Special considerations of antibiotic prescription in the geriatric population

Antibiotic Use and Risk of Microscopic Colitis in Older Adults: A Nationwide Self-Controlled Case Series Study

BACKGROUND

Several drugs have been linked to the risk of microscopic colitis (MC), a condition characterised by watery, non-bloody diarrhoea. Antibiotics can induce similar symptoms, but their connection to MC remains unclear.

AIM

To investigate the antibiotic-related risks of MC in adults aged 65 years and older.

METHODS

This was a nationwide, self-controlled case series study including adults aged ≥ 65 years with a new prescription for antibiotics and biopsy-confirmed, incident MC (Sweden, 2007-17). We identified cases from the nationwide histopathology cohort ESPRESSO individually linked to several registers. Using conditional Poisson regression, we estimated incidence rate ratios (IRR) for four risk periods: on treatment, and 1-14, 15-91, and 92-365 days post-treatment, compared with the non-treatment periods in the same individual. We also conducted a negative control outcome analysis to assess whether the association was specific to MC or due to diagnostic workup. E-values were used to assess robustness to unmeasured confounding.

RESULTS

We identified 2393 persons with incident biopsy-confirmed MC (median age at diagnosis 74; 67% women). Compared with the non-treatment periods, the risk of MC in the age-adjusted analysis increased with antibiotic treatment (IRR: 1.44 [95% CI: 1.13-1.84], E-value: 2.24), 1-14 days (IRR: 1.12 [0.83-1.49]), 15-91 days (1.12 [0.97-1.31]) and 92-365 days post-treatment (1.19 [1.07-1.32]). The negative control outcome analysis showed similar risks of biopsy-confirmed normal mucosa after antibiotic use.

CONCLUSION

The observed association between antibiotic use and MC may result from detection bias rather than a causal relationship.

The impact of a multifaceted intervention on antibiotic use for common infections in nursing homes in Spain. A before and after study

PURPOSE

The aim of this study was to assess the impact of a multifaceted intervention aimed at nursing home staff on antibiotic use and hygiene elements for nursing home residents with common infections.

METHODS

Before-and-after study carried out in nursing homes in five areas of Spain. Nursing staff registered residents with common infections and documented hygiene practices over three months, before and after a 2-h educational intervention in autumn 2023. The intervention focused on the initial registration results, antibiotic guidelines, infection prevention, and management strategies for nursing homes. Indicators for potentially unnecessary antibiotic use and non-first-line antibiotics were developed, and results from both registration periods (Feb-Apr 2023 and Feb-Apr 2024) were compared to assess impact.

RESULTS

Of 34 nursing homes, 23 completed the intervention and the two registrations (67.6%). Staff reported 1003 infections in the first registration and 789 in the second. The overall antibiotic prescription rate was 84.6%. Potentially inappropriate antibiotic use for urinary tract infections decreased from 70.3 to 59.9% (P < 0.005) and use for respiratory infections dropped from 78.1 to 62.7% (P < 0.001), with inappropriate use decreasing from 46.3 to 31% (P < 0.001). The mean duration of antibiotics for cystitis reduced from 7 to 5.4 days (P < 0.05). The intervention had no impact on hygiene practices.

CONCLUSION

Potentially unnecessary antibiotic use was lower after the intervention, whereas hygiene practices were unchanged. A more intensive, multifaceted educational approach is needed for a greater impact.

General practice antibiotic prescriptions attributable to respiratory syncytial virus by age and antibiotic class: an ecological analysis of the English population

BACKGROUND

Respiratory syncytial virus (RSV) may contribute to a substantial volume of antibiotic prescriptions in primary care. However, data on the type of antibiotics prescribed for such infections are only available for children <5 years in the UK. Understanding the contribution of RSV to antibiotic prescribing would facilitate predicting the impact of RSV preventative measures on antibiotic use and resistance. The objective of this study was to estimate the proportion of antibiotic prescriptions in English general practice attributable to RSV by age and antibiotic class.

METHODS

Generalized additive models examined associations between weekly counts of general practice antibiotic prescriptions and laboratory-confirmed respiratory infections from 2015 to 2018, adjusting for temperature, practice holidays and remaining seasonal confounders. We used general practice records from the Clinical Practice Research Datalink and microbiology tests for RSV, influenza, rhinovirus, adenovirus, parainfluenza, human metapneumovirus, Mycoplasma pneumoniae and Streptococcus pneumoniae from England's Second Generation Surveillance System.

RESULTS

An estimated 2.1% of antibiotics were attributable to RSV, equating to an average of 640 000 prescriptions annually. Of these, adults ≥75 years contributed to the greatest volume, with an annual average of 149 078 (95% credible interval: 93 733-206 045). Infants 6-23 months had the highest average annual rate at 6580 prescriptions per 100 000 individuals (95% credible interval: 4522-8651). Most RSV-attributable antibiotic prescriptions were penicillins, macrolides or tetracyclines. Adults ≥65 years had a wider range of antibiotic classes associated with RSV compared with younger age groups.

CONCLUSIONS

Interventions to reduce the burden of RSV, particularly in older adults, could complement current strategies to reduce antibiotic use in England.

Global burden of antimicrobial resistance in lower respiratory infections in 2021: A systematic analysis

OBJECTIVES

The research aimed to provide a worldwide evaluation of antimicrobial resistance (AMR), focusing specifically on AMR related to lower respiratory infections (LRI).

METHODS

The data were derived from the Global Antimicrobial Resistance Burden 2021 (GARB 2021). Two counterfactuals were utilized to estimate the deaths attributable to AMR and the deaths associated with AMR. The primary estimation process involved various statistical methodologies, including polynomial estimation and ensemble spatiotemporal Gaussian regression models. Using the DisMod-MR 2.1 modeling framework, the incidence and prevalence of LRI were estimated, the mortality rates were subsequently calculated, and stratified by pathogens, regions, and age groups. In addition, these indexes were identified and visualized to present global burden of AMR.

RESULTS

In 2021, there were 20.89 (95% uncertain interval: 18.27-23.50) deaths per 100 000 individuals associated with AMR in LRI, and 5.05 (95% UI: 4.29-5.51) deaths per 100 000 individuals attributable to AMR in LRI. Trimethoprim-sulfamethoxazole-resistant S. pneumoniae exhibited the highest mortality rate of 5.15 (95% UI: 3.96- 6.34) deaths per 100 000 individuals associated with AMR, while Carbapenem -resistant S. pneumoniae exhibited the highest mortality rate of 0.66 (95% UI: 0.45-0.86) deaths per 100 000 individuals attributable to AMR. S. pneumoniae exhibited the greatest burden of AMR, followed by S. aureus. Central Sub-Saharan Africa had the highest AMR burden, with mortality rates of 73.75 (95% UI: 56.61-90.89) deaths per 100 000 individuals associated with AMR and 17.73 (95% UI: 12.71-2.74) deaths per 100 000 individuals attributable to AMR, followed by Eastern Sub-Saharan Africa and Western Sub-Saharan Africa. The individuals aged under 5 and over 65 years exhibited high prevalence of antibiotic resistance especially to Carbapenems, Methicillin, and Fluoroquinolones.

CONCLUSION

AMR in the LRI is still a pressing global health issue, particularly in developing countries and neonatal age groups. Global interventions need to be taken to reduce the prevalence of AMR.

Evaluation of elderly patients with bacteremia in the cardiology intensive care unit

In this study, the blood culture results of patients aged >65 years who were admitted to the cardiology intensive care unit in a training and research hospital and who had positive blood cultures within the first 48 hours were evaluated. This was a retrospective, observational and nonrandomized study. Patient data at the time of the blood culture were included in the study. Sex, age, length of hospital stay, mortality, Acute Physiology Chronic Health Evaluation II score, laboratory values, and microorganisms grown in blood culture included in the study. Two hundred forty-seven patients, 43.3% of whom were female (n = 107), were included in the study. The median age of the patients was 75 (range 70-83). The mean hospital stay was 5 days (range 3-8). All patients had a median Acute Physiology Chronic Health Evaluation II score of 21 (range 19-23). The overall mortality rate 48.2% (n = 119). The results showed that 49.8% of those died and 50.2% of survivors had positive blood culture results. The most common gram-positive cocci in those died were Staphylococcus hominis (15.6%), Staphylococcus epidermis (14.8%), Enterococcus faecium (9.6%). The most common gram-negative cocci were Escherichia coli (9.6%), Klebsiella pneumoniae (9.6%), Acinetobacter baummanii (1.6%). With an increase in the elderly population, infection management in elderly patients hospitalized in cardiology intensive care units has become increasingly critical.

Antibiotic consumption patterns in older adults: a comparative study of people 65 years and older in and outside nursing homes, Belgium, 2016 to 2022

BackgroundInappropriate antimicrobial consumption (AMC) drives the emergence of antimicrobial resistance. Institutionalised, older populations are associated with antimicrobial treatments of longer duration and broader spectrum than recommended, higher rates of multidrug-resistant infections and poorer outcomes for resistant infections. Yet systematic, national monitoring of AMC in nursing home (NH) residents is lacking.AimTo perform a retrospective analysis of antibiotic consumption in Belgian NHs, we compared analogous populations inside and outside NHs. We aimed to provide a blueprint for establishing surveillance of NH AMC, based on national reimbursement data.MethodsThe National Institute for Health and Disability Insurance supplied reimbursement AMC data for outpatients from 2016 to 2022. Data were classified by the Anatomical Therapeutic Chemical system, expressed as defined daily doses (DDD) and aggregated by prescription month, patient age, sex and residency inside/outside a NH. The number of ensured beneficiaries, aggregated by the same demographic variables, was collected from the Intermutualistic Agency. We compared the DDDs per 1,000 beneficiaries per day, along with secondary metrics for national and international targets for analogous populations inside and outside NHs.ResultsTotal antibiotic consumption decreased in both populations but remained twofold higher in NH residents. Proxy prescription quality metrics were consistently less favourable within NHs and diverged further during the COVID-19 pandemic. Distinct consumption patterns and greater seasonal fluctuations were observed in NH residents.ConclusionGiven the different infection risks and higher antibiotic consumption of NH residents, AMC surveillance and antimicrobial stewardship efforts targeting this fragile population are needed.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study

BACKGROUND

Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs).

OBJECTIVE

This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes.

METHODS

A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements.

RESULTS

A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025.

CONCLUSIONS

This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60099.

Antibiotic prescribing practice using WHO Access, Watch and Reserve classification and its determinants among outpatient prescriptions dispensed to elderly population in six community chain pharmacies in Asmara, Eritrea: a cross-sectional study

OBJECTIVE

To assess antibiotic prescribing practice and its determinants among outpatient prescriptions dispensed to the elderly population.

DESIGN

A prescription-based, cross-sectional study.

SETTING

Six community chain pharmacies in Asmara, Eritrea.

PARTICIPANTS

All outpatient prescriptions dispensed to the elderly population (aged 65 and above) in the six community chain pharmacies in Asmara, Eritrea.

DATA COLLECTION AND ANALYSIS

Data were collected retrospectively, between 16 June 2023 and 16 July 2023. Antibiotic prescribing practice was assessed using the 2023 World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification system. Descriptive statistics and logistic regression were performed using IBM SPSS (V.26.0). P values less than 0.05 were considered as significant.

RESULTS

Of the 2680 outpatient prescriptions dispensed to elderly population, 35.8% (95% CI: 34.0, 37.6) contained at least one antibiotic. Moreover, a total of 1061 antibiotics were prescribed to the elderly population. The most commonly prescribed antibiotics were ciprofloxacin (n=322, 30.3%) and amoxicillin/clavulanic acid (n=145, 13.7%). The Access category accounted for the majority of antibiotics (53.7%) with 32.1% from the Watch category. Prescriber qualification (Adjusted Odds Ratio (AOR)= 0.60, 95% CI: 0.44, 0.81) and polypharmacy (AOR= 2.32, 95% CI: 1.26, 4.27) were significant determinants of antibiotic prescribing in the elderly population. Besides, sex (AOR=0.74, 95% CI: 0.56, 0.98), prescriber qualification (AOR=0.49, 95% CI: 0.30 to0.81) and level of health facility (AOR 0.52, 95% CI 0.34 to 0.81) were significant determinants of a Watch antibiotic prescription.

CONCLUSION

Antibiotics were prescribed to a considerable number of the elderly population, with more than half of them falling into the Access category. Further efforts by policy-makers are needed to promote the use of Access antibiotics while reducing the use of Watch antibiotics to mitigate risks associated with antimicrobial resistance.

Appropriate use of antibiotics for oral/dental conditions in older adults: a narrative review

OBJECTIVES

Considering the high rates in the use of antibiotics for oral/dental conditions in older patients and the rise in antimicrobial resistance, appropriate antibiotic prescription is important. This narrative review aimed to discuss the challenges and special considerations when prescribing antibiotics to older patients for oral/dental conditions.

METHODS

PubMed/MEDLINE, Scopus, Web of Science, and articles' reference lists were searched for antibiotics use for oral conditions by older patients. Moreover, scientific and professional organisations' official websites were searched for guidelines on antibiotic use in dentistry.

RESULTS

Despite several guidelines about the use of antibiotics in dentistry, specific information on their administration to older patients is missing. Relevant challenges include age-related changes in pharmacokinetics and pharmacodynamics, comorbidities and polypharmacy associated with low adherence, contraindications, adverse reactions, and drug-drug interactions. In unfit and frail older patients some antibiotics should be avoided, or doses should be adjusted, according to medical conditions or medications received. Amoxicillin, with doses adapted to renal function, is one of the safest options, while other antibiotics should be chosen with caution upon indications and individual patient characteristics.

CONCLUSIONS

Healthcare providers should prescribe antibiotics to unfit and frail older adults with caution, given the multitude of comorbidities and potential interactions with medications received. Further research is needed on the safe and effective use of antibiotics in older patients.

Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities

HIGHLIGHTS

The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.

What influences antibiotic initiation? Developing a scale to measure nursing behaviour in residential aged-care facilities

AIM

The purpose of the current study was to develop and assess the psychometric properties of a measure that captures nursing behaviours that have the potential to influence the initiation of antibiotics in residential aged-care facilities.

DESIGN

Cross-sectional online survey.

METHOD

One hundred and fifty-seven nurses completed an online survey. The survey consisted of two clinical vignettes and measures of tolerance of uncertainty and anxiety. The vignettes consisted of the most common presentations (urinary tract infections and upper respiratory tract infections) of two hypothetical residents in aged-care facilities. The vignettes provided participants with incremental information with varying levels of symptoms, input from other people and availability of test results. Both vignettes were subjected to exploratory factor analysis.

RESULTS

The results focus on the 16 items in the second vignette which resulted in the extraction of three factors. The derived factors were labelled as follows: (i) Noting and Calling GP, (ii) Consult a Colleague and (iii) Immediate Assessment and Antibiotics. Reliability analysis revealed excellent to satisfactory reliability. All three scales were significantly correlated with measures of clinical tolerance of uncertainty, and the 'noting and calling GP' scale was also negatively correlated with measures of anxiety and general tolerance of uncertainty. The measure showed satisfactory reliability and validity for capturing nursing behaviours that have the potential to influence decisions regarding antibiotics. As such, the current study provides a first step towards addressing the lack of ecologically valid measures that capture the complex and nuanced context of nurses' behaviours in RACF that have the potential to inform future stewardship interventions.

Safety of subcutaneous versus intravenous ceftriaxone administration in older patients: A retrospective study

BACKGROUND

Antibiotics play a central role in infection management. In older patients, antibiotics are frequently administered subcutaneously. Ceftriaxone pharmacokinetics after subcutaneous administration is well documented, but little data are available on its safety.

METHODS

We compared the occurrence of adverse events associated with ceftriaxone administered subcutaneously versus intravenously in ≥75-year-old patients. We used data from a single-center, retrospective, clinical-administrative database to compare the occurrence of adverse events at day 14 and outcome at day 21 in older patients who received ceftriaxone via the subcutaneous route or the intravenous route at Rennes University Hospital, France, from May 2020 to February 2023.

RESULTS

The subcutaneous and intravenous groups included 402 and 3387 patients, respectively. Patients in the subcutaneous group were older and more likely to receive palliative care. At least one adverse event was reported for 18% and 40% of patients in the subcutaneous and intravenous group, respectively (RR = 2.21). Mortality at day 21 was higher in the subcutaneous route group, which could be linked to between-group differences in clinical and demographic features.

CONCLUSIONS

In ≥75-year-old patients, ceftriaxone administered by the subcutaneous route is associated with less-adverse events than by the intravenous route. The subcutaneous route, which is easier to use, has a place in infection management in geriatric settings.

Blood-Stream Infections: Causative Agents, Antibiotic Resistance and Associated Factors in Older Patients

Background

The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance.

Methods

This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019.

Results

Moyen's age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock.

Conclusion

The mortality rate was still high, especially for antibiotic-resistant agents.

Comparison of antibiotic resistance rates and outcomes among older adult patients with urinary tract infections living in long- term care hospitals and the community

OBJECTIVE

In this study, we compared the proportion of antibiotic resistance between patients who visited the emergency department (ED) with urinary tract infection (UTI) from long-term care hospitals (LTCH), which is a type of long-term care facilities (LTCF) and the community. We assessed the resulting difference in prognosis.

METHOD

Older adults who visited the ED between January and December 2019 and were diagnosed with UTI were divided into community residents and LTCH residents. We investigated the antibiotics sensitivity rates, end of therapy (EOT), and the patient's outcomes were evaluated.

RESULTS

The antibiotic resistance rate was higher in LTCH residents. LTCH residents had a higher in hospital mortality rate compared to community residents. EOT was found to be longer, and admission rate and in-hospital mortality rate were also higher in LTCH residents.

CONCLUSION

LTCF residents had a higher rate of antibiotic resistance and a poor prognosis.

Resistance pattern of isolated microorganisms from 783 clinical specimen cultures in patients admitted to Yasuj Educational Hospitals, Iran

BACKGROUND

Infectious diseases are still one of the leading causes of morbidity and mortality in resource-limited settings. Serious infection caused mostly by gram-negative pathogens causes significant morbidity. According to the Centers for Disease Control and Prevention, antimicrobial resistance kills over 700,000 people worldwide. Antibiotic resistance is on the rise, and as a consequence, serious public health issues are arising. The present study investigated isolated clinical samples from Yasuj teaching hospitals to determine the antimicrobial resistance profile to various antibiotics.

MATERIALS AND METHODS

Microbial isolates regarding cultures from urine, blood, wound, abdominal tap, throat, stool, cerebrospinal fluid, endotracheal tube, sputum, skin lesion, nasal, and mouth secretion were collected from patients admitted to hospitals affiliated with Yasuj teaching hospitals. Antibiotic susceptibility profiles were determined by using the Kirby-Bauer disc diffusion method. Data were tabulated and analyzed with SPSS version 26.0.

RESULTS

A total of 783 samples were evaluated in our study, with an average of 30.6 years and 54.5% female patients. Most of the bacterial isolates were gram-negative (64.2%). The majority of cultures were Escherichia coli (49.9%), mainly among urine samples (64.2%). The frequency distribution of norfloxacin antibiotic resistance was more common in internal medicine (66.7%), infectious (63.6%), and emergency wards (58.8%). The frequency distribution of penicillin antibiotic resistance was statistically significant in different wards. All cases of oxacillin were resistant.

CONCLUSION

Our data showed a high level of antibiotic resistance among bacterial isolates in our center. Considering widespread empirical antibiotic therapy in Iran, the rate of increasing resistance to common antibiotics prescribed for ambulatory and hospitalized patients is concerning. We recommend providing more strict guidelines and policies to control the overuse and overprescription of antimicrobials by health policy-making organizations.

Evaluating the Counseling Standards and Ability of Pharmacy Staff to Detect Antibiotic-Drugs Interactions: A Simulated Client Study from Pakistan

Effective and safe medication use can be maximized by providing medication counseling, which aims to optimize therapeutic results. This approach improves the effectiveness of antibacterial treatment, reduces treatment expenses, and mitigates the emergence of antimicrobial resistance. No research from Pakistan has been previously documented. The purpose of this research was to evaluate both the quality of antibiotic counseling provided and the level of understanding exhibited by pharmacy employees with regard to interactions involving antibiotic medications. Using a simulated client method, two scenarios were used to assess 562 pharmacies that were systematically selected. Scenario 1 focused the counseling for use of prescribed medicines with non-prescribed antibiotics. Scenario2 indicated counseling provision for prescribed antibiotics that have possible antibiotic-drug interactions. The evaluation of counseling skills was also conducted. The analysis involved the use of descriptive statistics and chi-square tests. Only 34.1% of simulated clients received medication counseling directly; 45% received it on request. About 31.2% of clients were referred to a physician without counseling. The most frequently provided information was therapy dose (81.6%) and duration (57.4%). More than half (54.0%) of clients were asked about disease duration, but drug storage was ignored. Insufficient information was provided about side effects (1.1%) and antibiotic-drug interactions (1.4%). Most (54.3%) clients were instructed about dietary or lifestyle modifications. Only 1.9% of clients received information about drug administration route. No information was provided about other medication during therapy, effect of medicine withdrawal, and compliance to medication. The current level of antibiotic counseling within Pakistani community pharmacies is inadequate and requires the attention of medical authorities. Professional training of staff could improve counseling.

Association between multidimensional prognostic index (MPI) and infections in a population of older people affected by COVID-19

BACKGROUND

Only limited studies analyzed a possible relationship between frailty and infections. Our aim was to investigate the possible association between higher multidimensional prognostic index (MPI) values, a tool for evaluating multidimensional frailty, and the prevalence of infectious diseases, including antibiotics' cost and the prevalence of MDR (multidrug resistance) pathogens.

METHODS

Older patients, affected by COVID-19, were enrolled in the hospital of Palermo over four months.

RESULTS

112 participants (mean age 77.6, 55.4% males) were included. After adjusting for potential confounders, frailer participants had a higher odds of any positivity to pathogens (prevalence: 61.5%, odds ratio = 15.56, p < 0.0001) compared to a prevalence of 8.6% in more robust, including MDR, and a higher costs in antibiotics.

CONCLUSIONS

Higher MPI values, indicating frailer subjects, were associated with a higher prevalence of infections, particularly of MDR pathogens, and a consequent increase in antibiotics' cost.

Antibiotic Misuse Behaviours of Older People: Confirmation of the Factor Structure of the Antibiotic Use Questionnaire

Antibacterial resistance (AR) is responsible for steadily rising numbers of untreatable bacterial infections, most prevalently found in the older adult (OA) population due to age-related physical and cognitive deterioration, more frequent and long-lasting hospital visits, and reduced immunity. There are currently no established measures of antibiotic use behaviours for older adults, and theory-informed approaches to identifying the drivers of antibiotic use in older adults are lacking in the literature. The objective of this study was to identify predictors of antibiotic use and misuse in older adults using the Antibiotic Use Questionnaire (AUQ), a measure informed by the factors of the Theory of Planned Behaviour (TPB): attitudes and beliefs, social norms, perceived behavioural control, behaviour, and a covariate-knowledge. A measure of social desirability was included, and participants scoring highly were excluded to control for social desirability bias. Confirmatory Factor Analyses and regression analyses were conducted to test the hypotheses in a cross-sectional, anonymous survey. A total of 211 participants completed the survey, 47 of which were excluded due to incompletion and high social desirability scores (≥5). Results of the factor analysis confirmed that some (but not all) factors from previous research in the general population were confirmed in the OA sample. No factors were found to be significant predictors of antibiotic use behaviour. Several suggestions for the variance in results from that of the first study are suggested, including challenges with meeting requirement for statistical power. The paper concludes that further research is required to determine the validity of the AUQ in an older adult population.

Evaluation of duration of antibiotic therapy across hospitals in Scotland including the impact of COVID-19 pandemic: a segmented interrupted time series analysis

BACKGROUND

Little is known about the duration of antibiotic use in hospital settings. We evaluated the duration of hospital antibiotic therapy for four commonly prescribed antibiotics (amoxicillin, co-amoxiclav, doxycycline, and flucloxacillin) including the assessment of COVID-19 impact.

METHODS

A repeated, cross-sectional study using the Hospital Electronic Prescribing and Medicines Administration system (January/2019-March/2022). Monthly median duration of therapy/duration categories was calculated, stratified by routes of administration, age, and sex. The impact of COVID-19 was assessed using segmented time-series analysis.

RESULTS

There were significant variations in the median duration of therapy across routes of administration (P < 0.05), with the highest value among those antibiotic courses composed of both oral and IV antibiotics ('Both' group). Significantly higher proportions of prescriptions within the 'Both' group had a duration of >7 days compared to oral or IV. The duration of therapy differed significantly by age. Some small statistically significant changes in the level/trends of duration of therapy were observed in the post-COVID-19 period.

CONCLUSIONS

No evidence for prolonged duration of therapy were observed, even during COVID-19 pandemic. The duration of IV therapy was relatively short, suggesting timely clinical review and consideration of IV to oral switch. Longer duration of therapy was observed among older patients.

Sequential Therapy of Linezolid and Contezolid to Treat Vancomycin-Resistant Enterococcus faecium Pneumonia in a Centenarian Patient: Case Report

Enterococcus faecium (E. faecium) is one of the core components of enterococci and causes serious illnesses in the elderly and immunocompromised patients. Due to its adaptive traits and antibiotic resistance, E. faecium has evolved as a worldwide hospital-associated pathogen, especially vancomsycin-resistant Enterococcus faecium (VREfm). Pneumonia caused by VREfm is quite rare in clinical settings, and optimal treatment has not yet been determined. Here, we present a case of nosocomial VREfm pneumonia with lung cavitation following adenovirus infection, which was successfully treated with linezolid and contezolid.

Intrinsic values of procalcitonin in bacterial bloodstream infections in people aged 75 years and over: a retrospective study

OBJECTIVE

To evaluate PCT measurement in the diagnosis of bloodstream infection (BSI) in hospitalized patients aged 75+.

METHOD

Descriptive, retrospective, monocentric study conducted in France, in patients with at least one blood culture and PCT and CRP measurements within the 24 hours before or after blood culture.

RESULTS

The mean PCT and CRP values for the 118 (15.2%) positive blood cultures were 18.90 ng/ml [95%CI: 0.007-334.7] and 153.93 mg/l [1-557], respectively. With a threshold of 0.3 ng/ml, PCT measurement had a sensitivity of 84%, a specificity of 53%, a PPV of 24%, and an NPV of 95%, making it possible to rule out BSI in 350 (45.1%) patients (α-risk=5%).

CONCLUSION

PCT measurement may eliminate BSI diagnosis more quickly than does blood culture reducing the inadequate and detrimental use of antibiotic therapy. A prospective study is required to validate its usefulness and confirm the cut-off value in geriatric populations.

Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research

OBJECTIVES

To present a systematic review and critical analysis of clinical studies for necrotising otitis externa (NOE), with the aim of informing best practice for diagnosis and management.

DESIGN

Medline, Embase, Cochrane Library and Web of Science were searched from database inception until 30 April 2021 for all clinical articles on NOE. The review was registered on PROSPERO (ID: CRD42020128957) and conducted in accordance with PRISMA guidelines.

RESULTS

Seventy articles, including 2274 patients were included in the final synthesis. Seventy-three percent were retrospective case series; the remainder were of low methodological quality. Case definitions varied widely. Median patient age was 69.2 years; 68% were male, 84% had diabetes and 10% had no reported immunosuppressive risk factor. Otalgia was almost universal (96%), with granulation (69%) and oedema (76%) the commonest signs reported. Pseudomonas aeruginosa was isolated in 62%, but a range of bacterial and fungal pathogens were reported and 14% grew no organism. Optimal imaging modality for diagnosis or follow-up was unclear. Median antimicrobial therapy duration was 7.2 weeks, with no definitive evidence for optimal regimens. Twenty-one percent had surgery with widely variable timing, indication, or procedure. One-year disease-specific mortality was 2%; treatment failure and relapse rates were 22% and 7%, respectively.

CONCLUSION

There is a lack of robust, high-quality data to support best practice for diagnosis and management for this neglected condition. A minimum set of reporting requirements is proposed for future studies. A consensus case definition is urgently needed to facilitate high-quality research.

Procalcitonin to reduce exposure to antibiotics and individualise treatment in hospitalised old patients with pneumonia: a randomised study

BACKGROUND

Treating pneumonia in old patients remains challenging for clinicians. Moreover, bacterial antimicrobial resistance is a major public health threat.

OBJECTIVE

The PROPAGE study evaluated the interest of a strategy using serial measurements of procalcitonin (PCT) to reduce the duration of antibiotic therapy in old patients with pneumonia.

METHODS

PROPAGE took place from Dec.-2013 to Jun.-2016 in eight French geriatric units. It was a prospective, comparative, randomised, open-label study involving old patients (≥ 80 years) who had initiated antibiotic treatment for pneumonia in the previous 48 h. PCT was monitored in all patients and two decision-making PCT-based algorithms guided antibiotic therapy in patients from the PCT group.

RESULTS

107 patients were randomised (PCT, n = 50; Control, n = 57). Antibiotic therapy exposure was reduced in the PCT group as compared to the Control group (median duration of antibiotic therapy, 8 vs. 10 days [rank-test, p = 0.001]; antibiotic persistence rates on Days 6 and 8, 54% and 44% vs. 91% and 72%) and no significant difference was found in recovery rate (84% vs. 89.5%; Pearson Chi² test, p = 0.402).

CONCLUSION

Although, the superiority of the strategy was not tested using a composite criterion combining antibiotic therapy duration and recovery rate was not tested due to the small sample size, the present study showed that monitoring associated with PCT-guided algorithm could help shorten antibiotic treatment duration in the very old patients without detrimental effects. Measuring PCT levels between Day 4 and Day 6 could be helpful when making the decision regarding antibiotic discontinuation.

TRIAL REGISTRATION

NCT02173613. This study was first registered on 25/06/2014.

Factors influencing receipt of an antibiotic prescription among insured patients in Tanzania: a cross-sectional study

OBJECTIVES

There are limited data on factors influencing antibiotic prescription among insured patients. We assessed for correlates of an antibiotic prescription among insured patients.

DESIGN

A cross-sectional study.

SETTING

The study was conducted at the National Health Insurance Fund offices, Dar es Salaam, Tanzania.

DATA SOURCE

We captured data from the claim forms, containing inpatient and outpatient treatment information for insured patients, for the month of September 2019.

OUTCOME VARIABLE

Receipt of an antibiotic prescription.

EXPOSURE VARIABLES

Age, sex, diagnosis, prescriber qualification, health facility level, ownership and department were exposure variables. Predictors of receipt of an antibiotic prescription were determined by Poisson regression analysis.

RESULTS

Of 993 analysed patients, the mean (±SD) age was 36.3 (±23.2) years, 581 (58.5%) were females and 535 (53.9%) were adults. The prevalence of antibiotic prescription was 46.4% (95% CI 42.8% to 50.0%). Strong predictors of an antibiotic prescription were being a child (1.7, 95% CI 1.3 to 2.2); acute upper respiratory tract infection (URTI) of multiple and unspecified sites (1.6, 95% CI 1.3 to 1.4); chronic rhinitis, nasopharyngitis and pharyngitis (4.0, 95% CI 2.4 to 6.4); being attended by a clinical officer (1.9, 95% CI 1.2 to 3.0); attending a health centre (1.5, 95% CI 1.1 to 2.0); attending a public facility (1.2, 95% CI 1.0 to 1.4) and visiting an inpatient department (2.0, 95% CI 1.2 to 3.4).

CONCLUSIONS

Among insured patients, being a child, acute URTI, being attended by a clinical officer or dental therapist, being attended by an assistant medical/dental officer, attending a health centre or a district hospital, attending a public health facility and visiting an inpatient department predicted an antibiotic prescription. Incorporation of these findings in revisions or establishment of targeted antimicrobial stewardship programmes may lead to better antibiotic prescribing practices that are critical for combating antibiotic resistance.

Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS)

Recent social science scholarship has sought to understand the visible and invisible impacts of how antibiotics are entrenched as infrastructures and put to work as a proxy for higher levels of care (clinical or otherwise) within modern healthcare. Using a qualitative research design, in this paper our aim is to draw attention to less visible aspects of antimicrobial stewardship (AMS) in residential aged care and their implications for nurse-led optimization of antibiotic use in these settings. By developing an account of the perceptions, experiences and practices of staff regarding the 'on the ground' work associated with implementing and upholding AMS objectives our study extends research on attempts to dismantle antibiotic infrastructures in Australian residential aged care facilities (RACF). Drawing on a review of relevant policies, empirical data is presented from fifty-six in-depth interviews conducted in 2021 with staff at 8 different RACFs. Interview participants included managers, nurses, and senior and junior personal care assistants. Our results suggest that registered nurses in residential aged care have been tasked with promoting antibiotic optimization and assigned with AMS responsibilities without sufficient authority and resourcing. A host of hidden care work associated with AMS strategies was evident, reinforcing some staff support for empirical antibiotic prescribing as a 'safety net' in uncertain clinical cases. We argue that this hidden work occurs where AMS strategies displace the infrastructural role previously performed by antibiotics, exposing structural gaps and pressures. The inability of organisational accounting systems and the broader AMS policy agenda to capture hidden AMS workflows in RACFs has consequences for future resourcing and organisational learning in ways that mean AMS gaps may remain unaddressed. These results support findings that AMS interventions might not be easily accepted by aged care staff in view of associated burdens which are under recognised and under supported in this domain.

Prognostic Values of the Timing of Antibiotic Administration and the Sepsis Bundle Component in Elderly Patients With Septic Shock: A Retrospective Study

INTRODUCTION

Elderly patients are more susceptible to sepsis and septic shock. Early administration of broad-spectrum antibiotics is a key element of the sepsis management of bundle. Our study aimed to investigate the association between the timing of antibiotics administration and the risk of adverse outcomes in elderly patients with septic shock, and to examine the prognostic value of other bundle elements.

METHOD

This is a single-center, retrospective, case-control study including elderly patients (aged ≥ 65 years) diagnosed with septic shock in the emergency department between October 1, 2018, and December 31, 2019. Eligible patients were divided into early (within 1 h) and late (beyond 1 h) groups according to the time interval between septic shock recognition and initial antibiotic administration. The characteristics, sepsis-related severity scores, management strategy, and outcomes were recorded. A multivariate logistic regression model was used to identify the independent prognostic factors.

RESULTS

A total of 331 patients were included in the study. The overall 90-day mortality rate was 43.8% (145/331). There were no significant differences in baseline characteristics, sepsis-related severity scores, and management strategy between the two groups. There was no significant difference between the early and late groups in the rate of intensive care unit transfer (46.4% vs. 46.6%, P = 0.96), endotracheal intubation (28.3% vs. 27.5%, P = 0.87), renal replacement therapy (21.7% vs. 21.8%, P = 1.00), or 90-day mortality (44.2% vs. 43.5%, P = 0.90). Serum lactate level (hazard ratio [HR] = 1.15, P < 0.01) and source control (HR = 0.56, P = 0.03) were identified as independent factors associated with 90-day mortality.

CONCLUSION

The timing of antibiotic administration was not associated with adverse outcomes in elderly patients with septic shock. Serum lactate level and source control implementation were independent prognostic factors in these patients.

Understanding the gut microbiota and sarcopenia: a systematic review

BACKGROUND

Gut microbiota dysbiosis and sarcopenia commonly occur in the elderly. Although the concept of the gut-muscle axis has been raised, the casual relationship is still unclear. This systematic review analyses the current evidence of gut microbiota effects on muscle/sarcopenia.

METHODS

A systematic review was performed in PubMed, Embase, Web of Science, and The Cochrane Library databases using the keywords (microbiota* OR microbiome*) AND (sarcopen* OR muscle). Studies reporting the alterations of gut microbiota and muscle/physical performance were analysed.

RESULTS

A total of 26 pre-clinical and 10 clinical studies were included. For animal studies, three revealed age-related changes and relationships between gut microbiota and muscle. Three studies focused on muscle characteristics of germ-free mice. Seventy-five per cent of eight faecal microbiota transplantation studies showed that the recipient mice successfully replicated the muscle phenotype of donors. There were positive effects on muscle from seven probiotics, two prebiotics, and short-chain fatty acids (SCFAs). Ten studies investigated on other dietary supplements, antibiotics, exercise, and food withdrawal that affected both muscle and gut microbiota. Twelve studies explored the potential mechanisms of the gut-muscle axis. For clinical studies, 6 studies recruited 676 elderly people (72.8 ± 5.6 years, 57.8% female), while 4 studies focused on 244 young adults (29.7 ± 7.8 years, 55.4% female). The associations of gut microbiota and muscle had been shown in four observational studies. Probiotics, prebiotics, synbiotics, fermented milk, caloric restriction, and exercise in six studies displayed inconsistent effects on muscle mass, function, and gut microbiota.

CONCLUSIONS

Altering the gut microbiota through bacteria depletion, faecal transplantation, and various supplements was shown to directly affect muscle phenotypes. Probiotics, prebiotics, SCFAs, and bacterial products are potential novel therapies to enhance muscle mass and physical performance. Lactobacillus and Bifidobacterium strains restored age-related muscle loss. Potential mechanisms of microbiome modulating muscle mainly include protein, energy, lipid, and glucose metabolism, inflammation level, neuromuscular junction, and mitochondrial function. The role of the gut microbiota in the development of muscle loss during aging is a crucial area that requires further studies for translation to patients.

Antibiotic prescribing in Danish general practice in the elderly population from 2010 to 2017

OBJECTIVE

This study aimed to describe prescription of antibiotics to the elderly population in general practice in Denmark from 2010-2017.

DESIGN

This is a national register-based observational study.

SETTING

General practice, Denmark.

MAIN OUTCOME MEASURE

The main outcome measure was prescriptions/1,000 inhabitants/day (PrID) in relation to year, age and sex, indication, and antibiotic agent.

SUBJECTS

In this study, we included inhabitants of Denmark, ≥65 years of age between 01st July 2010-30th June 2017.

RESULTS

A total of 5,168,878 prescriptions were included in the study. Antibiotic prescriptions decreased from 2.2 PrID to 1.7 (-26.9%, CI95% [-31.1;-22.4]) PrID during the study. The decrease in PrID was most noticeable among 65-74-year-olds (-25%). The ≥85-year-olds were exposed to twice as many PrID than the 65-74-year-olds, but only accounted for 20% of the total use. Urinary tract infection (UTI) was the most common indication for antibiotic prescription and increased with advancing age. The most commonly prescribed antibiotics were pivmecillinam and phenoxymethylpenicillin. Prescribing with no informative indication was present in one third of all cases.

CONCLUSION

The prescription of antibiotics in the elderly population in general practice decreased from 2010 to 2017. The oldest age group was exposed twice as frequently to antibiotic prescriptions as the 65-74-year-olds. The smallest reduction was observed for the ≥85-year-olds, suggesting targeting interventions at this group.Key PointsHigh antibiotic use among elderly is well known and studies indicate mis- and overuse within this population. Our study shows.The prescription rate is decreasing within all age groups of the elderly population.The ≥85-year-olds receive twice as many prescriptions/1000/day as the 65-74-years-olds.

Antibiotic use and associated factors in adult outpatients from 2000 to 2019

The aims of the study were to assess the changes in 19-years use of antibiotics (overall, by age, sex and geographical area) and of those classes deemed to be quality indicators for their consumption and to evaluate factors associated to antibiotic use. We analyzed drug prescription data collected in the administrative database of the Lombardy Region (Northern Italy) for outpatients aged 40+ years from 2000 to 2019. Logistic regression analyses were performed to evaluate the association between receiving at least one antibiotic prescription and year of observation, gender, age groups, area of residence, polypharmacy and hospitalizations in the index year. The prevalence of patients prescribed with antibiotics remained high from 2000 (33.8%) to 2019 (32.6%). Prevalence of use of second-line choice antibiotics (penicillin combinations with beta-lactamase inhibitors, third and fourth generation cephalosporins, macrolides) continued to increase, only fluoroquinolones decreased in 2019 (19%) comparing to 2018 (26%), at the time when the Italian Medicines Agency promulgated safety warnings. Females (OR 1.28, 95%CI 1.27-1.28), people living in Brescia (OR 1.24, 95%CI 1.24-1.25), those exposed to polypharmacy (OR 2.57, 95%CI 2.56-2.57) and those hospitalized 1 to 3 (OR 1.86, 95%CI 1.85-1.86) or more than 3 (OR 2.02, 95%CI 2.01-2.03) times a year had a statistically significant higher risk of receiving antibiotics. The high use of antibiotics over the study period further reinforces the need of impactful interventions, in order to improve the rational use of antibiotics and to reduce the risks of antimicrobial resistance. The differences outlined should be considered when monitoring and planning these interventions.

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study

BACKGROUND

Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment.

METHODS

We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment.

RESULTS

Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44).

CONCLUSION

In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

Common combinations of medications used among oldest-old women: a population-based study over 15 years

BACKGROUND

Older people use many medications, but combinations of medications used among the oldest old (≥ 80 years) are not commonly reported.

AIMS

This study aimed to determine common combinations of medications used among women aged 77-96 years and to describe characteristics associated with these combinations.

METHODS

A cohort study of older women enroled in the Australian Longitudinal Study on Women's Health over a 15-year period was used to determine combinations of medications using latent class analysis. Multinomial logistic regression was used to determine characteristics associated with these combinations.

RESULTS

The highest medication users during the study were for the cardiovascular (2003: 80.28%; 2017: 85.63%) and nervous (2003: 66.03%; 2017: 75.41%) systems. A 3-class latent model described medication use combinations: class 1: 'Cardiovascular & neurology anatomical group' (27.25%) included participants using medications of the cardiovascular and nervous systems in their later years; class 2: 'Multiple anatomical group' (16.49%) and class 3: 'Antiinfectives & multiple anatomical group' (56.27%). When compared to the reference class (class 1), the risk of participants being in class 3 was slightly higher than being in class 2 if they had > 4 general practitioner visits (RRR 2.37; 95% CI 2.08, 2.71), Department of Veterans Affairs' coverage (RRR 1.59; 95% CI 1.36, 1.86), ≥ 4 chronic diseases (RRR 3.16; 95% CI 2.56, 3.90) and were frail (RRR 1.47; 95% CI 1.27, 1.69).

CONCLUSION

Identification of combinations of medication use may provide opportunities to develop multimorbidity guidelines and target medication reviews, and may help reduce medication load for older individuals.

Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience

PURPOSE

Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population.

PATIENTS AND METHODS

Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016-2019.

RESULTS

A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs.

CONCLUSION

Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.

Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria

Healthcare-associated infections (HCAI) are a common cause for residents’ mortality and morbidity associated with a significant socio-economic burden. Data on HCAIs in Austrian long-term care facilities are scare. Therefore, we evaluated the incidence rate of HCAIs per 1000 resident days in four LTC facilities in Graz, Austria, characterized the spectrum of HCAIs and the use of antimicrobial substances. We conducted a prospective surveillance study from 1 January to 31 December 2018 in four LTCFs of the Geriatric Health Centre of the City of Graz (total of 388 beds). Nursing staff collected data on HCAIs once a week using an electronic reporting system. During the 12-month surveillance period, 252 infections of 165 residents were recorded. The overall incidence rate of HCAIs was 2.1 per 1000 resident days. Urinary tract infections were the most commonly recorded HCAIs (49%, 124/252, 1.03 per 1000 resident days), followed by skin and soft tissue infections and respiratory tract infections. Beta-lactams (ATC class J01C) were prescribed most frequently (63/212), followed by fluoroquinolones (J01M; 54/212). In conclusion, the overall incidence rate for HCAIs was relatively low at 2.1 per 1000 resident days. Our real-life data can serve as a basis for future antimicrobial stewardship and infection prevention interventions.

Perception and practices of community pharmacists towards antimicrobial stewardship in Lahore, Pakistan

OBJECTIVES

Antimicrobial resistance is a major health concern worldwide. Community pharmacists can play an important role in rational antibiotic use. This study aimed to evaluate the perception and practices of community pharmacists regarding antimicrobial stewardship (AMS) in Lahore, Pakistan.

METHODS

A descriptive cross-sectional study was conducted among community pharmacists in Lahore from 1 November 2017 to 31 December 2017. A self-administered questionnaire was used for data collection. Non-probability convenience sampling was performed to select community pharmacists. Descriptive statistics were applied and Mann-Whitney U-tests and Kruskal-Wallis tests were performed to compare independent groups using SPSS v.20.0. A P-value of <0.05 was considered statistically significant. Perception and practice scores were determined to access community pharmacist knowledge regarding AMS. A score of 0.5-1 was considered to be very good.

RESULTS

The overall response rate was 70.9%. Sex, age, work experience and education level did not significantly influence the perception and practices of community pharmacists. Experienced pharmacists showed a better response to AMS. The majority of pharmacists strongly agreed that they educate patients on the use of antimicrobials and resistance-related issues.

CONCLUSION

It was concluded that community pharmacists in Lahore have good perception regarding AMS and they are practicing it well. But there are several gaps in their practices that must be filled, such as dispensing without a prescription and dispensing for a longer duration than prescribed. Additionally, there should be strict implementation of guidelines for dispensing antibiotics in order to rationalise antibiotic use and decrease antimicrobial resistance.

Bloodstream infections in older population: epidemiology, outcome, and impact of multidrug resistance

Bloodstream infections (BSIs) among older patients are frequent with high rate of mortality. Infections with multidrug-resistant organisms (MDRO) are associated with higher mortality than with susceptible microorganisms. We aimed to evaluate the prevalence of MDRO infection during BSI in older population and the factors associated with unfavorable outcome. This study is a retrospective cohort of all BSI episodes occurring among older patients (> 65yo), from April 1, 2010, to December 31, 2016, in a French university hospital for geriatric medicine. A total of 255 BSI episodes were analyzed. Mean age was 86.3±6.5 years, and sex ratio (M/F) was 0.96. Main comorbidities were orthopedic device (26.7%), active neoplasia (24.3%), and diabetes mellitus (18.4%). Main primary sites of infection were urinary tract infections (56.9%), respiratory tract infections (10.6%), intra-abdominal infections (7.1%), and skin and soft tissue infections (4.7%). Main bacteria identified were Escherichia coli (45.1%), Staphylococcus aureus (14.1%), enterococci (10.7%), coagulase-negative staphylococci (CoNS) (5.5%), and streptococci (5.1%). MDROs were involved in 17.2% of BSI (gram-negative bacilli: 9.0%; CoNS: 4.3%; and methicillin-resistant S. aureus (MRSA): 3.9%). The main factor associated with MDRO BSI was colonization with MDRO (OR=6.29; 95%CI=2.9-14.32). Total mortality was 18.4% and significantly higher in case of initial severity (OR=3.83; 95%CI=1.75-8.38), healthcare-associated infection (OR=5.29; 95%CI=1.11-25.30), and MRSA BSI (OR=9.16; 95%CI=1.67-50.16). BSI due to MDRO is frequent in older population and is strongly associated with carriage of MDRO. Healthcare-associated BSI, severe episodes, and BSI due to MRSA are associated with unfavorable outcome. In these cases, a broad-spectrum antibiotic should be promptly initiated.

Trends in antibiotics use among long-term US nursing-home residents

OBJECTIVES

Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions.

DESIGN

Retrospective, repeated cross-sectional analysis.

SETTING AND PARTICIPANTS

All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes.

MEASUREMENTS

We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer's disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012-2016.

RESULTS

Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97-1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04-1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12-1.25), and no infection (AOR, 1.13; 95% CI, 1.09-1.17). Results were similar by cognitive status.

CONCLUSIONS

The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.

Evaluation of procalcitonin as a contribution to antimicrobial stewardship in SARS-CoV-2 infection: a retrospective cohort study

It can be a diagnostic challenge to identify patients with coronavirus disease 2019 in whom antibiotics can be safely withheld. This study evaluated the effectiveness of a guideline implemented at Sheffield Teaching Hospitals NHS Foundation Trust that recommends withholding antibiotics in patients with low serum procalcitonin (PCT), defined as ≤0.25 ng/mL. Results showed reduced antibiotic consumption in patients with PCT ≤0.25 ng/mL with no increase in mortality, alongside a reduction in subsequent carbapenem prescriptions during admission. The results support the effectiveness of this guideline, and further research is recommended to identify the optimal cut-off value for PCT in this setting.

The ongoing challenge of vancomycin-resistant Enterococcus faecium and Enterococcus faecalis in Europe: an epidemiological analysis of bloodstream infections

Vancomycin-resistant enterococci infections are of great public health significance due to limited therapeutic options. We investigated epidemiological trends and risk factors of vancomycin resistance in enterococci isolates from patients with bloodstream infections in the EU/EEA from 2012 to 2018. Routine vancomycin susceptibility data of clinical E. faecium (n = 67,022) and E. faecalis (n = 103,112) blood isolates from the European Antimicrobial Resistance Surveillance Network were analysed using descriptive statistics and multivariable regression analyses. In Europe, proportions of vancomycin-resistant E. faecium (VREFm) increased from 8.1% (95%CI 6.7-9.7%) in 2012 to 19.0% (95%CI 16.8-21.5%) in 2018. Rising VREFm proportions were observed across all European regions, both genders and all age groups except children and adolescents (1-19 years). Adults (20-59 years) and elderly (≥60 years) had an increased likelihood of VREFm compared to children and adolescents (1-19 years) (OR: 1.99 [95%CI 1.42-2.79, p < 0.001] and OR: 1.56 [95%CI 1.09-2.23, p = 0.014], respectively). Inpatients hospital units, including internal medicine and ICUs, were associated with an increased likelihood of VREFm (OR: 2.29 (95%CI 1.58-3.32, p < 0.001) compared to the emergency department which reflects patients with community origin of E. faecium infections. The mean proportion of vancomycin-resistant E. faecalis in Europe was found to be low (1.1% [95%CI 0.9-1.4%]). Local and regional authorities should intensify efforts directed at diagnostic and antimicrobial stewardship for vancomycin and all last resort drugs for the management of VREFm, particularly for hospitalized elderly patients.

A snapshot of geriatric infections in Turkey: ratio of geriatric inpatients in hospitals and evaluation of their infectious diseases: A multicenter point prevalence study

INTRODUCTION

The human population is aging at an astonishing rate. The aim of this study is to capture a situation snapshot revealing the proportion of individuals aged 65 years and over among inpatients in healthcare institutions in Turkey and the prevalence and type of infections in this patient group in order to draw a road map.

MATERIALS AND METHODS

Hospitalized patients over 65 years at any of the 62 hospitals in 29 cities across Turkey on February 9, 2017 were included in the study. Web-based SurveyMonkey was used for data recording and evaluation system.

RESULTS

Of 17,351 patients 5871 (33.8%) were ≥65 years old. The mean age was 75.1±7.2 years; 3075 (52.4%) patients were male. Infection was reason for admission for 1556 (26.5%) patients. Pneumonia was the most common infection. The median length of hospital stay was 5 days (IQR: 2-11 days). The Antibiotic therapy was initiated for 2917 (49.7%) patients at the time of admission, and 23% of the antibiotics prescribed were inappropriate. Healthcare-associated infections developed in 1059 (18%) patients. Urinary catheters were placed in 2388 (40.7%) patients with 7.5% invalid indication.

CONCLUSION

This study used real data to reveal the proportion of elderly patients in hospital admissions. The interventions done, infections developed during hospitalization, length of hospital stay, and excessive drug load emphasize the significant impact on health costs and illustrate the importance of preventive medicine in this group of patients.

Subcutaneous Antibiotic Therapy: The Why, How, Which Drugs and When

OBJECTIVES

To describe the rationale for subcutaneous (SC) administration of antibiotics from available published data and to make propositions to help clinicians in daily practice.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

Hospitalized patients, persons in long-term care facilities and ambulatory care.

METHODS

We searched the MEDLINE/PubMed electronic database for evidence supporting SC administration of antibiotics up to September 2019; the results of this primary search were supplemented by searching the references of the identified articles, as well as by searching in Google Scholar.

RESULTS

Regarding tolerability, efficacy, and pharmacokinetic/pharmacodynamic profiles, most studies suggest that the SC route could be an alternative to the intravenous route, particularly for time-dependent antibiotics and among certain patient populations, such as patients with poor venous access, swallowing disorders, or behavioral disturbance. However, clinical evidence of the benefits and risks of SC antibiotic administration is still scarce and of low level.

CONCLUSIONS AND IMPLICATIONS

SC administration of antibiotics may be useful in various settings such as in hospitalized patients and among those in long-term care facilities or being cared for at home. However, further clinical studies are needed to assess the pharmacokinetic/pharmacodynamic properties, as well as the risks and benefits of SC administration of antibiotics. In this review, we highlight the potential benefits of SC administration of antibiotics and address practical recommendations for its use. This information will enable improvement of treatment strategies and present the SC route as a potential option in specific situations.

Prevalence and Determinants of Antibiotic Consumption in the Elderly during 2006-2017

Elderly people are a particularly important population with regard to antibiotic overuse, using around 50% more antibiotics per capita than younger adults. The aim of this study was to analyze the prevalence, associated factors and evolution over time of antibiotic consumption among the Spanish population aged ≥ 65 years from 2006 to 2017. A descriptive cross-sectional study was conducted using data from the Spanish National Health Survey in 2006, 2011/2012 and 2017, and from the European Health Survey in Spain in 2009 and 2014. The sample consisted of 26,891 non-institutionalized individuals ≥ 65 years. Antibiotic consumption was the dependent variable, and sociodemographic variables, lifestyle habits and health status were analyzed using a logistic regression model. The prevalence of antibiotic consumption was 4.94%, with a marked increase from 2006 (4.64%) to 2017 (5.81%) (p < 0.0001). Higher antibiotic consumption was associated with poor or very poor self-perceived health status, no polypharmacy and not having been in hospital during the previous twelve months, while a lower consumption was linked to being limited but not severely due to a health problem and not being at all limited.

Infection in older adults: a qualitative study of patient experience

BACKGROUND

Infection is common in older adults. Serious infection has a high mortality rate and is associated with unplanned hospital admissions. Little is known about the factors that prompt older patients to seek medical advice when they may have an infection.

AIM

To explore the symptoms of infection from the perspective of older adults, and when and why older patients seek healthcare advice for a possible infection.

DESIGN AND SETTING

A qualitative interview study among adults aged ≥70 years with a clinical diagnosis of infection recruited from ambulatory care units in Oxford, UK.

METHOD

Interviews were semi-structured and based on a flexible topic guide. Participants were given the option to be interviewed with their carer. Thematic analysis was facilitated using NVivo (version 11).

RESULTS

A total of 28 participants (22 patients and six carers) took part. Patients (aged 70-92 years) had experienced a range of different infections. Several early non-specific symptoms were described (fever, feeling unwell, lethargy, vomiting, pain, and confusion/delirium). Internally minimising symptoms was common and participants with historical experience of infection tended to be better able to interpret their symptoms. Factors influencing seeking healthcare advice included prompts from family, specific or intolerable symptoms, symptom duration, and being unable to manage with self-care. For some, not wanting to be a burden affected their desire to seek help.

CONCLUSION

Tailored advice to older adults highlighting early symptoms of infection may be beneficial. Knowing whether patients have had previous experience of infection may help healthcare professionals in assessing older patients with possible infection.

Calculated parenteral initial therapy of bacterial infections: Antibiotic treatment in the elderly

This is the fifteenth chapter of the guideline “Calculated initial parenteral treatment of bacterial infections in adults – update 2018” in the 2^nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience.

Multimorbidity, an atypical symptomatology of infections in combination with multimedication, the associated interaction risks and serious consequences of synergistic side effects characterize the conditions when deciding on the use of antibiotics in old age. Strict decision regarding the indication itself, choice of the best antibiotic even considering rare side effects which may be dangerous in the elderly, determining the correct dose, dosing interval and the shortest possible duration according to the physiological status of the patient as well as monitoring effectiveness and toxicity detect expected and unexpected side effects early. Recommendations must reflect the peculiarities of antibiotic treatment in elderly patients.

Antimicrobial prescribing in older adults

Infectious diseases pose a significant threat to older adult health and well-being. Determining the appropriate use and selection of antimicrobials in older adults can be challenging. Age-related physiologic changes, multiple comorbidities, and polypharmacy are factors that can make prescribing antimicrobials complicated and the effectiveness of therapy unpredictable.

Knowledge and Expectations on Antibiotic Use among Older Adults in Malaysia: A Cross-Sectional Survey

Antibiotics are commonly prescribed among older adults, and inappropriate use of antibiotics has been noted. However, there is limited information about their knowledge and expectations for antibiotics. This study aimed to assess older adults' knowledge of antibiotic use and resistance, their expectations for antibiotics and the relationship between knowledge, expectation and inappropriate practices related to antibiotic use. A cross-sectional survey involving respondents aged 60 years and above was conducted, using a validated questionnaire. A lack of knowledge about the role of antibiotics was observed, whereby more than half of the respondents incorrectly believed that antibiotics can treat viral infections (53.5%) and colds and coughs (53.7%). Also, 67.9% of respondents incorrectly believed that antibiotic resistance occurs when the body becomes resistant to antibiotics. Almost half of the respondents would expect antibiotics for symptoms of self-limiting viral infections. Respondents who answered correctly for the role of antibiotics in viral infections were more likely not to expect antibiotics for cold, flu and cough (p < 0.001). Respondents who answered correctly regarding the need to adhere to antibiotics were more likely to have completed their antibiotic course (p < 0.001). Future educational initiatives should provide key information on the role of antibiotics and the importance of complying with antibiotics in this population.

Community-onset Pseudomonas aeruginosa urinary sepsis in elderly people: Predictive factors, adequacy of empirical therapy and outcomes

Purpose To know the predictive factors for Pseudomonas aeruginosa (PA) urinary sepsis in hospitalised elderly patients coming from community, the adequacy of empirical antibiotic therapy and its outcomes. Methods Retrospective case-control study conducted between 2007 and 2017. Patients aged 65 years or older with PA urinary sepsis were included as cases. Three age-matched controls, with urinary sepsis caused by other microorganisms, were selected for each case. Predictors for PA urinary sepsis were determined by logistic regression analysis. Adequacy of empirical antibiotic therapy and outcomes were compared between both groups. Results A total of 332 patients, from which 83 were cases, were included. Predictive factors for PA urinary sepsis were as follows: male sex (OR 3.16, 95% CI 1.61-6.10; P < .001), urinary catheter (OR 3.25, 95% CI 1.73-6.11; P < .001) and healthcare-associated infection (OR 5.52, 95% CI 1.76 -17.29; P = .003). Inadequate empirical antimicrobial therapy (IEAT) and length of hospital stay were higher in PA group (42% vs 24%, P = .002; 7.45 ± 4.36 days vs 6.43 ± 3.82 days, P = .045, respectively), but mortality was not different (7.2% vs 8.8%, P = .648). Conclusions Pseudomonas aeruginosa urinary sepsis in elderly people was associated with male sex, urinary catheter and healthcare-associated infection. These infections had a higher rate of IEAT and a longer hospital stay than urinary sepsis caused by other microorganisms.

Risk factors for carbapenem-resistant Klebsiella pneumoniae infection: A meta-analysis

OBJECTIVES

Rates of nosocomial infections caused by carbapenem-resistant Klebsiella pneumoniae (CRKP) have increased. A meta-analysis was conducted to explore risk factors for CRKP infection in order to provide a theoretical basis for reducing the CRKP infection rate and actively preventing CRKP infection.

METHODS

Online databases, including PubMed, EMBASE, OVID, ClinicalKey, CNKI, CBM, Wanfang Database and CHKD, were searched from inception up to 31 October 2018 for articles regarding risk factors for CRKP infection. Relevant articles were retrieved, supplemented by retrospective and manual search literature. RevMan 5.3 software was used for statistical analysis.

RESULTS

A total of 30 articles comprising 5075 cases were included in the study, of which 24 were in English and 6 were in Chinese. The results showed that age, sex and diabetes mellitus were not associated with CRKP infection. The odds ratio (95% confidence interval) of risk factors for CRKP infection were as follows: immunosuppression, 1.47 (1.14-1.90); ICU admission, 3.25 (2.36-4.47); antibiotic exposure, 2.53 (1.56-4.11); carbapenem exposure, 3.99 (2.86-5.56); quinolone exposure, 1.75 (1.38-2.22); glycopeptide exposure, 3.08 (1.93-4.91); β‑lactam/β‑lactamase inhibitor (BL/BLI) exposure, 2.28 (1.37-3.80); surgery, 1.59 (1.08-2.34); mechanical ventilation, 2.91 (1.96-4.31); central venous catheterisation, 2.93 (2.00-4.28); indwelling catheter, 2.62 (1.65-4.17); and nasogastric intubation, 2.38 (1.22-4.62).

CONCLUSION

Immunosuppression, ICU admission, antibiotic exposure (including carbapenems, quinolones, glycopeptides and BL/BLIs), surgery, mechanical ventilation, central venous catheterisation, indwelling catheter and nasogastric intubation were identified as risk factors for CRKP infection and should to be considered in clinical practice.

Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years

OBJECTIVES

To describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally.

DESIGN

Descriptive study.

SETTING

146 VA CLCs.

PARTICIPANTS

We identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017.

MEASURES

We measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs).

RESULTS

Over 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI -8.7%, -3.2%). The proportion of positive cultures decreased by 0.9% (95% CI -1.4%, -0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common.

CONCLUSION AND IMPLICATIONS

We identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary cultures in VA CLCs nationally due to increased antibiotic stewardship efforts targeting unnecessary culturing and antibiotic treatment.