Decreasing the Peril of Antimicrobial Resistance Through Enhanced Health Literacy in Outpatient Settings: An Underrecognized Approach to Advance Antimicrobial Stewardship

Bacteria-visualizing nano-bactericide with anti-inflammation and wound healing properties for in situ NIR phototherapeutic strategies

Anti-infection and wound healing are critical to the survival of patients with skin burns or postoperative infections, and there is an urgent clinical demand for drugs that combine anti-inflammatory and tissue recovery functions, especially new drugs that can overcome the inherent drug resistance of bacteria to conventional antibiotics. In this work, a phototherapeutic bactericide SiPc-CMCS was constructed by covalently grafting silicon phthalocyanine onto natural carboxymethyl chitosan. SiPc-CMCS ingeniously exhibited combined effects of photodynamic and photothermal therapies with wound healing effects for synergistic anti-inflammation and wound recovery, without the constraints of dosage and drug resistance. Two ROS, namely, O2˙- and 1O2, which belong to type I and type II photodynamic pathways, respectively, were observed, and SiPc-CMCS exhibited a photothermal conversion efficiency of η = 26.80%. In vitro and in vivo studies showed effective NIR photodynamic-photothermal antibacterial effect of SiPc-CMCS against both Gram-positive and Gram-negative bacteria. Furthermore, it realized in situ wound healing and fluorescence bacteria visualizing capability. These data prove that SiPc-CMCS is a potential bacteria-readout-guided NIR phototherapeutic bactericide, which is effective against both aerobic and anaerobic bacterial infections, and it possesses excellent wound-healing capability for treating skin burns and postoperative infections.

pH-responsive molybdenum disulphide composite nanomaterials for skin wound healing using "ROS leveraging" synergistic immunomodulation

With the increasing prevalence of drug-resistant bacterial infections, wound bacterial infections have evolved into an escalating medical problem that poses a threat to the individual health as well as global public health. Traditional drug therapy not only suffers from a single treatment method, low drug utilisation and limited therapeutic effect, but long-term antibiotic abuse has significantly increased bacterial resistance. It is imperative to develop an antibiotic-free biomaterial with antibacterial and anti-inflammatory properties. The current use of photothermal therapy (PTT) and photodynamic therapy (PDT) relies on the generation of massive reactive oxygen species (ROS), which inevitably aggravates the inflammatory response. Herein, we developed AuAg bimetallic nanoparticles based on PDA modification and prepared a novel MoS2-based composite nanomaterials (AuAg@PDA-MoS2 NPs) with multiple mechanisms of antibacterial and anti-inflammatory potentials through the adhesion of PDA. In the early phase, PDT and PTT generated a large amount of ROS for rapid sterilisation. While in the later stage, MoS2 mimicked the peroxidase activity to leverage the ROS, balancing the generation of ROS in the infected environment to achieve the long-term anti-inflammatory. In vitro experiments showed that the killing efficiency of AuAg@PDA-MoS2 NPs was nearly 99 % under the irradiation of 808 nm near-infrared light for 10 min, which demonstrated excellent antibacterial activity. In vivo experiments showed that 808 nm NIR-assisted AuAg@PDA-MoS2 NPs to effectively inhibit infection, alleviated the inflammation, and accelerated the wound healing process. Therefore, AuAg@PDA-MoS2 NPs as a novel biomaterial could achieve programmed antimicrobial and anti-inflammatory effects, which has a promising potential for future application in the treatment of infected wounds.

Prevalence and characterization of class I integrons in multidrug-resistant Escherichia coli isolates from humans and food-producing animals in Zhejiang Province, China

Class I integrons have garnered significant attention due to pivotal roles in the dissemination of antimicrobial resistance genes (ARGs), which impose risks to public health and food safety. Here, the prevalence and characteristics of class I integrons in Escherichia coli isolates derived from food-producing animals and human patients were assessed. Of 721 E. coli isolates collected from human patients (113), pigs (298), and poultry (310), 93 (12.90%) carried the class I integrase gene (intI1). Multilocus sequence typing identified 39 sequence types from 93 intI1-postive isolates, including three novel types. Sequence analysis revealed that 59 classical class I integrons encompassed six distinct gene cassettes arrangements [dfrA17-aadA5, dfrA12-aadA2, dfrA1-aadA1, dfrA7, aac(6')-Ib, and aadA1-aac(3)-VIa]. Six insertion sequences (IS1, IS6, IS21, IS91, IS110, and IS256) and one transposon (Tn3) were harbored in proximity to the integrons. A comparison with sequences retrieved from the National Center for Biotechnology Information database demonstrated that E. coli isolates with integron sequences were detected in various food-producing animals and human hosts in environmental niches across Asia, Europe, and North America. These findings indicate the potential risk of ARG transmission between food-producing animals and humans by bacteria populations and provide useful baseline data for monitoring of ARGs.

Antimicrobial stewardship situation analysis in selected hospitals in Zambia: findings and implications from a national survey

Background

Antimicrobial stewardship (AMS) programs are critical in combating antimicrobial resistance (AMR). In Zambia, there is little information regarding the capacity of hospitals to establish and implement AMS programs. The objective of this study was to conduct a baseline assessment of WHO core elements for an AMS program implementation in eight hospitals in Zambia.

Materials and methods

We conducted an exploratory cross-sectional study from September 2023 to December 2023 using a self-scoring Periodic National and Healthcare Facility Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Eight public hospitals were surveyed across the five provinces of Zambia. Data was analyzed using the WHO self-scoring tool and thematic analysis.

Results

Overall, 62.5% (6/8) of the facilities scored low (below 60%) in implementing AMS programs. Most facilities had challenges with reporting AMS feedback within the hospital (average score = 46%), Drugs and Therapeutics Committee (DTC) functionality (average score = 49%), AMS actions (average score = 50%), education and training (average score = 54%), and leadership commitment to AMS activities (average score = 56%). The overall score for all AMS core elements was average (56%). All the hospitals (100%) did not have an allocated budget for AMS programs. Finally, there were neither antibiograms to guide antimicrobial utilization nor AMS-trained staff in more than 50% of the hospitals surveyed.

Conclusion

This study found low AMS implementation in these public hospitals, especially where DTCs were non-functional. The identified challenges and gaps require urgent attention for sustainable multidisciplinary AMS programs.

Nurses' knowledge, attitudes, and practices on CLABSI prevention in the Intensive Care Unit: An observational study

BACKGROUND

Management of central venous catheters (CVC) is a frequent procedure in intensive care units (ICUs) and the risk of bloodstream infections (CLABSI) is found to be high. The literature provides healthcare professionals with guidelines to prevent the risk of CLABSI infections. The aim of this study was to observe the knowledge, attitudes, and practices of ICU nurses on the prevention of CLABSI.

METHODS

A multicenter cross-sectional study was conducted between March 2023 and September 2023; the research was carried out among six ICUs in Bari both on the web and in paper mode. The survey consisted of multiple-choice questions structured in two sections: demographic sample data and the 2017 Esposito MR questionnaire, drawn up based on the 2011 guidelines of the Centers for Disease Control and Prevention, consisting of four dimensions: knowledge, attitudes, practices, information.

RESULTS

121 nurses (57.1%) participated in the study. 72% were unfamiliar with the guidelines, especially nurses aged 41-50 years (RR = 1.88; CI = 0.78-4.51; p = 0.13) and more than 10 years' work experience (RR = 1.56; CI = 0.76-3.23; p = 0.20). Regarding attitudes, nurses were aware of the usefulness of the guidelines (Me = 10; IQR = 8-10) and the importance of hand washing for prevention (Me = 10; IQR = 10-10) despite 39.7% (n = 48) believing that gloves replace hand washing, and there were no statistically significant differences in comparing scores with age, work experience, and educational qualification. 96.7% always substituted dressing for CVC; 120 nurses (99.2%) were always replacing infusion sets and 71.2% always sanitized the access ports before infusions. Finally, 102 participants (84.3%) felt the need to get more information about the prevention of CLABSI.

CONCLUSIONS

We observed a reduced knowledge of the guidelines for the prevention of CLABSI despite the attitudes and practices of the nurses being satisfactory. In addition to implementing training, strategies for disseminating guidelines should be adopted.

Achieving Clearance of Drug-Resistant Bacterial Infection and Rapid Cutaneous Wound Regeneration Using an ROS-Balancing-Engineered Heterojunction

Intractable infected microenvironments caused by drug-resistant bacteria stalls the normal course of wound healing. Sono-piezodynamic therapy (SPT) is harnessed to combat pathogenic bacteria, but the superabundant reactive oxygen species (ROS) generated during SPT inevitably provoke severe inflammatory response, hindering tissue regeneration. Consequently, an intelligent nanocatalytic membrane composed of poly(lactic-co-glycolic acid) (PLGA) and black phosphorus /V2C MXene bio-heterojunctions (2D2-bioHJs) is devised. Under ultrasonication, 2D2-bioHJs effectively eliminate drug-resistant bacteria by disrupting metabolism and electron transport chain (ETC). When ultrasonication ceases, they enable the elimination of SPT-generated ROS. The 2D2-bioHJs act as a "lever" that effectively achieves a balance between ROS generation and annihilation, delivering both antibacterial and anti-inflammatory properties to the engineered membrane. More importantly, in vivo assays corroborate that the nanocatalytic membranes transform the stalled chronic wound environment into a regenerative one by eradicating the bacterial population, dampening the NF-κB inflammatory pathway and promoting angiogenesis. As envisaged, this work demonstrates a novel tactic to arm membranes with programmed antibacterial and anti-inflammatory effects to remedy refractory infected wounds from drug-fast bacteria.

Communicating Antibiotic Resistance via Linguistic Agency Assignment

Antibiotic resistance is a serious health threat that healthcare providers must communicate to the public to decelerate its development. Prior studies have shown that linguistic agency assignment is a viable strategy to frame health threats in a way that both conveys their severity and preserves audience members' sense of self-efficacy. In the current study, we examined this messaging strategy in the context of antibiotic resistance. Individuals' perceptions of the threat and efficacy, behavioral intentions, fear appeals, and evaluations of the educational fact sheet were explored. Participants (N = 449) were randomly assigned to one of the eight conditions crossing threat agency (bacteria/human), temporal agency (antibiotic resistance/human) and imagery agency (taking antibiotics/antibiotics). The results revealed that individuals' perceived severity, susceptibility, response efficacy, and self-efficacy were positively associated with their intentions to use antibiotics judiciously. The interaction effects between perceived threat and efficacy predicted behavioral intentions and the persuasiveness of the fact sheet. Relative to bacteria threat agency, human agency assignment led to significantly higher behavioral intentions. Also, readers of the human temporal agency condition reported higher persuasiveness toward the fact sheet than readers of the resistance condition. The implications, limitations, and future research directions of the study are discussed.

The Role of Adult Vaccines as Part of Antimicrobial Stewardship: A Scoping Review

BACKGROUND

Antimicrobial resistance (AMR) is a significant global health concern, causing an estimated 700,000 deaths annually. Although immunisation has been shown to significantly reduce AMR, the role of vaccines as part of antimicrobial stewardship (AMS) practices is often overlooked.

OBJECTIVE

To identify and examine the available literature on the role of vaccines as part of AMS practices.

METHOD

A scoping review was conducted in the following databases: MEDLINE, Embase, Scopus, CINAHL, CCRCT, IPA, and WoS, along with grey literature sources. The review was conducted using the JBI Methodology for Scoping Reviews and reported in line with the PRISMA-SCr checklist.

RESULTS

Among the 1711 records identified, 34 met the inclusion criteria; 8 discussed only the concept, while 26 discussed both the concept and the vaccine implementation method in AMS practices. There were eight recommended and/or utilised types of AMS activities identified involving vaccines, under four key themes of vaccine-related AMS strategies: Education, Screening, Vaccination, and Monitoring. Influenza and pneumococcal vaccines had the most evidence for inclusion.

CONCLUSION

Overall, the evidence supports the role of vaccines as part of AMS practices and the value of their inclusion in creating improved and comprehensive AMS strategies to further combat the development of AMR.

The elephant in the room: Exploring the influence and participation of patients in infection-related care across surgical pathways in South Africa and India

OBJECTIVE

The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection-related care, including antibiotic decision-making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala).

METHODS

Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face-to-face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection-related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software.

RESULTS

Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision-making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection-related decision-making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection-related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities.

CONCLUSION

For patients to have a valuable role in AS and make informed decisions regarding their infection-related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient-centred healthcare delivery.

PATIENT OR PUBLIC CONTRIBUTION

Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings.

The social construction of genomics and genetic analysis in ocular diseases in Ibadan, South-western Nigeria

Genomics, an emerging field to improve public health practice, has potential benefits to understanding ocular diseases. This study explored the social construction of genomics in ocular diseases in the blind community in Ibadan, Nigeria, through two focus group discussions and twelve in-depth interview sessions conducted among people living with ocular disorders. The data were thematic and content-analysed. Although the participants had limited knowledge about ocular diseases, genomics, and their nexus, they maintained a positive attitude toward its potential benefits. This informed their willingness to participate in genomics testing for ocular diseases. The participants preferred saliva-based sample collection over blood-based, and expressed concern for the procedure and accrued benefits of genomics studies. Thus, public sensitisation about ocular diseases and client-centred genomics testing procedures should be engendered.

Impact of therapeutic drug monitoring of antibiotics in the management of infective endocarditis

Treatment of infective endocarditis (IE) is based on high doses of antibiotics with a prolonged duration. Therapeutic drug monitoring (TDM) allows antibiotic prescription optimization and leads to a personalized medicine, but no study evaluates its interest in the management of IE. We conducted a retrospective, bicentric, descriptive study, from January 2007 to December 2019. We included patients cared for IE, defined according to Duke's criteria, for whom a TDM was requested. Clinical and microbiological data were collected after patients' charts review. We considered a trough or steady-state concentration target of 20 to 50 mg/L. We included 322 IE episodes, corresponding to 306 patients, with 78.6% (253/326) were considered definite according to Duke's criteria. Native valves were involved in 60.5% (185/306) with aortic valve in 46.6% (150/322) and mitral in 36.3% (117/322). Echocardiography was positive in 76.7% (247/322) of cases. After TDM, a dosage modification was performed in 51.5% (166/322) (decrease in 84.3% (140/166)). After initial dosage, 46.3% (82/177) and 92.8% (52/56) were considered overdosed, when amoxicillin and cloxacillin were used, respectively. The length of hospital stay was higher for patient overdosed (25 days versus 20 days (p = 0.04)), and altered creatinine clearance was associated with overdosage (p = 0.01). Our study suggests that the use of current guidelines probably leads to unnecessarily high concentrations in most patients. TDM benefits predominate in patients with altered renal function, but probably limit adverse effects related to overdosing in most patients.

Pharmacist beliefs about antimicrobial resistance and impacts on antibiotic supply: a multinational survey

Background

Pharmacists have important antimicrobial stewardship (AMS) roles yet limited literature exists on pharmacists' knowledge and beliefs about antimicrobial resistance (AMR) and antimicrobials and how these beliefs influence antimicrobial supply in different countries.

Methods

A cross-sectional survey was disseminated to pharmacists around the world via the Commonwealth Pharmacists' Association and related networks. Data were collected on demographics, antibiotic supply practices, and knowledge and beliefs about AMR.

Results

A total of 546 pharmacists responded from 59 countries, most commonly from Africa (41%) followed by Asia (26%) and Oceania (22%). Respondents supplied a mean of 46 ± 81 antibiotic prescriptions/week, 73%±35% of which were given in response to a prescription. Overall, 60.2% dispensed antibiotics at least once without a prescription. Respondents had good knowledge (mean 9.6 ± 1.3 (out of 12), and held positive beliefs about AMR [mean 3.9 ± 0.6 (out of 5)]. Knowledge about antibiotics and beliefs about AMR were positively correlated. The odds of supplying antibiotics without a prescription were 7.4 times higher among respondents from lower income countries [adjusted odds ratio (AOR) = 7.42, 95% CI 4.16-13.24]. Conversely, more positive AMR beliefs were associated with a lower odds of supplying antibiotics without a prescription (AOR = 0.91, 95% CI 0.86-0.95).

Conclusions

Most pharmacists had the good knowledge about antibiotics and positive beliefs about AMR. These beliefs were influenced by knowledge, work setting, and country income. A proportion of respondents provided antibiotics without a prescription; the likelihood of this occurring was higher in those who held more negative beliefs about AMR.

System Mapping of Antimicrobial Resistance to Combat a Rising Global Health Crisis

Antimicrobial resistance (AMR) decreases the effectiveness of antimicrobials to treat bacterial infections in humans and animals. The increased occurrence of AMR in bacterial population in humans, animals, and the environment requires the measures to combat a rising global health crisis. The aim of this research was to present current knowledge on AMR in a system map and to identify potential explanations of former identified variables significantly associated with AMR. This study applies a systems thinking approach and uses feedback loops to visualize the interconnections between human, animal, and environmental components in a circular AMR system map model. First, a literature review focusing on AMR and socioeconomic factors, wicked problem, and system change was carried out, which was then processed in a system map to conceptualize the present core challenges of AMR via feedback loops. Second, to investigate possible underlying values of the society and those that influence humans' behavior in the present AMR system, an iceberg model was established. Third, leverage points were assessed to estimate which kinds of interventions would have the greatest effect to mitigate AMR in the system. The present AMR system map implies the potential to identify and visualize important risk factors that are direct or indirect drivers of AMR. Our results show that the tool of system mapping, which interconnects animals, humans, and environment in one model, can approach AMR holistically and be used to assess potential powerful entry points for system wide interventions. This study shows that system maps are beneficial as a model to predict the relative effect of different interventions and adapt to rapidly changing environments in a complex world. Systems thinking is considered as a complementing approach to the statistical thinking, and further research is needed to evaluate the use of such tools for the development and monitoring of interventions.

Education level and misuse of antibiotics in the general population: a systematic review and dose-response meta-analysis

BACKGROUND

Numerous studies evaluated the association of education level with misuse of antibiotics by the general population, yet divergent findings were reported. Therefore, a meta-analysis was conducted to summarize this association.

METHODS

A categorical and continuous dose-response meta-analysis of the association of education level with antibiotic misuse was undertaken. Summary odds ratios (ORs) and their 95% confidence intervals (CIs) were estimated using random-effect model.

RESULTS

The meta-analysis included 85 studies from 42 countries of different socioeconomic status. Compared to low education (≤ 9 years), medium education (> 9-12 years) is associated with 20% lower odds of antibiotic misuse in high-income countries (OR = 0.80; 95% CI 0.66, 0.97), while high education (> 12 years) is associated with 14% lower odds of any aspect of antibiotic misuse (OR = 0.86; 95% CI 0.72, 1.03). The association is more pronounced in Middle East (OR = 0.64; 95% CI 0.42, 1.00) and countries of lower-middle economies (OR = 0.67, 95% CI 0.41, 1.11). Inversely, in Europe, high education is associated with 25% higher odds of antibiotic misuse (OR = 1.25, 95% CI 1.00, 1.58). Each additional year of education was associated with 4% lower odds of any aspect of antibiotic misuse in lower-middle economies (OR = 0.96; 95% CI 0.92, 1.00) and in Middle East (OR = 0.96; 95% CI 0.93, 1.00). Conversely, it was associated with 3% higher odds of antibiotic storage, a specific type of misuse (OR = 1.03, 95% CI 1.01, 1.06).

CONCLUSION

Individuals misuse antibiotics irrespective of their education level. Intervention programs to enhance the proper use of antibiotics should target all communities independent of their education level.

Antimicrobial Stewardship in College and University Health Settings: A Public Health Opportunity

Antimicrobial resistance poses a significant threat to public health and safety across the globe. Many factors contribute to antibiotic resistance, most especially are the concerns of excessive prescribing and misuse of antibiotics. Because patient expectations for antibiotics may contribute to prescriber pressures, experts recommend targeting antimicrobial stewardship (AMS) education efforts towards prescribers as well as patients in outpatient settings. Undergraduate university students are a unique and promising target population for AMS efforts because they are in a transformative life stage of social, cognitive, and physical development in which they are learning to independently care for themselves without the presence or influence of parents. By introducing AMS education during this transition, university students may adopt positive antibiotic use behaviors that they will carry throughout their lives. Not only will their personal health be improved, but widespread adoption of AMS in university settings may have a broader effect on public health of present and future generations. Despite public health opportunities, minimal research has examined AMS in university health settings. This article explores current evidence on knowledge, attitudes, and use of antibiotics among university students and discusses opportunities for AMS initiatives in college and university health settings.

A novel framework to guide antibiotic stewardship nursing practice

BACKGROUND

There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices.

METHODS

We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts.

RESULTS

Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice.

CONCLUSIONS

Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.

Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.

Knowledge, Perceptions, and Attitudes Regarding Antibiotic Use for Lower Respiratory Tract Infections: Insights from Patients in Sri Lanka

Antibiotic resistance is an emerging global public health threat. One of the main drivers of this threat is the inappropriate use of antibiotics. In Sri Lanka, antibiotic consumption is increasing, but little is known locally about how patients perceive antibiotics. We conducted a qualitative study to gain a better understanding of the knowledge, perceptions, and attitudes of patients regarding antibiotics and antibiotic resistance. Semi-structured interviews involving 18 patients with lower respiratory tract infection (LRTI) admitted to a large, public tertiary care hospital in southern Sri Lanka were conducted. Interviews were analyzed to identify themes regarding the patients' knowledge of LRTI etiology and treatment, perceptions and attitudes toward LRTI treatment, including antibiotics, and patient-physician communication. Most patients mentioned multiple care visits and the use of multiple pharmaceuticals prior to admission. Patients sought a quick resolution to their ailments and frequently visited several private physicians to obtain a satisfying answer. Self-medication was also common. Patients reused prescriptions for antibiotics, kept antibiotics for later use after prematurely stopping their course of treatment, and bought over-the-counter antibiotics. Patients' knowledge of disease etiology and antibiotics was poor. Only a few patients were aware of antibiotic resistance. Despite the desire to receive more information regarding disease and treatment, patient-provider communication was limited and mainly confined to prescription instructions. This qualitative study performed in Sri Lanka suggests that inappropriate use of antibiotics is a multifactorial problem. To improve antibiotic use, a multifactorial approach that includes educating the public, increasing awareness among physicians, and implementing systems-level changes to restrict access to antibiotics is urgently needed.

Ubiquitousness of Haloferax and Carotenoid Producing Genes in Arabian Sea Coastal Biosystems of India

This study presents a comparative analysis of halophiles from the global open sea and coastal biosystems through shotgun metagenomes (n = 209) retrieved from public repositories. The open sea was significantly enriched with Prochlorococcus and Candidatus pelagibacter. Meanwhile, coastal biosystems were dominated by Marinobacter and Alcanivorax. Halophilic archaea Haloarcula and Haloquandratum, predominant in the coastal biosystem, were significantly (p < 0.05) enriched in coastal biosystems compared to the open sea. Analysis of whole genomes (n = 23,540), retrieved from EzBioCloud, detected crtI in 64.66% of genomes, while cruF was observed in 1.69% Bacteria and 40.75% Archaea. We further confirmed the viability and carotenoid pigment production by pure culture isolation (n = 1351) of extreme halophiles from sediments (n = 410 × 3) sampling at the Arabian coastline of India. All red-pigmented isolates were represented exclusively by Haloferax, resistant to saturated NaCl (6 M), and had >60% G + C content. Multidrug resistance to tetracycline, gentamicin, ampicillin, and chloramphenicol were also observed. Our study showed that coastal biosystems could be more suited for bioprospection of halophiles rather than the open sea.

Knowledge about infections is associated with antibiotic use: cross-sectional evidence from the health survey Northern Ireland

BACKGROUND

Antibiotic overuse is the main modifiable driver of antibiotic resistance. Factors associated with overuse have been inconsistently reported and vary across populations. Given the burgeoning occurrence of infectious diseases around the world, there remains a great need to identify barriers and solutions to the control of infections. We examined whether knowledge about infections and antibiotic resistance is associated with antibiotic use in a northern European population sample.

METHODS

The Health Survey Northern Ireland 2014/15 was completed by a cross-sectional sample of 4135 participants aged > 16 years. Participants were asked whether they had taken an antibiotic in the past 12 months; and six questions were asked concerning knowledge about infections and antibiotic resistance. Correct answers to the six knowledge questions defined a knowledge score (score range 0-6 correct answers). We used multivariable logistic regression to estimate odds of self-reported antibiotic use during the last 12 months in association with knowledge score (lowest score, 0/6, as referent), and response to each knowledge question. Covariates included sex, age group, smoking, alcohol drinking, deprivation index, self-rated health, and satisfaction with life. Results were outputted as Odds Ratios (OR) and 95% Confidence Intervals (CI).

RESULTS

Antibiotic use in the past 12 months was reported by 39.0% (1614/4135); and 84.2% (3482/4135) scored < 6/6 correct on knowledge statements. Compared to the lowest knowledge score (0/6 correct), the highest knowledge score (6/6 correct) was associated with higher odds of antibiotic use (adjusted OR 2.03, 95% CI [1.46, 2.81], p < 0.001), with a P-value < 0.001 for trend with increasing knowledge score. Female sex, age, high deprivation, and poor general health, were independently associated with higher odds of antibiotic use. Stratified analyses showed sex and age group differences.

CONCLUSION

Knowledge, and other modifiable and non-modifiable risk factors, were positively associated with antibiotic use in the past 12 months. While the causal direction of these associations could not be determined, given the high prevalence of lesser knowledge, as well as independent contributions of other factors including socioeconomic characteristics, health literacy campaigns to raise awareness of antibiotic resistance should take a multi-pronged approach.

Paediatric nurses', children's and parents' adherence to infection prevention and control and knowledge of antimicrobial stewardship: A systematic review

INTRODUCTION

Infection prevention and control precautions help to decrease microbial transmission, and through the appropriate use of antibiotics, Antimicrobial Stewardship programs aim to decrease the prevalence and emergence of Antimicrobial Resistance.

METHODS

A systematic review was undertaken to critically appraise and synthesise evidence for nurses', children's and parents' knowledge and understanding of antimicrobial stewardship, and of infection prevention and control in acute paediatric care settings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guided the review. Studies were included if they examined the factors that contributed to nurses' adherence to, or consumers' practice in relation to, antimicrobial stewardship and infection prevention and control.

RESULTS

Of the 16,957 papers identified, 50 studies conducted in acute paediatric settings met the eligibility criteria, and were included. Most studies were of low methodological quality. Fourteen studies evaluated nurses' knowledge and self-reported adherence to Infection Prevention and Control principles and identified consistent practice gaps by nurses. Six studies evaluating the effectiveness of education programs reported modest improvements in nurses' knowledge and adherence to infection prevention and control. There were 15 studies, that investigated consumers' involvement in infection prevention and control that identified the following themes: Consumer knowledge and attitudes to infection prevention and control and transmission-based precautions, and parents' willingness to take an active role in infection prevention. Six studies focused on paediatric nurses' role in antimicrobial stewardship, exploring the following themes: (1) nurses' understanding and beliefs of antimicrobial stewardship roles, and (2) barriers to nurses taking a greater role in antimicrobial stewardship. Nine studies explored the role of consumers in antimicrobial stewardship and identified consumers' misconceptions about the benefits and downplayed concerns regarding antibiotic use.

DISCUSSION

Although consumers articulated a willingness to be actively involved in infection prevention, observed practice remained lower than that required to consistently prevent infection transmission.

CONCLUSION

These findings highlight a critically important gap in current practice. In relation to optimal use of antimicrobials, although paediatric nurses were involved in supporting antimicrobial stewardship processes and educating consumers, they identified limited antimicrobial stewardship knowledge. Consumers appeared to lack understanding about the benefits of antibiotics and negated concerns regarding antibiotic use.

Self-prescribing of antibiotics by patients seeking care in Indian emergency departments

STUDY OBJECTIVE

Antibiotic resistance is a global health threat. India has one of the highest rates of antibiotic use in the world. The objective of this study was to evaluate the prevalence of self-prescribed antibiotic use of patients presenting with febrile and infectious disease-related complaints to Indian emergency departments.

METHODS

This was a prospective observational study conducted at 6 Indian emergency departments (EDs) between January 1, 2019 and December 31, 2019. Adult patients who presented with a chief complaint of febrile illness or infectious disease complaints were included. Our principal outcomes of interest were self-prescribed use of antibiotics within the prior 6 months or for the presenting complaint. We queried respondents about source of antibiotics as well as about demographic characteristics that influenced use.

RESULTS

A total of 1421 patients were enrolled. Sixty percent (n = 856) of respondents reported using antibiotics in the prior 6 months or for their current complaint. Those who reported self-prescribing antibiotics either in the past or currently had at least some college education (P < 0.001), tended to use the pharmacy (P < 0.001) or the ED (P = 0.001) for their care when sick, and were more likely to have some comorbid conditions (P = 0.014) as compared to the group that did not self-prescribe antibiotics. The most common reason respondents reported self-prescribing antibiotics was because they did not want to wait to see their doctor (n = 278, 33%). Thirty-five percent of patients who were self-prescribed antibiotics before presentation did not receive and were not prescribed antibiotics in the ED, at discharge, or both.

CONCLUSIONS

Self-prescribing of antibiotics occurs commonly in India. This use increases the risk for resistance due to inappropriate or unnecessary use. Promotion of antibiotic stewardship is needed to curtail such use.

Divergent and Convergent Attitudes and Views of General Practitioners and Community Pharmacists to Collaboratively Implement Antimicrobial Stewardship Programs in Australia: A Nationwide Study

Setting up an interprofessional team for antimicrobial stewardship (AMS) to improve the quality and safety of antimicrobial use in primary care is essential but challenging. This study aimed to investigate the convergent and divergent attitudes and views of general practitioners (GPs) and community pharmacists (CPs) about AMS implementation and their perceived challenges of collaboration to design a GP–pharmacist collaborative AMS (GPPAS) model. Nationwide surveys of GPs and CPs across Australia were conducted January-October 2019. Chi square statistics and a theoretical framework were used for comparative analyses of quantitative and qualitative data, respectively. In total, 999 participants responded to the surveys with 15.4% (n = 386) response rates for GPs and 30.7% (n = 613) for CPs. GPs and CPs were aware about AMS however their interprofessional perceptions varied to the benefits of AMS programs. CPs indicated that they would need AMS training; significantly higher than GPs (GP vs. CP; 46.4% vs. 76.5%; p < 0.0001). GPs’ use of the Therapeutic Guideline Antibiotic was much higher than CPs (83.2% vs. 45.5%; p < 0.0001). No interprofessional difference was found in the very-limited use of patient information leaflets (p < 0.1162) and point-of-care tests (p < 0.7848). While CPs were more willing (p < 0.0001) to collaborate with GPs, both groups were convergent in views that policies that support GP–CP collaboration are needed to implement GPPAS strategies. GP–pharmacist collaborative group meetings (54.9% vs. 82.5%) and antimicrobial audit (46.1% vs. 86.5%) models were inter-professionally supported to optimise antimicrobial therapy, but an attitudinal divergence was significant (p < 0.001). The challenges towards GP–CP collaboration in AMS were identified by both at personal, logistical and organisational environment level. There are opportunities for GP–CP collaboration to improve AMS in Australian primary care. However, strengthening GP–pharmacy collaborative system structure and practice agreements is a priority to improve interprofessional trust, competencies, and communications for AMS and to establish a GPPAS model in future.

The Role of Pharmaceutical Companies in Antimicrobial Stewardship: A Case Study

Rising levels of antimicrobial resistance pose serious dangers to patients, population health, food security, and economic stability worldwide. In response to this threat, the United Nations and the World Health Organization have called for multisectoral, multidisciplinary action, recognizing that human, animal, and environmental health are interdependent. Although the pharmaceutical industry clearly has a leading role in developing novel antimicrobials and vaccines, it is also active in many areas supporting antimicrobial stewardship. This article describes why pharmaceutical companies invest in antimicrobial stewardship, outlines why they are well suited to help address this issue, and provides examples of how the pharmaceutical industry can support the responsible use of antimicrobials. Merck & Co., Inc. (Kenilworth, NJ, USA), a large, globally operating pharmaceutical company that develops and markets both human and veterinary antimicrobials and vaccines is used as a case study for illustrating industry involvement in antimicrobial stewardship efforts.

Antimicrobial stewardship in the outpatient setting: A review and proposed framework

Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.