Costs and Outcomes of 1-year post-discharge care trajectories of patients admitted with infection due to antibiotic-resistant bacteria

Quantitative and qualitative evaluation of antimicrobial usage: the first step for antimicrobial stewardship

The identification of antimicrobial use patterns is essential for determining key targets for antimicrobial stewardship interventions and evaluating the effectiveness thereof. Accurately identifying antimicrobial use patterns requires quantitative evaluation, which focuses on measuring the quantity and frequency of antimicrobial use, and qualitative evaluation, which assesses the appropriateness, effectiveness, and potential side effects of antimicrobial prescriptions. This paper summarizes the quantitative and qualitative methods used to evaluate antimicrobials, drawing insights from overseas and domestic cases.

Mathematical modelling of antibiotic interaction on evolution of antibiotic resistance: an analytical approach

Background

The emergence and spread of antibiotic-resistant pathogens have led to the exploration of antibiotic combinations to enhance clinical effectiveness and counter resistance development. Synergistic and antagonistic interactions between antibiotics can intensify or diminish the combined therapy's impact. Moreover, these interactions can evolve as bacteria transition from wildtype to mutant (resistant) strains. Experimental studies have shown that the antagonistically interacting antibiotics against wildtype bacteria slow down the evolution of resistance. Interestingly, other studies have shown that antibiotics that interact antagonistically against mutants accelerate resistance. However, it is unclear if the beneficial effect of antagonism in the wildtype bacteria is more critical than the detrimental effect of antagonism in the mutants. This study aims to illuminate the importance of antibiotic interactions against wildtype bacteria and mutants on the deacceleration of antimicrobial resistance.

Methods

To address this, we developed and analyzed a mathematical model that explores the population dynamics of wildtype and mutant bacteria under the influence of interacting antibiotics. The model investigates the relationship between synergistic and antagonistic antibiotic interactions with respect to the growth rate of mutant bacteria acquiring resistance. Stability analysis was conducted for equilibrium points representing bacteria-free conditions, all-mutant scenarios, and coexistence of both types. Numerical simulations corroborated the analytical findings, illustrating the temporal dynamics of wildtype and mutant bacteria under different combination therapies.

Results

Our analysis provides analytical clarification and numerical validation that antibiotic interactions against wildtype bacteria exert a more significant effect on reducing the rate of resistance development than interactions against mutants. Specifically, our findings highlight the crucial role of antagonistic antibiotic interactions against wildtype bacteria in slowing the growth rate of resistant mutants. In contrast, antagonistic interactions against mutants only marginally affect resistance evolution and may even accelerate it.

Conclusion

Our results emphasize the importance of considering the nature of antibiotic interactions against wildtype bacteria rather than mutants when aiming to slow down the acquisition of antibiotic resistance.

Applying sequence analysis to uncover 'real-world' clinical pathways from routinely collected data: a systematic review

OBJECTIVES

This systematic review aims to elucidate the methodological practices and reporting standards associated with sequence analysis (SA) for the identification of clinical pathways in real-world scenarios, using routinely collected data.

STUDY DESIGN AND SETTING

We conducted a methodological systematic review, searching five medical and health databases: MEDLINE, PsycINFO, CINAHL, EMBASE and Web of Science. The search encompassed articles from the inception of these databases up to February 28, 2023. The search strategy comprised two distinctive sets of search terms, specifically focused on sequence analysis and clinical pathways.

RESULTS

19 studies met the eligibility criteria for this systematic review. Nearly 60% of the included studies were published in or after 2021, with a significant proportion originating from Canada (n = 7) and France (n = 5). 90% of the studies adhered to the fundamental SA steps. The optimal matching (OM) method emerged as the most frequently employed dissimilarity measure (63%), while agglomerative hierarchical clustering using Ward's linkage was the preferred clustering algorithm (53%). However, it is imperative to underline that a majority of the studies inadequately reported key methodological decisions pertaining to SA.

CONCLUSION

This review underscores the necessity for enhanced transparency in reporting both data management procedures and key methodological choices within SA processes. The development of reporting guidelines and a robust appraisal tool tailored to assess the quality of SA would be invaluable for researchers in this field.

Care pathways of sepsis survivors: sequelae, mortality and use of healthcare services in France, 2015-2018

BACKGROUND

Individuals who survive sepsis are at high risk of chronic sequelae, resulting in significant health-economic costs. Several studies have focused on aspects of healthcare pathways of sepsis survivors but comprehensive, longitudinal overview of their pathways of care are scarce. The aim of this retrospective, longitudinal cohort study is to identify sepsis survivor profiles based on their healthcare pathways and describe their healthcare consumption and costs over the 3 years following their index hospitalization.

METHODS

The data were extracted from the French National Hospital Discharge Database. The study population included all patients above 15 years old, with bacterial sepsis, who survived an incident hospitalization in an acute care facility in 2015. To identify survivor profiles, state sequence and clustering analyses were conducted over the year following the index hospitalization. For each profile, patient characteristics and their index hospital stay and sequelae were described, as well as use of care and its associated monetary costs, both pre- and post-sepsis.

RESULTS

New medical (79.2%), psychological (26.9%) and cognitive (18.5%) impairments were identified post-sepsis, and 65.3% of survivors were rehospitalized in acute care. Cumulative mortality reached 36.6% by 3 years post-sepsis. The total medical cost increased by 856 million € in the year post-sepsis. Five patient clusters were identified: home (65.6% of patients), early death (12.9%), late death (6.8%), short-term rehabilitation (11.3%) and long-term rehabilitation (3.3%). Survivors with early and late death clusters had high rates of cancer and primary bacteremia and experienced more hospital-at-home care post-sepsis. Survivors in short- or long-term rehabilitation clusters were older, with higher percentage of septic shock than those coming back home, and had high rates of multiple site infections and higher rates of new psychological and cognitive impairment.

CONCLUSIONS

Over three years post-sepsis, different profiles of sepsis survivors were identified with different mortality rates, sequels and healthcare services usage and cost. This study confirmed the importance of sepsis burden and suggests that strategies of post-discharge care, in accordance with patient profile, should be further tested in order to reduce sepsis burden.

The Phytochemical Tactics for Battling Antibiotic Resistance in Microbes: Secondary Metabolites and Nano Antibiotics Methods

One of the most serious threats to human health is antibiotic resistance, which has left the world without effective antibiotics. While continuous research and inventions for new antibiotics are going on, especially those with new modes of action, it is unlikely that this alone would be sufficient to win the battle. Furthermore, it is also important to investigate additional approaches. One such strategy for improving the efficacy of existing antibiotics is the discovery of adjuvants. This review has collected data from various studies on the current crisis and approaches for combating multi-drug resistance in microbial pathogens using phytochemicals. In addition, the nano antibiotic approaches, are discussed, highlighting the high potentials of essential oils, alkaloids, phenolic compounds, and nano antibiotics in combating antibiotic resistance.

The Long-Term Effects of Hospitalization on Health Care Expenditures: An Empirical Analysis for the Young-Old Population in Lombardy

As the burden of acute care on government budgets is mounting in many countries, documenting the evolution of health costs following patients' hospital admission is essential for assessing overall hospital-related costs. In this paper, we investigate the short- and long-term effects of hospitalization on different types of health care expenditures. We specify and estimate a dynamic DID model using register data of the entire population of individuals aged 50-70 residing in Milan, Italy, over the period 2008-2017. We find evidence of a large and persistent effect of hospitalization on total health care expenditures, with future medical expenses mostly accounted for by inpatient care. Considering all health treatments, the overall effect is sizable and is about twice the cost of a single hospital admission. We show that chronically ill and disabled individuals require greater post-discharge medical assistance, especially for inpatient care, and that cardiovascular and oncological diseases together account for more than half of expenditures on future hospitalizations. Alternative out-of-hospital management practices are discussed as a post-admission cost-containment measure.

Development of a Roadmap for the Antimicrobial Usage Monitoring System for Medical Institutions in Korea: a Delphi Study

Background

It is necessary to develop a roadmap for antimicrobial usage monitoring in order to perform monitoring of antimicrobial use at the national level properly. Therefore, this study aimed to develop a roadmap for establishing surveillance and monitoring of antimicrobial use in medical institutions at the national level.

Materials and Methods

A modified Delphi study was conducted, including 3 rounds of an online survey and a virtual meeting with 16 expert panels. The survey items were developed based on a literature review of the surveillance systems for antimicrobial use in 12 countries and interviews with experts. The questionnaire was designed to include both the surveillance and benchmarking systems.

Results

Regarding the scope of target institutions to be included in the surveillance system, medical institutions for sentinel surveillance had the highest proportion of agreement among the panels (75.0%, 9/12). For the benchmarking system, “tertiary- and secondary-care hospitals” were accepted as the scope of target institutions at the current moment. Furthermore, the National Health Insurance claims and prescription data of individual hospitals were considered appropriate data sources for the surveillance system. As for the measures to promote the participation of hospitals in the benchmarking system, “compensation through the establishment of antimicrobial management fees” and “set the participation in the program as a quality evaluation or accreditation index for hospital evaluation” were accepted.

Conclusion

This study provides a roadmap for establishing an antimicrobial use monitoring and benchmarking system for medical institutions at a national level in Korea.