Relevance of the Consensus Principles for Appropriate Antibiotic Prescribing in 2022

Prevalence, pandemic, preventions and policies to overcome antimicrobial resistance

Antimicrobial resistance (AMR) is a growing concern in Asia, and it is essential to understand the prevalence, pandemic, prevention, and policies to overcome it. According to the World Health Organization (WHO), AMR is one of the main causes of death; in 2019, it was linked to 4.95 million fatalities and caused about 1.27 million deaths. A core package of actions has been provided by WHO to help countries prioritize their needs when creating, carrying out, and overseeing national action plans on antimicrobial resistance. Using a people-cantered approach to AMR, the interventions address the needs and obstacles that individuals and patients encounter when trying to obtain healthcare. The people-cantered core package of AMR treatments seeks to improve public and policymakers; awareness and comprehension of AMR by changing the narrative of AMR to emphasize the needs of people and systemic impairments. Additionally, it backs a more comprehensive and programmatic national response to AMR, which emphasizes the value of fair and inexpensive access to high-quality healthcare services for the avoidance, identification, and management of drug-resistant diseases. The report signals increasing resistance to antibiotics in bacterial infections in humans and the need for better data. In conclusion, the prevalence of AMR in Asia is a significant public health concern, and it is crucial to implement policies and interventions to overcome it.

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.

Assessing the quality of antimicrobial prescribing in solid organ transplant recipients: a new frontier in antimicrobial stewardship

Background

Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTRs) and local standardized antimicrobial treatment guidelines may contribute to improved clinical outcomes. Our study assessed the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes.

Methods

Consecutive adult SOTRs admitted to the transplant floor from January-September 2020 and were treated for an infectious syndrome were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records. Guideline compliance was characterized as either appropriate, effective but unnecessary, undertreatment, or inappropriate.

Results

Nine hundred and thirty-six SOTR were admitted to the transplant ward, of which 328 patients (35%) received treatment for infectious syndromes. Guidelines were applicable to 252 patients, constituting 275 syndromes: 86 pneumonias; 82 urinary tract infections; 40 intra-abdominal infections; 38 bloodstream infections; and 29 C. difficile infections. 200/246 (81%) of infectious syndromes received appropriate or effective but unnecessary empiric treatment. In addition, appropriate tailoring of antimicrobials resulted in a significant difference in 30-day all-cause mortality (adjusted OR of 0.07, 95% CI 0.01-0.38; P = .002). Lastly, we found that guideline-compliant empiric therapy was found to prevent the development of multi-drug resistance in a time-dependent analysis (adjusted HR of 0.21, 95% CI 0.08-0.52; P = .001).

Conclusion

Our data show that adherence to locally developed guidelines was associated with reduced mortality and resistant-organism development in our cohort of SOTR.

Knowledge, Attitudes, and Practices (KAP) of community pharmacists regarding antibiotic use and resistance: a cross-sectional study from the United Arab Emirates

One of the main contributing factors of antibiotic resistance is the dispensing of antibiotics without prescription. This study investigated community pharmacists' knowledge, attitudes, and practices in relation to antibiotic dispensing and resistance in United Arab Emirates (UAE). A cross-sectional survey was conducted using validated questionnaire. (40.1%) had an overall positive KAP score. A total of (88%) respondents were aware of the illegality of dispensing antibiotics without a prescription. Only (31%) had good knowledge regarding amoxicillin dosage for upper respiratory tract infection. The primary misconduct found numerous pharmacists prescribing antibiotics without a prescription, even though they were aware that this should never be done. Pharmacists who attended events focused on antibiotic use and resistance were more likely to have good knowledge about antibiotics (Adjusted Odd Ratio (AOR): 1.673; 95%CI: 1.029-2.719; p = 0.038), more likely to have positive attitude (AOR: 1.889; 95%CI: 1.133-3.149; p = 0.015), and more likely to have good practice (AOR: 3.182; 95%CI: 1.541-6.572; p = 0.002).

Personalising intravenous to oral antibiotic switch decision making through fair interpretable machine learning

Antimicrobial resistance (AMR) and healthcare associated infections pose a significant threat globally. One key prevention strategy is to follow antimicrobial stewardship practices, in particular, to maximise targeted oral therapy and reduce the use of indwelling vascular devices for intravenous (IV) administration. Appreciating when an individual patient can switch from IV to oral antibiotic treatment is often non-trivial and not standardised. To tackle this problem we created a machine learning model to predict when a patient could switch based on routinely collected clinical parameters. 10,362 unique intensive care unit stays were extracted and two informative feature sets identified. Our best model achieved a mean AUROC of 0.80 (SD 0.01) on the hold-out set while not being biased to individuals protected characteristics. Interpretability methodologies were employed to create clinically useful visual explanations. In summary, our model provides individualised, fair, and interpretable predictions for when a patient could switch from IV-to-oral antibiotic treatment. Prospectively evaluation of safety and efficacy is needed before such technology can be applied clinically.

Impact of antimicrobial stewardship in organisms causing nosocomial infection among COVID-19 critically ill adults

OBJECTIVE

To evaluate the implementation of an antibiotic stewardship program in critically ill COVID-19 patients and to establish risk factors for coinfection. Secondary objective was to analyze the evolution of the etiology of respiratory nosocomial infections.

METHODS

Single-center observational cohort study of consecutive patients admitted to ICU due to COVID-19 pneumonia from March 2020 to October 2022. An antibiotic stewardship program was implemented at the end of the second wave.

RESULTS

A total of 878 patients were included during 6 pandemic waves. Empirical antibiotic consumption decreased from the 96% of the patients during the first pandemic wave, mainly in combination (90%) to the 30% of the patients in the 6th pandemic wave most in monotherapy (90%). There were not differences in ICU and Hospital mortality between the different pandemic periods. In multivariate analysis, SOFA at admission was the only independent risk factor for coinfection in critically ill COVID-19 patients (OR 1,23 95%CI 1,14 to 1,35). Differences in bacterial etiology of first nosocomial respiratory infection were observed. There was a progressive reduction in Enterobacteriaceae and non- fermentative Gram Negative Bacilli as responsible pathogens, while methicillin-sensitive Staphylococcus aureus increased during pandemic waves. In the last wave, however, a trend to increase of potentially resistant pathogens was observed.

CONCLUSIONS

Implementation of an antibiotic stewardship program was safe and not associated with worse clinical outcomes, being severity at admission the main risk factor for bacterial coinfection in covid-19 patients. A decline in potentially resistant pathogens was documented throughout the pandemic.

Multidrug-Resistant Escherichia coli Strains to Last Resort Human Antibiotics Isolated from Healthy Companion Animals in Valencia Region

Failure in antibiotic therapies due to the increase in antimicrobial-resistant (AMR) bacteria is one of the main threats to public and animal health. In recent decades, the perception of companion animals has changed, from being considered as a work tool to a household member, creating a family bond and sharing spaces in their daily routine. Hence, the aim of this study is to assess the current epidemiological situation regarding the presence of AMR and multidrug resistance (MDR) in companion animals in the Valencia Region, using the indicator bacteria Escherichia coli as a sentinel. For this purpose, 244 samples of dogs and cats were collected from veterinary centres to assess antimicrobial susceptibility against a panel of 22 antibiotics with public health relevance. A total of 197 E. coli strains were isolated from asymptomatic dogs and cats. The results showed AMR against all the 22 antibiotics studied, including those critically important to human medicine. Moreover, almost 50% of the strains presented MDR. The present study revealed the importance of monitoring AMR and MDR trends in companion animals, as they could pose a risk due to the spread of AMR and its resistance genes to humans, other animals and the environment they cohabit.

Insights from a Cross-Sectional Study on Knowledge, Attitudes and Behaviors Concerning Antibiotic Use in a Large Metropolitan Area: Implications for Public Health and Policy Interventions

The overuse and inappropriate use of antibiotics pose a grave threat to public health, contributing significantly to the accelerated development of antimicrobial resistance (AMR) and increased rates of morbidity and mortality, making it a leading cause of death globally. To examine the relationship between demographic variables and knowledge, attitudes, and behaviors concerning antibiotic use, a survey-based cross-sectional study was conducted involving 1158 individuals. The questionnaire included two sections: in the first section, participants' socio-demographic characteristics were analyzed; the second investigated knowledge, attitudes, and behaviors concerning antibiotics utilization using a total of 36 questions. Descriptive statistics were used, and then a multiple linear regression analysis (MLRA) using three models was carried out. In Model I, knowledge about antibiotics exhibited correlations with smoking habits and educational attainment. In Model II, attitudes were significantly associated with gender, smoking habits, age, education, relationship status, and knowledge. In Model III, behaviors related to antibiotics were correlated with educational attainment, having children, knowledge, and attitudes. Implementing tailored public health programs could be a cost-effective intervention to enhance behaviors associated with antibiotic use in the general population. This study offers valuable insights into the determinants of knowledge, attitudes, and behaviors regarding antibiotics in the general population.

Social demographics determinants for resistome and microbiome variation of a multiethnic community in Southern Malaysia

The prevalence of antibiotic-resistant bacteria in Southeast Asia is a significant concern, yet there is limited research on the gut resistome and its correlation with lifestyle and environmental factors in the region. This study aimed to profile the gut resistome of 200 individuals in Malaysia using shotgun metagenomic sequencing and investigate its association with questionnaire data comprising demographic and lifestyle variables. A total of 1038 antibiotic resistance genes from 26 classes were detected with a mean carriage rate of 1.74 ± 1.18 gene copies per cell per person. Correlation analysis identified 14 environmental factors, including hygiene habits, health parameters, and intestinal colonization, that were significantly associated with the resistome (adjusted multivariate PERMANOVA, p < 0.05). Notably, individuals with positive yeast cultures exhibited a reduced copy number of 15 antibiotic resistance genes. Network analysis highlighted Escherichia coli as a major resistome network hub, with a positive correlation to 36 antibiotic-resistance genes. Our findings suggest that E. coli may play a pivotal role in shaping the resistome dynamics in Segamat, Malaysia, and its abundance is strongly associated with the community's health and lifestyle habits. Furthermore, the presence of yeast appears to be associated with the suppression of antibiotic-resistance genes.

Risk for primary cephalosporin resistance in Gram-negative bacteremia

Objective

This study aimed to examine the clinical risk factors for cephalosporin resistance in patients with Gram-negative bacteremia caused by Escherichia coli (EC), Klebsiella pneumoniae (KP), Enterobacter cloacae (ENC), and Pseudomonas aeruginosa (PS).

Methods

This retrospective cohort study included 400 adults with Gram-negative bacteremia. The goal was to review 100 cases involving each species and approximately half resistant and half susceptible to first-line cephalosporins, ceftriaxone (EC or KP), or cefepime (ENC or PS). Logistic regression was used to identify factors predictive of resistance.

Results

A total of 378 cases of Gram-negative bacteremia were included in the analysis. Multivariate analysis identified significant risk factors for resistance, including admission from a chronic care hospital, skilled nursing facility, or having a history of infection within the prior 6 months (OR 3.00, P < .0001), requirement for mechanical ventilation (OR 3.76, P < .0001), presence of hemiplegia (OR 3.54, P = .0304), and presence of a connective tissue disease (OR 3.77, P = .0291).

Conclusions

Patients without the identified risk factors should be strongly considered for receiving ceftriaxone or cefepime rather than carbapenems and newer broad-spectrum agents.

Knowledge, Attitudes, and Practices among Pharmacy and Non-Pharmacy Interns in Saudi Arabia Regarding Antibiotic Use and Antibiotic Resistance: A Cross-Sectional Descriptive Study

This cross-sectional descriptive study aims to explore the knowledge, attitudes, and practices among pharmacy, dentistry, medicine, and nursing interns in Saudi Arabia regarding antibiotic use and antibiotic resistance. Interns received a soft copy of a structured and validated self-administered questionnaire using an online survey platform. A total of 266 interns responded to the questionnaire. On average, the participants achieved good scores in the knowledge and practice domains, followed by the attitude domain. The average knowledge percentage was 76.1% (SD 17.1) compared to 84.6% (SD 20.5) for practices and 61.5% (SD 23.2) for attitudes. The results suggest that pharmacy interns had insignificantly better overall scores compared to non-pharmacy interns for knowledge, attitudes, and practices. This study shows that the scores for knowledge, attitudes, and practices of pharmacy, dentistry, medicine, and nursing interns regarding antibiotic use and resistance were high overall. However, interns' belief in their responsibility in preventing antibiotic resistance is lacking.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

Hospital Antibiotic Use during COVID-19 Pandemic in Italy

Antimicrobial resistance (AMR) represents a major issue in healthcare being correlated to global inappropriate use of antibiotics. The aim of this study was to compare the data on hospital antibiotic consumption in 2020-2021 with those related to 2019 in order to evaluate the impact of the COVID-19 pandemic on antibiotic prescriptions and appropriate use at national level and in the different geographical areas. To estimate the consumption of antibiotics, two indicators were calculated: "number of DDD per 1000 inhabitants per day" and "number of DDD per 100 hospitalisation days". Consumption data on antibiotics dispensed in public health facilities were based on the Italian "traceability of medicines" information flow. Data on hospitalisation days were extracted from the Italian "hospital discharge form" flow. Pearson correlation analysis was performed between the number of patients hospitalised for COVID-19 and the consumption of antibiotics in public healthcare facilities. During 2020, about 1.7 DDD/1000 inhabitants per day (12.3% of the overall consumption of reimbursed antibiotics) were dispensed exclusively in Italian hospitals (+0.8% compared to 2019). Considering the number of DDD per 100 hospitalisation days, consumption increased by 19.3% in 2020 compared to 2019. Comparing the first semester of 2020 and 2019, a decrease of DDD/1000 inhabitants per day was observed (-1.6%) at national level, with opposite trends in the different geographical areas; an increase in the use of azithromycin and carbapenems was also observed, with a stable consumption of third-generation cephalosporins. The use of antibiotics in the second semester of 2020 compared to the same period of 2019 showed a clear reduction at national level (-8.5%), appreciable to a similar extent in all geographic areas. In the first semester of 2021 compared to the same period of 2020, there was a huge reduction (-31.4%) in consumption at national level. However, the variations were heterogeneous between different geographical areas. To our knowledge, this study represents the most comprehensive analysis performed on antibiotic consumption data in hospital settings in Italy during the COVID-19 pandemic to date. Despite international and national guideline recommendations, a substantial overall increase in antibiotic prescriptions was observed during the COVID-19 pandemic, with variability in terms of geographical distribution and prescription strategies. These findings may be related to the dichotomy between perceived and real significance of guidelines, expert panels, or consensus. Therefore, new approaches or strategies to antimicrobial stewardship should be proposed.

An Improvement in the Antimicrobial Resistance Patterns of Urinary Isolates in the Out-Of-Hospital Setting following Decreased Community Use of Antibiotics during the COVID-19 Pandemic

After the onset of COVID-19 pandemic, a decrease in antibiotic consumption in the out-of-hospital setting was observed. However, data about the impact of this reduction on antimicrobial resistance are lacking. The aim of this study was to assess antibiotic consumption and antibiotic resistance at the community level in an Italian province before and after the beginning of the COVID-19 pandemic. We carried out an observational study, comparing antibiotic consumption in the community during 2019 and 2020 and the antibiotic resistance patterns of Enterobacterales cultured from urine samples from the out-of-hospital setting during the first semester of 2020 and 2021. Overall, antibiotic consumption decreased by 28% from 2019 to 2020 (from 13.9 to 9.97 DDD/1000 inhabitants/day). The main reductions involved penicillins (ATC J01C, from 6.9 to 4.8 DDD/1000 inhabitants/day, −31%), particularly amoxicillin/clavulanate (ATC J01CR02, −30%) and amoxicillin (J01CA04, −35.2%). Overall, 6445 strains of Enterobacterales were analyzed; in 2020, the susceptibility rate of amoxicillin/clavulanate increased from 57.5% to 87% among isolates from the primary care setting (p < 0.001) and from 39% to 72% (p < 0.001) among isolates from LTCF. The reduction in the community use of antibiotics observed in 2020 was followed by a change in the antimicrobial resistance patterns of urinary isolates.

Country data on AMR in Russia in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

BACKGROUND

Antimicrobial reistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

OBJECTIVES

To review AMR in Russia and any initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Russia and to improve patient outcomes.

METHODS

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from both a local clinician and a local clinical microbiologist were sought to contextualize this information.

CONCLUSIONS

Russia launched a national strategy in 2017 to prevent the spread of AMR and the WHO reports that as of 2020-21, it is being implemented and actively monitored. Reports suggest outpatient antibiotic use of antibiotics is high and that non-prescription access and self-medication are very common. Antibiotic susceptibility studies in Russia include PeHASus, a multicentre epidemiological study focusing on susceptibilities of community-acquired respiratory pathogens and international studies such as Survey of Antibiotic Resistance (SOAR), Antimicrobial Testing Leadership and Surveillance (ATLAS) and SENTRY Antimicrobial Surveillance Program. International guidelines are used to support the development of local guidelines in Russia, and for the common CA-RTIs Russian clinicians use of several country-specific local antibiotic prescribing guidelines. A standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Russia, could make guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.