What is the evidence base of used aggregated antibiotic resistance percentages to change empiric antibiotic treatment? A scoping review

Selection of Antibiotics as Prophylaxis for Close Contacts of Patients with Meningococcal Disease in Areas with Ciprofloxacin Resistance - United States, 2024

Meningococcal disease, caused by the bacterium Neisseria meningitidis, is a rare but life-threatening illness that requires prompt antibiotic treatment for patients and antibiotic prophylaxis for their close contacts. Historically, N. meningitidis isolates in the United States have been largely susceptible to the antibiotics recommended for prophylaxis, including ciprofloxacin. Since 2019, however, the number of meningococcal disease cases caused by ciprofloxacin-resistant strains has increased. Antibiotic prophylaxis with ciprofloxacin in areas with ciprofloxacin resistance might result in prophylaxis failure. Health departments should preferentially consider using antibiotics other than ciprofloxacin as prophylaxis for close contacts when both of the following criteria have been met in a local catchment area during a rolling 12-month period: 1) the reporting of two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains, and 2) ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains. Other than ciprofloxacin, alternative recommended antibiotic options include rifampin, ceftriaxone, or azithromycin. Ongoing monitoring for antibiotic resistance of meningococcal isolates through surveillance and health care providers' reporting of prophylaxis failures will guide future updates to prophylaxis considerations and recommendations.

Translation of Machine Learning-Based Prediction Algorithms to Personalised Empiric Antibiotic Selection: A Population-Based Cohort Study

BACKGROUND

Prediction of antibiotic non-susceptibility based on patient characteristics and clinical status may support selection of empiric antibiotics for suspected hospital-acquired urinary tract infections (HA-UTIs).

METHODS

Prediction models were developed to predict non-susceptible results of eight antibiotic susceptibility tests ordered for suspected HA-UTI. Eligible patients were those with urine culture and susceptibility test results after 48 hours of admission between 2010-2021. Patient demographics, diagnosis, prescriptions, exposure to multidrug-resistant organisms, transfer history, and a daily calculated antibiogram were used as predictors. Lasso logistic regression (LLR), extreme gradient boosting (XGB), random forest, and stacked ensemble methods were used for development. Parsimonious models were also developed for clinical utility. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC).

RESULTS

In 10 474 suspected HA-UTI cases, the mean age was 62.1 ± 16.2 years and 48.1% were male. Non-susceptibility prediction for ampicillin/sulbactam, cefepime, ciprofloxacin, imipenem, piperacillin/tazobactam, and trimethoprim/sulfamethoxazole performed best using the stacked ensemble (AUROC 76.9, 76.1, 77.0, 80.6, 76.1, and 76.5, respectively). The model for ampicillin performed best with LLR (AUROC 73.4). Extreme gradient boosting only performed best for gentamicin (AUROC 66.9). In the parsimonious models, the LLR yielded the highest AUROC for ampicillin, ampicillin/sulbactam, cefepime, gentamicin, and trimethoprim/sulfamethoxazole (AUROC 70.6, 71.8, 73.0, 65.9, and 73.0, respectively). The model for ciprofloxacin performed best with XGB (AUROC 70.3), while the model for imipenem performed best in the stacked ensemble (AUROC 71.3). A personalised application using the parsimonious models was publicly released.

CONCLUSIONS

Prediction models for antibiotic non-susceptibility were developed to support empiric antibiotic selection for HA-UTI.

Clinical Risk Scores to Predict Nonsusceptibility to Trimethoprim-Sulfamethoxazole, Fluoroquinolone, Nitrofurantoin, and Third-Generation Cephalosporin Among Adult Outpatient Episodes of Complicated Urinary Tract Infection

Background

Clinical risk scores were developed to estimate the risk of adult outpatients having a complicated urinary tract infection (cUTI) that was nonsusceptible to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone, nitrofurantoin, or third-generation cephalosporin (3-GC) based on variables available on clinical presentation.

Methods

A retrospective cohort study (1 December 2017-31 December 2020) was performed among adult members of Kaiser Permanente Southern California with an outpatient cUTI. Separate risk scores were developed for TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC. The models were translated into risk scores to quantify the likelihood of nonsusceptibility based on the presence of final model covariates in a given cUTI outpatient.

Results

A total of 30 450 cUTIs (26 326 patients) met the study criteria. Rates of nonsusceptibility to TMP-SMX, fluoroquinolone, nitrofurantoin, and 3-GC were 37%, 20%, 27%, and 24%, respectively. Receipt of prior antibiotics was the most important predictor across all models. The risk of nonsusceptibility in the TMP-SMX model exceeded 20% in the absence of any risk factors, suggesting that empiric use of TMP-SMX may not be advisable. For fluoroquinolone, nitrofurantoin, and 3-GC, clinical risk scores of 10, 7, and 11 predicted a ≥20% estimated probability of nonsusceptibility in the models that included cumulative number of prior antibiotics at model entry. This finding suggests that caution should be used when considering these agents empirically in patients who have several risk factors present in a given model at presentation.

Conclusions

We developed high-performing parsimonious risk scores to facilitate empiric treatment selection for adult outpatients with cUTIs in the critical period between infection presentation and availability of susceptibility results.

Friends Not Foes: Optimizing Collaboration with Subspecialists

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.

ESCMID/EUCIC clinical practice guidelines on perioperative antibiotic prophylaxis in patients colonized by multidrug-resistant Gram-negative bacteria before surgery

SCOPE

The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery.

METHODS

These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development.

RECOMMENDATIONS

The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.

Unbiased antimicrobial resistance prevalence estimates through population-based surveillance

BACKGROUND

Current antimicrobial resistance surveillance (AMR) is mainly laboratory-based. This approach can have inherent biases given the potential for selective specimen submission for microbiological analysis, and for its inability to map antibiotic susceptibility test results to a clinical syndrome.

OBJECTIVES

To discuss the need for population-based surveillance of AMR, and highlight the pros and cons of threshold surveys.

SOURCES

Studies on methodology for AMR surveillance published in the last 10 years, obtained through a PubMed search on antimicrobial resistance (all fields) and surveillance/method (MeSH term).

CONTENT

We discuss the use of threshold surveys to overcome the challenge of sample size in population-bases AMR surveys, which are a suitable approach in both low- and high-resource settings.

IMPLICATION

Scale up in the use of population-based threshold survey on the prevalence of AMR will provide necessary information to triangulate the data from routinely-reported laboratory-based AMR surveillance at the local, national and global level.

Alginate-based aerogels as wound dressings for efficient bacterial capture and enhanced antibacterial photodynamic therapy

The development of novel wound dressings, such as aerogels, with rapid hemostasis and bactericidal capacities for pre-hospital care is necessary. To prevent the occurrence of bacterial resistance, antibacterial photodynamic therapy (aPDT) with broad-spectrum antibacterial ability and negligible bacterial resistance has been intensively studied. However, photosensitizers often suffer from poor water solubility, short singlet oxygen (¹O₂) half-life and restricted ¹O₂ diffusion distance. Herein, sodium alginate was covalently modified by photosensitizers and phenylboronic acid, and cross-linked by Ca(II) ions to generate SA@TPAPP@PBA aerogel after lyophilization as an antibacterial photodynamic wound dressing. Afterwards, its photodynamic and bacterial capture activities were intensively evaluated. Furthermore, its hemostasis and bactericidal efficiency against Staphylococcus aureus were assessed via in vitro and in vivo assays. First, chemical immobilization of photosensitizers led to an enhancement of its solubility. Moreover, it showed an excellent hemostasis capacity. Due to the formation of reversible covalent bonds between phenylboronic acid and diol groups on bacterial cell surface, the aerogel could capture S. aureus tightly and dramatically enhance aPDT. To sum up, the prepared aerogel illustrated excellent hemostasis capacity and antibacterial ability against S. aureus. Therefore, they have great potential to be utilized as wound dressing in clinical trials.