antimicrobial stewardship, with the introduction of an empiric antimicrobial manual and continuous education, resulted in reductions in both antimicrobial use and healthcare-associated BSI caused by multidrug-resistant organisms. More studies with longer follow up are needed to investigate the effect of antimicrobial stewardship on clinical outcomes.

Impact of an Antibiotic Stewardship Program on the Incidence of Resistant Escherichia coli: A Quasi-Experimental Study

Infections caused by multidrug-resistant Gram-negative bacteria increase hospitalizations and mortality rates; antibiotic pressure increases resistance rates. We evaluated the impact of the antibiotics stewardship program (ASP) on Escherichia coli resistance rates, evaluating all antibiotic use and patients with positive cultures hospitalized between 2011 and 2018. Data on antibiotics were collected quarterly as the defined daily dose (DDD)/100 days hospitalization. In 2014, an intervention was introduced, targeting the reduction of overall antibiotic use as well as specifically targeting quinolones and other broad-spectrum antibiotics. Using interrupted time series analysis (ITS), we compared the rates and trends of antibiotic use and resistant E. coli. We included 6001 patients, 3182 pre-ASP and 2819 post-ASP. We observed significant changes in absolute numbers as well as in trends for use of DDD/100 days of all antibiotics by 31% from 76 to 52, and by 52% from 10.4 to 4.9 for quinolones. ITS demonstrated that before the ASP intervention, there was a slope pattern for increased E. coli resistance to antibiotics. This slope was reversed following the intervention for quinolones −1.52, aminoglycosides −2.04, and amoxicillin clavulanate (amox/clav) −1.76; the effect of the intervention was observed as early as three months after the intervention and continued to decrease over time until the end of the study, at 48 months. We conclude that the ASP can positively impact the resistance rate of Gram-negative infections over time, regardless of the targeted combination of antibiotics, if the overall use is reduced.

The Kinetics of an Antibiotic Stewardship Intervention: A Quasi-Experimental Study

Introduction

Little is known about the kinetics and different phases of a successful antibiotic stewardship program (ASP) intervention.

Methods

We analyzed the trends of quarterly antibiotic use measured in defined daily dose (DDD)/100 days hospitalization using the Joinpoint Regression Program and interrupted time series analysis to objectively identify shifts in the trends of antibiotic use. We correlated these changes in trends with the introduction of a hospital-wide ASP intervention.

Results

The ASP intervention reduced the overall antibiotic use by 33%, from a prior steady state of 76.5 DDD/100 days hospitalization to a post-intervention steady state of 51.2 DDD/100 days hospitalization (p < 0.001). We identified four distinct phases in the trends: prior steady state (A), early intervention (B), accelerated phase (C), and post steady state (D). From A to B a change of slope (−1.46) [SE 0.37, 95% CI −2.23, −0.69 (p = 0.002)]; B to C, a further decrease of slope (−4.70) [SE 0.64, 95% CI −6.03, −3.37 (p = 0.001)]; between periods C and D, straightening out of the slope (+ 6.84) [SE 0.55, 95% CI 5.70, 7.98 (p < 0.001)] to a new post-intervention steady state. It took 1.5 years after completion of the intervention to reach the new steady state.

Conclusions

We demonstrate that ASP interventions require time to achieve the maximal effect. Successful interventions require physicians to adapt new prescribing behaviors and gain confidence in the change; this adaptation can be a prolonged process and might even take years after the introduction of the ASP. These factors should be considered when planning and implementing ASP interventions.

Amidochelocardin Overcomes Resistance Mechanisms Exerted on Tetracyclines and Natural Chelocardin

The reassessment of known but neglected natural compounds is a vital strategy for providing novel lead structures urgently needed to overcome antimicrobial resistance. Scaffolds with resistance-breaking properties represent the most promising candidates for a successful translation into future therapeutics. Our study focuses on chelocardin, a member of the atypical tetracyclines, and its bioengineered derivative amidochelocardin, both showing broad-spectrum antibacterial activity within the ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) panel. Further lead development of chelocardins requires extensive biological and chemical profiling to achieve favorable pharmaceutical properties and efficacy. This study shows that both molecules possess resistance-breaking properties enabling the escape from most common tetracycline resistance mechanisms. Further, we show that these compounds are potent candidates for treatment of urinary tract infections due to their in vitro activity against a large panel of multidrug-resistant uropathogenic clinical isolates. In addition, the mechanism of resistance to natural chelocardin was identified as relying on efflux processes, both in the chelocardin producer Amycolatopsis sulphurea and in the pathogen Klebsiella pneumoniae. Resistance development in Klebsiella led primarily to mutations in ramR, causing increased expression of the acrAB-tolC efflux pump. Most importantly, amidochelocardin overcomes this resistance mechanism, revealing not only the improved activity profile but also superior resistance-breaking properties of this novel antibacterial compound.

The Association of Antibiotic Stewardship With Fluoroquinolone Prescribing in Michigan Hospitals: A Multi-hospital Cohort Study

BACKGROUND

Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown.

METHODS

This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015-September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship.

RESULTS

There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003).

CONCLUSIONS

Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing.

Prescription of Levofloxacin and Moxifloxacin in Select Hospitals in Uganda: A Pilot Study to Assess Guideline Concordance

Background: In Uganda, national tuberculosis (TB) treatment guidelines were revised to include the newer generation fluoroquinolones among the second-line treatment options for multidrug-resistant TB. This study was designed to analyze if the prescription of these quinolones is compliant with country recommendations. Methods: This was an observational retrospective study of consumption data for 2017 and 2018 across four selected regional referral hospitals. The sources of consumption data were hospital pharmacy stock cards and the dispensing register. The medical files of patients who had been prescribed fluoroquinolones were also assessed to study compliance with the Uganda Clinical Guidelines and the British National Formulary (BNF). Results: None of the 371 levofloxacin prescriptions analyzed complied with the Uganda Clinical Guidelines, although 250 (67.3%) were prescribed for indications included in the BNF. According to WHO prescription indicators, only 220 (59.3%) prescriptions were appropriate. Conclusion: The prescription of levofloxacin and moxifloxacin increased in the hospitals studied, but in a high proportion of cases, they were not compliant with country recommendations. The findings call for the strengthening of national antimicrobial stewardship programs.

Assessing the association between fluoroquinolones and emerging adverse drug reactions raised by regulatory agencies: An umbrella review

BACKGROUND

Regulatory agencies warned against fluoroquinolones for the management of minor infections because of the risk of emerging adverse events (collagen-associated adverse events, neuropsychiatric toxicity and long-term disability). We aimed to assess quality and credibility of evidence as well as causality regarding these putative associations.

METHODS

MEDLINE, Scopus, Web of Science and PROSPERO were searched, from inception to August 2019, for systematic reviews with meta-analyses investigating emerging adverse events. Two investigators extracted data to grade quality (through validated AMSTAR-2 tool), rank credibility of the evidence (convincing, highly suggestive, suggestive, weak) through adapted criteria including E-value calculation, and assess causality (Hill's criteria).

RESULTS

Seven systematic reviews of observational studies providing 16 risk estimates [seven, five and four, respectively, for aortic aneurysm/dissection (AAD), retinal detachment (RD) and any tendon disorders (ATD)] met inclusion criteria. No systematic reviews with meta-analysis investigating the risk of neuropsychiatric toxicity or long-term disability were found. The associations between fluoroquinolones and AAD/ATD showed highly suggestive credibility and were supported by strong evidence of causality (double increased risk, especially within first 2 months of treatment). Conflicting data concerning the emergence of RD were retrieved, resulting in weak evidence of causality. Quality of the evidence ranged from high to low for AAD, from moderate to critically low for RD, and it was moderate for ATD.

CONCLUSION

Our analysis supports credible, plausible and highly suggestive associations with AAD (rare occurrence but strong causality) and ATD. Limitations of both umbrella reviews and observational evidence should be considered.

β-Lactam allergy and risk of multidrug-resistant bacteria in the intensive care unit: A cohort study

Patients identified as allergic to β-lactams are frequently exposed to treatment with broad-spectrum antibiotics. However, the risk of carriage of extended-spectrum β-lactamase (ESBL)-producing isolates in this population has been poorly investigated. The aim of this study was to evaluate the characteristics and clinical outcomes of patients admitted to the intensive care unit (ICU) with and without declared β-lactam allergy at admission. A retrospective monocentric study was performed including adult patients admitted to the ICU between 2007 and 2012. The presence of multidrug-resistant bacteria was documented in rectal and nasal swabs at admission and discharge. Patients labelled allergic to β-lactams and unlabelled patients were compared. Patients labelled allergic had significantly higher rates of ESBL at admission (13.3% vs. 4.3%; P = 0.0220) and discharge (20.0% vs. 9.0%; P = 0.0460) compared with unlabelled patients, but no significant difference in rates of ESBL acquisition in the ICU was detected. No differences in mortality, duration of hospitalisation or typical risk factors for ESBL acquisition (intubation, central venous catheter and duration of hospitalisation) were reported. No differences in carriage of methicillin-resistant Staphylococcus aureus were detected. This study showed that patients with declared β-lactam allergy had a higher risk of ESBL carriage at ICU admission and discharge.

Impact of an Antimicrobial Stewardship Program on Resistance to Fluoroquinolones of Urinary Enterobacteriaceae Isolated From Nursing Home Residents: A Retrospective Cohort Study

OBJECTIVES

This study investigated the impact of an antimicrobial stewardship program on fluoroquinolone (FLQ) resistance in urinary Enterobacteriaceae isolated from residents of 3 French nursing homes.

DESIGN

A multicentric retrospective before-and-after study was conducted.

SETTING AND PARTICIPANTS

All the first urinary Enterobacteriaceae isolates obtained from nursing home residents were included. Two time frames were analyzed: 2013-2015 and 2016-2017.

METHODS

The antimicrobial stewardship program started in 2015 and was based on (1) 1-day training for use of an "antimicrobial stewardship kit for nursing homes;" and (2) daily support and training of the coordinating physician by an antibiotic mobile team (AMT) in 2 of 3 nursing homes.

RESULTS

Overall, 338 urinary isolates were analyzed. Escherichia coli was the most frequent species (212/338, 63%). A significant reduction of resistance to ofloxacin was observed between 2013-2015 and 2016-2017 in general (Δ = -16%, P = .004) and among isolates obtained from patients hospitalized in the county nursing home with AMT support (Δ = -28%, P < .01). A nonstatistically significant reduction in ofloxacin resistance was also observed in the hospital nursing home with AMT support (Δ = -18%, P = .06).

CONCLUSIONS AND IMPLICATIONS

Our antimicrobial stewardship program resulted in a decrease in resistance to FLQ among urinary Enterobacteriaceae isolated from nursing home residents. The support of an AMT along with continuous training of the coordinating physician seems to be an important component to ensure efficacy of the intervention.

Generic MS-based method for the bioanalysis of therapeutic monoclonal antibodies in nonclinical studies

Aim: A generic bioanalytical method was developed to quantify therapeutic IgG1 monoclonal antibodies (mAbs) in mouse sera by combining an easy sample preparation method with LC/MS using selected reaction monitoring. Materials & methods: Rituximab and trastuzumab were used as model mAbs. A synthetic stable isotope-labeled peptide or a stable isotope-labeled mAb was used as an internal standard. The method feasibility was evaluated by a collaborative study involving six laboratories. Results: The calibration curve ranged from 1.0 to 1000.0 μg/ml (correlation coefficient >0.99). The validation parameters including selectivity, linearity of calibration curve, accuracy and precision met the predefined acceptance criteria. Conclusion: Our method is a useful bioanalytical method for the quantification of therapeutic IgG mAbs in nonclinical animal studies.

Restriction-free antimicrobial stewardship initiative targeting fluoroquinolone reduction across a regional health-system

Background

Fluoroquinolone (FQ) antibiotics have become a target of many antimicrobial stewardship programmes. Multiple post-marketing warnings from the Food and Drug Administration caution against use of this drug class for certain infections due to risk of harmful adverse effects outweighing benefit. Commonly employed strategies to affect antibiotic prescribing can be restrictive and without improvement in overall antibiotic appropriateness or decrease in collateral damage.

Aim

To develop a strategy for sustainable optimization of FQ antibiotics.

Setting

Multi-state health-system of 14 hospitals and medical centers.

Methods

The health-system antimicrobial stewardship program identified the opportunity to improve FQ utilization. In collaboration with our data and analytics team, specific targets of FQ use in pneumonia and chronic obstructive pulmonary disease were established. Face-to-face provider education and prospective audit and feedback were the mainstays of the campaign. Enhancements to the electronic medical record to support the initiative were also implemented.

Findings

There was an overall decrease in FQ utilization by 56.9%. For pneumonia use of FQs decreased from 16.4% to 8.1% and in COPD changed from 29.6% to 9.7% over the same time period.

Conclusions

A non-restrictive FQ optimization initiative based on education and feedback decreased both FQ consumption and total antibiotic use across a large multi-hospital health-system.

Impact of syndrome-specific antimicrobial stewardship interventions on use of and resistance to fluoroquinolones: An interrupted time series analysis

BACKGROUND

Fluoroquinolones are often prescribed unnecessarily and are an important risk factor for infection with fluoroquinolone-resistant gram-negative bacilli and Clostridioides difficile.

METHODS

We conducted a quasi-experimental study to determine the impact of sequential syndrome-specific stewardship interventions on use of and resistance to fluoroquinolones in a tertiary care hospital. An initial 2-year intervention focused on reducing treatment of asymptomatic bacteriuria and ensuring concordance of urinary tract infection treatment with guidelines. A second 5-year intervention focused on limiting overuse of fluoroquinolones for health care-associated pneumonia in conjunction with a formal stewardship program. The primary outcomes were fluoroquinolone use and changes in use over time analyzed by segmented regression analysis.

RESULTS

The asymptomatic bacteriuria and urinary tract infection intervention resulted in a significant reduction in fluoroquinolone use, with a significant change from an increasing to a decreasing rate of use (change in slope of quarterly defined daily doses/1,000 patient days -15.3, P < .01). The health care-associated pneumonia intervention resulted in a continued significant reduction in fluoroquinolone use (rate ratio = 0.68, P < .01). During the interventions, fluoroquinolone susceptibility increased significantly in Pseudomonas aeruginosa, but not in Escherichia coli, Klebsiella spp., or C difficile.

CONCLUSIONS

Antimicrobial stewardship interventions focused on specific syndromes may be effective in reducing fluoroquinolone use. In our hospital, reduction in fluoroquinolone use resulted in increased fluoroquinolone susceptibility in P aeruginosa, but not other Enterobacteriaceae or C difficile.

Extended-spectrum β-lactamase, plasmid-mediated AmpC β-lactamase, fluoroquinolone resistance, and decreased susceptibility to carbapenems in Enterobacteriaceae: fecal carriage rates and associated risk factors in the community of Northern Cyprus

Background

Antibiotic-resistant Enterobacteriaceae in the gastrointestinal flora can lead to infections with limited therapeutic options. Also, the resistant bacteria can be transferred from colonized persons to others. The present study was conducted to search the fecal carriage rates of (i) Enterobacteriaceae that produce extended-spectrum β-lactamase (ESBL-E) and/or (ii) plasmid-mediated AmpC β-lactamase (pAmpC-E), (iii) ciprofloxacin-resistant Enterobacteriaceae (CIP-RE), and (iv) carbapenem-intermediate or -resistant Enterobacteriaceae (CIRE) in Northern Cyprus.

Methods

A total of 500 community-dwellers were recruited from consecutive admissions to the clinical laboratories of four hospitals. One rectal swab or stool sample was collected from each participant. A questionnaire was applied to evaluate possible risk factors associated with intestinal colonization of resistant bacteria. The samples were cultured on antibiotic containing media to screen for resistant bacteria colonization. The bacterial colonies that grew on the plates were subjected to further phenotypic tests to confirm the resistance.

Results

Of 500 volunteers, ESBL-E, pAmpC-E, CIP-RE and CIRE carriage were detected in 107 (21.4%), 15 (3.0%), 51 (10.2%) and six (1.2%) participants, respectively. Escherichia coli was the most commonly recovered species among Enterobacteriaceae isolates. A significant proportion of ESBL-producing E. coli isolates (n = 22/107; 20.6%) was found to be co-resistant to CIP (p = 0.000, OR 3.21, 95% CI 1.76-5.87). In this study, higher socioeconomic status (CIP-RE: p = 0.024, OR 1.96, 95% CI 1.09-3.53), presence of gastrointestinal symptoms (CIRE: p = 0.033; OR 6.79, 95% CI 1.34-34.39), antibiotic use (ESBL-E: p = 0.031; OR 1.67, 95% CI 1.04-2.67; and CIRE: p = 0.033; OR 6.40, 95% CI 1.16-35.39), and travelling abroad (pAmpC-E: p = 0.010; OR 4.12, 95% CI 1.45-11.66) were indentified as risk factors.

Conclusion

The study indicates that resistant Enterobacteriaceae isolates are carried by humans in the community. To prevent further spread of resistance, rational use of antibiotics should be encouraged, and antibiotic resistance should be carefully monitored in Northern Cyprus.

Photophysical and photochemical insights of the photodegradation of norfloxacin: The rate-limiting step and the influence of Ca2+ ion

Photodegradation is one of the major degradation paths for antibiotics as aquatic micropollutants in surface water. The photodegradation involves a number of complicated photophysical and photochemical processes. Exploration for the rate-limiting step among these processes can be essential for the elimination of antibiotics. In this work norfloxacin was selected as a target compound. The rate constants of photophysical transitions and their competitions were discussed under the framework of Fermi Golden rule and time-depended perturbation theory. Using density functional theory, the reaction paths in triplet state were searched. The competitions among the photophysical transitions and photochemical reaction paths indicate the intersystem crossing (ISC) from the S₁ state to T₁ state is the rate-limiting step in the aquatic photodegradation of norfloxacin. Ca²⁺ ion significantly accelerates this bottleneck by coordinating with the carbonyl and carboxyl groups of norfloxacin. The coordination creates more ISC paths to triplet states and increases the spin-orbit coupling, Huang-Rhys factors, and the vibrational coupling of the ISCs.

Mixed effects of restriction strategies in antimicrobial stewardship programs on antimicrobial use in 121 tertiary hospitals in China, 2013-2017

Background: The research evaluated the impact of intravenous antimicrobial restriction strategy (IARS) on different types of hospitals in China for evidence-based management, for outpatients implemented in 2016. Methods: Based on panel data on antimicrobial use in 121 tertiary hospitals in Zhejiang, China, segmented regression analysis was used to evaluate the impact of IARS in children's hospitals (CHs), obstetrics and gynecology hospitals (OGHs), women's and children's hospitals (WCHs), traditional Chinese medicine hospitals (TCMHs) and general hospitals (GHs). Antimicrobial use was measured using the percentage of total encounters with prescribing and the percentage of total drug expenditure relating to antimicrobials (APP and AEP). Results: There was a downward baseline slope of APP in all types of hospitals and AEP in WCHs, TCMHs and GHs (P < 0.01). After IARS, a level reduction in AEP in CHs (-3.14%, 95% CI = -6.21 to 0.06), WCHs (-1.33%, 95% CI = -2.44 to 0.22) and TCMHs (-0.85%, 95%CI = -1.51 to 0.18). After IARS, the slope of AEP changed significantly in OGHs (-0.42%, 95%CI = -0.81 to 0.03) and WCHs (0.29%, 95% CI = 0.08 to 0.49), and the slope of APP changed significantly in CHs (2.35%, 95%CI = 1.20 to 3.49). Conclusions: IARS had the mixed effects including positive effect in AEP and no significant change in APP, and an unexpected rise in APP in CHs needs further study.