The global need for effective antibiotics-a summary of plenary presentations

The Impact of Prescribing Monitoring Policy on Drug Use and Expenditures in China: A Multi-center Interrupted Time Series Study

BACKGROUND

A prescribing monitoring policy (PMP) was implemented in November 2015 in Anhui province, China, the first province to pilot this policy to manage the use and costs of select drugs based on their large prescription volumes and/ or costs in hospitals. This study evaluated the impact of PMP on the use and expenditures of different drugs in three tertiary hospitals in Anhui.

METHODS

We obtained monthly drug use and expenditures data from three tertiary hospitals in Anhui (November 2014 through September 2017). An interrupted time series (ITS) design was used to estimate changes in defined daily doses (DDDs per month) and drug expenditures (dollars per month) of policy-targeted and non-targeted drugs after PMP implementation. Drugs were grouped based on whether they were recommended (recommended drugs) by any clinical guidelines or not (non-recommended drugs), or if they were potentially over-used (proton pump inhibitors, PPIs).

RESULTS

After PMP, DDDs and costs of the targeted PPIs (omeprazole) declined while use of non-targeted PPIs increased correspondingly with overall sustained declines in total PPIs. The policy impact on recommended drugs varied based on whether the targeted drugs have appropriate alternatives. The DDDs and costs of recommended drugs that have readily accessible appropriate alternatives (atorvastatin) declined, which offset increases in its alternative non-target drugs (rosuvastatin), while there was no significant change in those recommended drugs that did not have appropriate alternative drugs (clopidogrel and ticagrelor). Finally, the DDDs and costs of non-recommended drugs decreased significantly.

CONCLUSION

PMP policy impact was not the same across different drug groups. PMP did help contain the use and costs of potentially over-used drugs and non-recommended drugs. PMP did not seem to reduce the use of first-line therapeutic drugs recommended by clinical treatment guidelines, especially those lacking alternatives; such drugs are unlikely appropriate candidates for PMP.

Molecular Topology for the Search of New Anti-MRSA Compounds

The variability of methicillin-resistant Staphylococcus aureus (MRSA), its rapid adaptive response against environmental changes, and its continued acquisition of antibiotic resistance determinants have made it commonplace in hospitals, where it causes the problem of multidrug resistance. In this study, we used molecular topology to develop several discriminant equations capable of classifying compounds according to their anti-MRSA activity. Topological indices were used as structural descriptors and their relationship with anti-MRSA activity was determined by applying linear discriminant analysis (LDA) on a group of quinolones and quinolone-like compounds. Four extra equations were constructed, named DF_MRSA1, DF_MRSA2, DF_MRSA3 and DF_MRSA4 (DF_MRSA was built in a previous study), all with good statistical parameters, such as Fisher-Snedecor F (>68 in all cases), Wilk's lambda (<0.13 in all cases), and percentage of correct classification (>94% in all cases), which allows a reliable extrapolation prediction of antibacterial activity in any organic compound. The results obtained clearly reveal the high efficiency of combining molecular topology with LDA for the prediction of anti-MRSA activity.

Molecular Topology for the Discovery of New Broad-Spectrum Antibacterial Drugs

In this study, molecular topology was used to develop several discriminant equations capable of classifying compounds according to their antibacterial activity. Topological indices were used as structural descriptors and their relation to antibacterial activity was determined by applying linear discriminant analysis (LDA) on a group of quinolones and quinolone-like compounds. Four equations were constructed, named DF1, DF2, DF3, and DF4, all with good statistical parameters such as Fisher-Snedecor's F (over 25 in all cases), Wilk's lambda (below 0.36 in all cases) and percentage of correct classification (over 80% in all cases), which allows a reliable extrapolation prediction of antibacterial activity in any organic compound. From the four discriminant functions, it can be extracted that the presence of sp3 carbons, ramifications, and secondary amine groups in a molecule enhance antibacterial activity, whereas the presence of 5-member rings, sp2 carbons, and sp2 oxygens hinder it. The results obtained clearly reveal the high efficiency of combining molecular topology with LDA for the prediction of antibacterial activity.

Antibacterial and ATP Synthesis Modulating Compounds from Salvia tingitana

A surface extract of the aerial parts of Salvia tingitana afforded a nor-sesterterpenoid (1) and eight new sesterterpenoids (2-̵9), along with five known sesterterpenoids, five labdane and one abietane diterpenoid, one sesquiterpenoid, and four flavonoids. The structures of the new compounds were established by 1D and 2D NMR spectroscopy, HRESIMS, and VCD data and Mosher's esters analysis. The antimicrobial activity of compounds was evaluated against 30 human pathogens including 27 clinical strains and three isolates of marine origin for their possible implications on human health. The methyl ester of salvileucolide (10), salvileucolide-6,23-lactone (11), sclareol (15), and manool (17) were the most active against Gram-positive bacteria. The compounds were also tested for the inhibition of ATP production in purified mammalian rod outer segments. Terpenoids 10, 11, 15, and 17 inhibited ATP production, while only 17 inhibited also ATP hydrolysis. Molecular modeling studies confirmed the capacity of 17 to interact with mammalian ATP synthase. A significant reduction of ATP production in the presence of 17 was observed in Enterococcus faecalis and E. faecium isolates.

Assessment of Awareness about Antibiotic Resistance and Practices Followed by Veterinarians for Judicious Prescription of Antibiotics: An Exploratory Study in Eastern Haryana Region of India

The rise of antibiotic resistance and its global outreach has recently become a subject of increasing importance in veterinary research with an objective to reduce the load of antibiotic resistance in dairy farming practices. The present study was designed to analyze antibiotic prescriptions by veterinarians and to evaluate the appropriateness of prescribing behavior in consistent with prudent use of antibiotics. A total of 48 veterinarians were selected randomly from government Veterinary hospitals constituting a total of 48 veterinarians as respondents. The study revealed that most of prescriptions corresponded sound to prudent use of antibiotic and its treatment guidelines. To assess their awareness about antibiotic resistance and its related veterinary practices, an exclusively Awareness Index of antibiotic resistance was developed. It was observed that antibiotics were prescribed in initial encounter of diagnosis; thus, antibiotic conservation practices were found lacking. The ethical awareness of veterinarians was found lacking to establish valid veterinary-client relationship and ensure active involvement of stakeholders. This study largely looks into this angle by unearthing the drug prescribing behavior in order to shape the interdisciplinary research on this biological and profoundly social issue.

Bioprospection of actinobacteria derived from freshwater sediments for their potential to produce antimicrobial compounds

BACKGROUND

Actinobacteria from freshwater habitats have been explored less than from other habitats in the search for compounds of pharmaceutical value. This study highlighted the abundance of actinobacteria from freshwater sediments of two rivers and one lake, and the isolates were studied for their ability to produce antimicrobial bioactive compounds.

RESULTS

16S rRNA gene sequencing led to the identification of 84 actinobacterial isolates separated into a common genus (Streptomyces) and eight rare genera (Nocardiopsis, Saccharopolyspora, Rhodococcus, Prauserella, Amycolatopsis, Promicromonospora, Kocuria and Micrococcus). All strains that showed significant inhibition potentials were found against Gram-positive, Gram-negative and yeast pathogens. Further, three biosynthetic genes, polyketide synthases type II (PKS II), nonribosomal peptide synthetases (NRPS) and aminodeoxyisochorismate synthase (phzE), were detected in 38, 71 and 29% of the strains, respectively. Six isolates based on their antimicrobial potentials were selected for the detection and quantification of standard antibiotics using ultra performance liquid chromatography (UPLC-ESI-MS/MS) and volatile organic compounds (VOCs) using gas chromatography mass spectrometry (GC/MS). Four antibiotics (fluconazole, trimethoprim, ketoconazole and rifampicin) and 35 VOCs were quantified and determined from the methanolic crude extract of six selected Streptomyces strains.

CONCLUSION

Infectious diseases still remain one of the leading causes of death globally and bacterial infections caused millions of deaths annually. Culturable actinobacteria associated with freshwater lake and river sediments has the prospects for the production of bioactive secondary metabolites.

Molecular dynamics simulation studies of novel β-lactamase inhibitor

New Delhi Metallo-β-Lactamase-1 (NDM-1) has drawn great attention due to its diverse antibiotic resistant activity. It can hydrolyze almost all clinically available β-lactam antibiotics. To inhibit the activity of NDM-1 a new strategy is proposed using computational methods. Molecular dynamics (MD) simulations are used to analyze the molecular interactions between selected inhibitor candidates and NDM-1 structure. The enzyme-ligand complex is subject to binding free energy calculations using MM(PB/GB)SA methods. The role of each residue of the active site contributing in ligand binding affinity is explored using energy decomposition analysis. Furthermore, a hydrogen bonding network between ligand and enzyme active site is observed and key residues are identified ensuring that the ligand stays inside the active site and maintains its movement towards the active site pocket. A production run of 150ns is carried out and results are analyzed using root mean square deviation (RMSD), root mean square fluctuation (RMSF), and radius of gyration (Rg) to explain the stability of enzyme ligand complex. Important active site residue e.g. PHE70, VAL73, TRP93, HIS122, GLN123, ASP124, HIS189, LYS216, CYS208, LYS211, ALA215, HIS250, and SER251 were observed to be involved in ligand attachemet inside the active site pocket, hence depicting its inhibitor potential. Hydrogen bonds involved in structural stability are analyzed through radial distribution function (RDF) and contribution of important residues involved in ligand movement is explained using a novel analytical tool, axial frequency distribution (AFD) to observe the role of important hydrogen bonding partners between ligand atoms and active site residues.

Production of Potent Antimicrobial Compounds from Streptomyces cyaneofuscatus Associated with Fresh Water Sediment

The genus Streptomyces under phylum actinobacteria has been recognized as a prolific source for the production of bioactive secondary metabolites. An actinobacterial strain designated as DST103 isolated from a wetland fresh water sediment of Tamdil Lake, Mizoram, Northeast, India was identified as Streptomyces cyaneofuscatus (KY287599) using 16SrRNA gene sequencing which shares 99.87% sequence similarity with Streptomyces cyaneofuscatus NRRL B-2570^T. The strain showed broad spectrum antimicrobial activities against Gram negative bacteria (Escherichia coli MTCC 739 and Pseudomonas aeruginosa MTCC 2453), Gram positive bacteria (Micrococcus luteus NCIM 2170 and Staphylococcus aureus MTCC 96) and yeast pathogen Candida albicans MTCC 3017). The methanolic extract of the strain DST103 exhibited highest antimicrobial activity against E. coli (IC₅₀ = 2.10 μg/mL) and minimum activity against S. aureus (IC₅₀ = 43.63 μg/mL). Five antibiotics [trimethoprim (18 μg/g), fluconazole (6 μg/g), ketoconazole (18 μg/g), nalidixic acid (135 μg/g), and rifampicin (56 μg/g)] were detected and quantified using ultra-performance liquid chromatography (UPLC-ESI-MS/MS). Further, biosynthetic potential genes [polyketide synthases type II, non-ribosomal peptide synthetases, and aminodeoxyisochorismate synthase (phzE)] were also detected in strain DST103 which may possibly be responsible for the production of antimicrobial compounds. Additionally, gas chromatography-mass spectrometry analysis showed the presence of four volatile compounds which might be responsible for their diverse biological activity. The present study revealed the presence of bioactive compounds in strain DST103, which may be a promising resource for the discovery of novel bioactive metabolites against wide range of pathogens.

Survey of Spanish dentists on the prescription of antibiotics and antiseptics in surgery for impacted lower third molars

Background

This study explored the attitude of registered dentists in Biscay towards prescribing antibiotics and/or antiseptics to prevent potential infections after surgical extraction of completely bone-impacted third molars in otherwise healthy individuals, with no history of infection.

Material and Methods

We sent letters to 931 registered dentists in Biscay, with an explanation of the study objectives, description of a case of lower third molar impaction, including a panoramic radiograph, and a questionnaire. The questionnaire asked whether they would prescribe antibiotics and/or antiseptics, in the hypothetical case of lower third molar extraction surgery presented, and if so, when, what type, at what dose and how long for.

Results

The questionnaire was completed by 261 dentists (28%), with a mean age of 44.3 years old (SD 11.05) and mean of 18.7 years working as a dentist (SD 9). A total of 216 dentists (82.7%) considered it necessary to prescribe antibiotics. Of these, 126 (58.3%) would prescribe amoxicillin and 74 (34.5%) amoxicillin/clavulanic acid, while 129 dentists (59%) would prescribe antibiotics both before and after surgery and 10 (4.6%) only after surgery. The most common doses were amoxicillin 500 mg or 750 mg every 8 hours, and amoxicillin/clavulanic acid 875/125 mg every 8 hours, in both cases for a mean of 7 days. Further, 74 dentists (28%) said they would use immediate post-extraction socket irrigation with chlorhexidine, while 211 (81%) would prescribe antiseptics in the postoperative period, of whom 97% recommended chlorhexidine. We did not find significant differences in the use of antibiotics or antiseptics by dentist age (ANOVA p=0.22 and p=0.53, respectively), or professional experience (ANOVA p=0.45 and p=0.62).

Conclusions

In our sample, the prophylactic prescription of antibiotics and/or chlorhexidine is widespread in clinical practice, in most cases amoxicillin and amoxicillin/clavulanic acid for a week, starting the treatment before surgery.

Key words:Extraction, lower third molar, survey, antibiotics, antiseptics.

Microbubble-mediated ultrasound enhances the lethal effect of gentamicin on planktonic Escherichia coli

Previous research has found that low-intensity ultrasound enhanced the lethal effect of gentamicin on planktonic E. coli. We aimed to further investigate whether microbubble-mediated low-intensity ultrasound could further enhance the antimicrobial efficacy of gentamicin. The planktonic E. coli (ATCC 25922) was distributed to four different interventions: control (GCON), microbubble only (GMB), ultrasound only (GUS), and microbubble-mediated ultrasound (GMUS). Ultrasound was applied with 100 mW/cm(2) (average intensity) and 46.5 KHz, which presented no bactericidal activity. After 12 h, plate counting was used to estimate the number of bacteria, and bacterial micromorphology was observed with transmission electron microscope. The results showed that the viable counts of E. coli in GMUS were decreased by 1.01 to 1.42 log10 CFU/mL compared with GUS (P < 0.01). The minimal inhibitory concentration (MIC) of gentamicin against E. coli was 1 μ g/mL in the GMUS and GUS groups, lower than that in the GCON and GMB groups (2 μ g/mL). Transmission electron microscopy (TEM) images exhibited more destruction and higher thickness of bacterial cell membranes in the GMUS than those in other groups. The reason might be the increased permeability of cell membranes for gentamicin caused by acoustic cavitation.

The continuing challenge of providing drug information services to diminish the knowledge--practice gap in medical practice

Information must be collected, evaluated and utilized to support every qualified activity. Medicine, with a written scientific tradition stretching back more than 2,000 years, is no exception. Here, we discuss a number of important items associated with the establishment of a drug information centre run by clinical pharmacologists and information pharmacists, serving a broad demand, mainly among clinical specialists. The working methods include a professional literature search, critical evaluation of the material, writing a structured answer, quality control, feedback to the inquirer and storage in a database which is publicly available. One can foresee even more complex systems wherein a number of active and specialized databases communicate to provide relevant advice and support at the point of care, supplying information on drug recommendations, reimbursement, environmental aspects, antimicrobial resistance, pharmacogenetics and adverse effects, and linked to a list of prescribed drugs for the individual patient. This will be possible in both rich and poor countries through the application of modern and developing information technology. However, research on the best and safest methods of such decision support systems will be needed to ensure that they really do improve the quality of drug prescribing and use.

Inappropriate empirical antimicrobial therapy for multidrug-resistant organisms in critically ill patients with pneumonia is not an independent risk factor for mortality: Results of a prospective observational study of 758 patients

The benefits of broad-spectrum initial empirical antibiotic therapy for all patients in intensive care units (ICUs) with high rates of multidrug-resistant organisms (MDROs) have not been critically evaluated. In this study, 758 ICU patients with pneumonia were prospectively evaluated. Of 349 positive respiratory cultures, 119 (34.1%) were with MDRO isolates. These were associated with increased mortality [adjusted hazard ratio (HR)=1.65, 95% confidence interval (CI) 1.01-2.68; P=0.04] as was increasing age and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Among the patients with MDRO-associated pneumonia, increasing age, APACHE II score and inappropriate definitive antimicrobial therapy (IDAT) were found to be significant risk factors for mortality (in-ICU mortality, adjusted HR=2.8, 95% CI 1.3-5.8; P=0.007), but inappropriate empirical antimicrobial therapy (IEAT) was not (in-ICU mortality, unadjusted HR=1.6, 95% CI 0.7-3.6; P=0.3). In conclusion, we found that among critically ill patients with MDRO-associated pneumonia, IEAT is not an independent risk factor for ICU mortality. Hence, we do not recommend the use of broad-spectrum initial empirical antimicrobial therapy for all patients, as its benefits may not outweigh the potential risks. Early microbiological diagnosis to facilitate implementation of early definitive antimicrobial therapy through use of novel technologies is likely to have a major impact.

Antimicrobial agent exposure and the emergence and spread of resistant microorganisms: issues associated with study design

Antibiotics are essential agents that have greatly reduced human mortality due to infectious diseases. Their use, and sometimes overuse, have increased over the past several decades in humans, veterinary medicine and agriculture. However, the emergence of resistant pathogens is becoming an increasing problem that could result in the re-emergence of infectious diseases. Antibiotic prescription in human medicine plays a key role in this phenomenon. Under selection pressure, resistance can emerge in the commensal flora of treated individuals and disseminate to others. However, even if the effects of antimicrobial use on resistance is intuitively accepted, scientific rationales are required to convince physicians, legislators and public opinion to adopt appropriate behaviours and policies. With this review, we aim to provide an overview of different epidemiological study designs that are used to study the relationship between antibiotic use and the emergence and spread of resistance, as well as highlight their main strengths and weaknesses.

The 2012 Garrod lecture: discovery of antibacterial drugs in the 21st century

The discovery and development of antibacterial drugs in the twentieth century were major scientific and medical achievements that have had profound benefits for human society. However, in the twenty-first century the widespread global occurrence of bacteria resistant to the antibiotics and synthetic drugs discovered in the previous century threatens to reverse our ability to treat infectious diseases. Although some new drugs are in development they do not adequately cover growing medical needs. Furthermore, these drugs are mostly derivatives of older classes already in use and therefore prone to existing bacterial resistance mechanisms. Thus, new drug classes are urgently needed. Despite investment in antibacterial drug discovery, no new drug class has been discovered in the past 20 years. In this review, based upon my career as a research scientist in the field of antibacterial drug discovery, I consider some of the technical reasons for the recent failure and look to the future developments that may help to reverse the poor current success rate. Diversification of screening libraries to include new natural products will be important as well as ensuring that the promising drug hits arising from structure-based drug design can achieve effective concentrations at their target sites within the bacterial cell.

Synergistic bactericidal effects and mechanisms of low intensity ultrasound and antibiotics against bacteria: a review

Low intensity ultrasonic therapy is always an important research area of ultrasonic medicine. This review concentrates on low intensity ultrasound enhancing bactericidal action of antibiotics against bacteria in vitro and in vivo, including planktonic bacteria, bacterial biofilms, Chlamydia, and bacteria in implants. These literatures show that low intensity ultrasound alone is not effective in killing bacteria, while the combination of low intensity ultrasound and antibiotics is promising. Low intensity ultrasound facilitating antibiotic treatment is still in its infancy, and still requires a great deal of research in order to develop the technology on medical treatment scale.

High prevalence of extended-spectrum β-lactamase-producing pathogens: results of a surveillance study in two hospitals in Ujjain, India

BACKGROUND

Recent reports of the rapid evolution of bacterial resistance in India require urgent antibiotic stewardship programs. This study aimed to define the magnitude and pattern of resistance of bacterial pathogens to guide empirical therapy.

METHODS

We prospectively collected consecutive, clinically significant, and nonduplicate bacterial isolates from each patient from two hospitals in Ujjain, India. The antibiotic susceptibility of the bacteria was tested using a disc diffusion method as recommended by the Clinical and Laboratory Standards Institute.

RESULTS

A total of 716 pathogens were isolated from 2568 patients (median age, 25 years; range, 0 days to 92 years). Gram-negative infections were predominant (62%). The isolated pathogens included Staphylococcus aureus (n = 221; 31%), Escherichia coli (n = 149; 21%), Pseudomonas aeruginosa (n = 127; 18%), and Klebsiella pneumoniae (n = 107; 15%). Common diagnoses included abscesses (56%), urinary tract infections (14%), blood stream infections (10%), pneumonia (10%), and vaginal infections (10%). In E. coli isolates, 69% (95% confidence interval [CI] 61.6-76.6) were extended-spectrum β-lactamase (ESBL) producers and 41% (95% CI 31.6-50.5) of K. pneumoniae isolates were ESBL producers. These isolates had a high resistance to fluoroquinolones and β-lactams, except for imipenem and piperacillin-tazobactam. Salmonella typhi remained sensitive to third-generation cephalosporins. Methicillin-resistant S. aureus (MRSA) constituted 30% of all S. aureus isolates and showed resistance to ciprofloxacin (81%), cotrimoxazole (76%), and levofloxacin (60%).

CONCLUSION

Our results showed a high prevalence of ESBL among Gram-negative bacterial isolates and a high prevalence of MRSA among S. aureus isolates. Carbapenems provided the broadest coverage for Gram-negative bacteria, while glycopeptides were the most effective against MRSA; however, both classes of drugs need to be used judiciously. This study will help in planning future antibiotic stewardship programs.