Assessment of antibiotic prescribing pattern and cost for hospitalized patients: A study from Palestine

BACKGROUND

One of the largest problems facing the world today is the morbidity and mortality caused by antibiotic resistance in bacterial infections. A major factor in antimicrobial resistance (AMR) is the irrational use of antibiotics. The objective of this study was to assess the prescribing pattern and cost of antibiotics in two major governmental hospitals in the West Bank of Palestine.

METHODS

A retrospective cohort study was conducted on 428 inpatient prescriptions containing antibiotics from two major governmental hospitals, they were evaluated by some drug use indicators. The cost of antibiotics in these prescriptions was calculated based on the local cost. Descriptive statistics were performed using IBM-SPSS version 21.

RESULTS

The mean ± SD number of drugs per prescription (NDPP) was 6.72 ± 4.37. Of these medicines, 38.9% were antibiotics. The mean ± SD number of antibiotics per prescription (NAPP) was 2.61 ± 1.54. The average ± SD cost per prescription (CPP) was 392 ± 744 USD. The average ± SD antibiotic cost per prescription (ACPP) was 276 ± 553 USD. The most commonly prescribed antibiotics were ceftriaxone (52.8%), metronidazole (24.8%), and vancomycin (21.0%). About 19% of the antibiotics were prescribed for intra-abdominal infections; followed by 16% used as prophylactics to prevent infections. Almost all antibiotics prescribed were administered intravenously (IV) 94.63%. In general, the average duration of antibiotic therapy was 7.33 ± 8.19 days. The study indicated that the number of antibiotics per prescription was statistically different between the hospitals (p = 0.022), and it was also affected by other variables like the diagnosis (p = 0.006), the duration of hospitalization (p < 0.001), and the NDPP (p < 0.001). The most commonly prescribed antibiotics and the cost of antibiotics per prescription were significantly different between the two hospitals (p < 0.001); The cost was much higher in the Palestinian Medical Complex.

CONCLUSION

The practice of prescribing antibiotics in Palestine's public hospitals may be unnecessary and expensive. This has to be improved through education, adherence to recommendations, yearly immunization, and stewardship programs; intra-abdominal infections were the most commonly seen infection in inpatients and ceftriaxone was the most frequently administered antibiotic.

Gender and equity considerations in AMR research: a systematic scoping review

Research on gender and antimicrobial resistance (AMR) beyond women's biological susceptibility is limited. A gender and equity lens in AMR research is necessary to promote gender equality and support the effectiveness, uptake, and sustainability of real-world AMR solutions. We argue that it is an ethical and social justice imperative to include gender and related intersectional issues in AMR research and implementation. An intersectional exploration of the interplay between people's diverse identities and experiences, including their gender, socio-economic status, race, disability, age, and sexuality, may help us understand how these factors reinforce AMR risk and vulnerability and ensure that interventions to reduce the risk of AMR do not impact unevenly. This paper reports on the findings of a systematic scoping review on the interlinkages between AMR, gender and other socio-behavioural characteristics to identify priority knowledge gaps in human and animal health in LMICs. The review focused on peer-reviewed and grey literature published between 2017 and 2022. Three overarching themes were gendered division of caregiving roles and responsibilities, gender power relations in decision-making, and interactions between gender norms and health-seeking behaviours. Research that fails to account for gender and its intersections with other lines of disadvantage, such as race, class and ability, risks being irrelevant and will have little impact on the continued and dangerous spread of AMR. We provide recommendations for integrating an intersectional gender lens in AMR research, policy and practice.

Clinicians' interpretation of thresholds in hospital antibiograms for gram-negative rod infections: A survey and contingent valuation study of hospitalists

Clinical guidelines suggest that hospital antibiograms are a key component when deciding empiric therapy, but little is known about how often clinicians use antibiograms and how they influence clinicians' empiric therapy decisions. We surveyed hospitalists at seven healthcare systems in the United States on their reported practices related to antibiograms and their hypothetical prescribing for four clinical scenarios associated with gram-negative rod pathogens. Each was given a randomly assigned antibiogram susceptibility percentage, and we used contingent valuation analysis to assess whether the antibiogram susceptibility percentage was associated with prescribing practices. Of the 193 survey responders, only 52 (26.9%) respondents reported using antibiograms more than monthly. Across all four clinical scenarios, there was no evidence that antibiogram susceptibility levels influenced antibiotic prescribing practices. With limited utilization and no evidence that they influenced practice, antibiograms may have a limited role in hospitalist care delivery for common gram-negative rod infections.

Predictive Modeling of Phenotypic Antimicrobial Susceptibility of Selected Beta-Lactam Antimicrobials from Beta-Lactamase Resistance Genes

The outcome of bacterial infection management relies on prompt diagnosis and effective treatment, but conventional antimicrobial susceptibility testing can be slow and labor-intensive. Therefore, this study aims to predict phenotypic antimicrobial susceptibility of selected beta-lactam antimicrobials in the bacteria of the family Enterobacteriaceae from different beta-lactamase resistance genotypes. Using human datasets extracted from the Antimicrobial Testing Leadership and Surveillance (ATLAS) program conducted by Pfizer and retail meat datasets from the National Antimicrobial Resistance Monitoring System for Enteric Bacteria (NARMS), we used a robust or weighted least square multivariable linear regression modeling framework to explore the relationship between antimicrobial susceptibility data of beta-lactam antimicrobials and different types of beta-lactamase resistance genes. In humans, in the presence of the blaCTX-M-1, blaCTX-M-2, blaCTX-M-8/25, and blaCTX-M-9 groups, MICs of cephalosporins significantly increased by values between 0.34-3.07 μg/mL, however, the MICs of carbapenem significantly decreased by values between 0.81-0.87 μg/mL. In the presence of carbapenemase genes (blaKPC, blaNDM, blaIMP, and blaVIM), the MICs of cephalosporin antimicrobials significantly increased by values between 1.06-5.77 μg/mL, while the MICs of carbapenem antimicrobials significantly increased by values between 5.39-67.38 μg/mL. In retail meat, MIC of ceftriaxone increased significantly in the presence of blaCMY-2, blaCTX-M-1, blaCTX-M-55, blaCTX-M-65, and blaSHV-2 by 55.16 μg/mL, 222.70 μg/mL, 250.81 μg/mL, 204.89 μg/mL, and 31.51 μg/mL respectively. MIC of cefoxitin increased significantly in the presence of blaCTX-M-65 and blaTEM-1 by 1.57 μg/mL and 1.04 μg/mL respectively. In the presence of blaCMY-2, MIC of cefoxitin increased by an average of 8.66 μg/mL over 17 years. Compared to E. coli isolates, MIC of cefoxitin in Salmonella enterica isolates decreased significantly by 0.67 μg/mL. On the other hand, MIC of ceftiofur increased in the presence of blaCTX-M-1, blaCTX-M-65, blaSHV-2, and blaTEM-1 by 8.82 μg/mL, 9.11 μg/mL, 8.18 μg/mL, and 1.04 μg/mL respectively. In the presence of blaCMY-2, MIC of ceftiofur increased by an average of 10.20 μg/mL over 14 years. The ability to predict antimicrobial susceptibility of beta-lactam antimicrobials directly from beta-lactamase resistance genes may help reduce the reliance on routine phenotypic testing with higher turnaround times in diagnostic, therapeutic, and surveillance of antimicrobial-resistant bacteria of the family Enterobacteriaceae.

Sociodemographic characterisation of antibiotic heavy users in the Danish elderly population

AIMS

The development of effective interventions to reduce inappropriate use of antibiotics in the elderly population requires knowledge on who can benefit from such interventions. Thus, we aimed to identify and characterise antibiotic heavy users among elderly patients in general practice with respect to sociodemographic variables.

METHODS

We conducted a retrospective nationwide register-based study on all Danish elderly citizens (⩾65 years) who redeemed an antibiotic prescription in 2017. Heavy users were defined as the 10% with the highest excess use, that is, their recorded use minus the average use for their sex, age group and comorbidity level as estimated from a linear regression model. Comparative analyses of sociodemographic characteristics (civil status, employment status, urbanity, educational level and country of origin) of heavy users and non-heavy users were performed using logistic regression models.

RESULTS

The study population consisted of 251,733 elderly individuals, who in total redeemed 573,265 prescriptions of antibiotics. Heavy users accounted for 68% of all excess use of antibiotics. In multivariable analyses, individuals with an educational level above basic schooling, non-retired, residing in an urban municipality and being born in a country outside Scandinavia all had lower odds of being a heavy user. Widowed, divorced or single individuals had higher odds of being a heavy user compared with married individuals. Relative importance analyses showed that civil status and educational level contributed considerably to the explained variance.

CONCLUSIONS

This study found an association between sociodemographic characteristics and risk of being a heavy user, indicating that sociodemographic variation exists with regard to antibiotic prescribing.

A Systematic Literature Review on Risk Factors for and Timing of Clostridioides difficile Infection in the United States

INTRODUCTION

Clostridioides difficile infection (CDI) is a major public health threat. Up to 40% of patients with CDI experience recurrent CDI (rCDI), which is associated with increased morbidity. This study aimed to define an at-risk population by obtaining a detailed understanding of the different factors leading to CDI, rCDI, and CDI-related morbidity and of time to CDI.

METHODS

We conducted a systematic literature review (SLR) of MEDLINE (using PubMed) and EMBASE for relevant articles published between January 1, 2016, and November 11, 2022, covering the US population.

RESULTS

Of the 1324 articles identified, 151 met prespecified inclusion criteria. Advanced patient age was a likely risk factor for primary CDI within a general population, with significant risk estimates identified in nine of 10 studies. Older age was less important in specific populations with comorbidities usually diagnosed at earlier age, such as bowel disease and cancer. In terms of comorbidities, the established factors of infection, kidney disease, liver disease, cardiovascular disease, and bowel disease along with several new factors (including anemia, fluid and electrolyte disorders, and coagulation disorders) were likely risk factors for primary CDI. Data on diabetes, cancer, and obesity were mixed. Other primary CDI risk factors were antibiotics, proton pump inhibitors, female sex, prior hospitalization, and the length of stay in hospital. Similar factors were identified for rCDI, but evidence was limited. Older age was a likely risk factor for mortality. Timing of primary CDI varied depending on the population: 2-3 weeks in patients receiving stem cell transplants, within 3 weeks for patients undergoing surgery, and generally more than 3 weeks following solid organ transplant.

CONCLUSION

This SLR uses recent evidence to define the most important factors associated with CDI, confirming those that are well established and highlighting new ones that could help to identify patient populations at high risk.

Disease-modifying drugs, multiple sclerosis and infection-related healthcare use in British Columbia, Canada: a population-based study

Background

Much remains unknown surrounding the disease-modifying drugs (DMDs) used to treat multiple sclerosis and infection-related healthcare use in the 'real-world' setting. We examined if DMD exposure was associated with altered infection-related healthcare use.

Methods

We assessed if DMD (versus no) exposure was associated with altered infection-related hospitalizations, physician claims, and prescriptions filled in British Columbia, Canada (1996-2017). Healthcare use was assessed using negative binomial and proportional means regression models, reported as sex-/age-/comorbidity-/calendar year-/socioeconomic-adjusted rate and hazard ratios [aRR, aHR], with 95% confidence intervals [CIs]).

Findings

We identified 19,360 multiple sclerosis cases (13,940/19,360; 72.0% women; mean age at study start = 44.5 standard deviation, SD = 13.3; mean follow-up = 11.7 [SD = 7.3] years). Relative to unexposed periods, exposure to any DMD was associated with a lower infection-related rate of physician claims (aRR = 0.88; 95% CI:0.85-0.92) and hazard of hospitalization (aHR = 0.64; 95% CI:0.56-0.73), and a higher rate of infection-related prescriptions (aRR = 1.14; 95% CI:1.08-1.20). Exposure to any injectable or oral DMD was associated with a lower infection-related rate of physician claims (injectable aRR = 0.88; 95% CI:0.84-0.92, oral aRR = 0.83; 95% CI:0.77-0.90) and hazard of hospitalization (injectable aHR = 0.65; 95% CI:0.56-0.75, oral aHR = 0.54; 95% CI:0.38-0.77), whereas intravenous DMD exposure was not (aRR = 0.99; 95% CI:0.86-1.14, aHR = 0.73; 95% CI:0.49-1.09). Exposure to any injectable or intravenous DMD was associated with a higher rate of infection-related prescriptions (injectable aRR = 1.15; 95% CI:1.08-1.22, intravenous = 1.34; 95% CI:1.15-1.56), whereas oral DMDs were not (aRR = 0.98; 95% CI:0.91-1.05).

Interpretation

DMD exposure for the treatment of MS was associated with differences in infection-related healthcare use. While infection-related hospitalizations and physician visits were lower, prescription fills were higher. How these differences in infection-related healthcare use affect outcomes in persons with multiple sclerosis warrants consideration.

Funding

Canadian Institutes of Health Research (CIHR); German Research Foundation (DFG).

Demographic and Geographic Inequities in Antimicrobial Use and Prescribing

Little is known about how social determinants of health may impact antimicrobial prescribing among racial and ethnic minority populations, different age groups and genders, and across geographic regions. The factors that influence antimicrobial prescribing are complex, but evidence suggests that demographic and socioeconomic factors do influence prescribing patterns. This review describes the inequities observed in antimicrobial use and prescribing that have been heretofore published, with a focus on differences observed by race and ethnicity, age, gender, and geographic region of the United States.

Factors Associated with Geographical Variability of Antimicrobial Use in Japan

INTRODUCTION

Evidence regarding the factors affecting the geographical variation of antimicrobial use (AMU) is relatively scarce. This study aimed to evaluate factors potentially associated with geographical variability of AMU per day per 1000 habitants in the 47 prefectures of Japan.

METHODS

This is an observational ecological study using the Japanese national database in 2019. The outcome was the defined daily doses per 1000 inhabitants per day by prefecture. Multivariable negative binomial regression analysis was conducted using patient- and physician-level variables.

RESULTS

The study included 605,391,054 defined daily doses of AMU in 2019 from the 47 prefectures. In the multivariable negative binomial regression analyses for the outcome of total AMU, the proportion of female individuals (adjusted rate ratio [aRR] 1.04 [1.01-1.08] per 1% increase, p = 0.021), the proportion of upper secondary graduates going to further education (aRR 1.01 [1.00-1.01] per 1% increase, p = 0.005), and the annual number of diagnoses related to upper respiratory infections (URIs) per 1000 inhabitants per day (aRR 1.21 [1.10-1.34], p < 0.001) were significantly correlated with total AMU.

CONCLUSIONS

In this ecological study, the variability of total AMU by Japanese prefecture was associated with the proportion of female individuals, education level, and the number of URI diagnoses per population. The results suggest the potential need for additional stewardship efforts to reduce unnecessary antimicrobial prescriptions for URI.

Gut microbiota research nexus: One Health relationship between human, animal, and environmental resistomes

The emergence and rapid spread of antimicrobial resistance is of global public health concern. The gut microbiota harboring diverse commensal and opportunistic bacteria that can acquire resistance via horizontal and vertical gene transfers is considered an important reservoir and sink of antibiotic resistance genes (ARGs). In this review, we describe the reservoirs of gut ARGs and their dynamics in both animals and humans, use the One Health perspective to track the transmission of ARG-containing bacteria between humans, animals, and the environment, and assess the impact of antimicrobial resistance on human health and socioeconomic development. The gut resistome can evolve in an environment subject to various selective pressures, including antibiotic administration and environmental and lifestyle factors (e.g., diet, age, gender, and living conditions), and interventions through probiotics. Strategies to reduce the abundance of clinically relevant antibiotic-resistant bacteria and their resistance determinants in various environmental niches are needed to ensure the mitigation of acquired antibiotic resistance. With the help of effective measures taken at the national, local, personal, and intestinal management, it will also result in preventing or minimizing the spread of infectious diseases. This review aims to improve our understanding of the correlations between intestinal microbiota and antimicrobial resistance and provide a basis for the development of management strategies to mitigate the antimicrobial resistance crisis.

Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries

Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.

Ambulatory Antibiotic Use Patterns in Bolivia: Identifying Targets for Future Antibiotic Stewardship Efforts in Latin America

We evaluated antibiotic use in a private health insurance network in Bolivia with two different healthcare plans. The Health Maintenance Organization plan had 29% lower antibiotic consumption and fewer broad-spectrum antibiotics prescribed than the Preferred Provider Organization. Furthermore, we identified potential targets for future antibiotic stewardship efforts.

Irrational use of antibiotics and factors associated with antibiotic resistance: Findings from a cross-sectional study in Bangladesh

Background and aims

Irrational antibiotic (AB) usage poses a serious concern to third-world countries because of poor surveillance, lack of information, and patients' propensity for self-medication. Additionally, the unpredictability of the coronavirus disease 2019 (COVID-19) pandemic promoted the abuse of ABs, which accelerated the prevalence of antibiotic resistance (ABR). The primary aim of this study was to assess the pattern of AB usage and irrational use of ABs-related potential factors associated with ABR among the students and teachers of a leading public university of Bangladesh.

Methods

A cross-sectional web-based survey was conducted among the students and teachers (n = 783) of the selected university, from January 1 to February 28, 2022. Descriptive statistics, χ ² test, and logistic regression analysis were employed to analyze the collected data.

Results

The regression analysis supported that male participants had a 34% lower experience of acquiring ABR than female respondents (adjusted odds ratio [AOR] = 0.66, 95% confidence interval [CI] = 0.448, 0.973; p = 0.036). The 1st/2nd-year level students had more than two times higher experience with ABR than the master's or higher-class students (AOR = 2.149, 95% CI = 1.047, 4.412; p = 0.037). The participants who took ABs for 4-6 days showed more than two times ABR experience than those who took ABs for above 10 days (AOR = 2.016, 95% CI = 1.016, 4.003; p = 0.045). Respondents who finished their AB medication (dose completion) had a 57% less chance of acquiring ABR than the participants who did not complete their dose.

Conclusion

This study found that irrational use of ABs is more prevalent among the youth and female participants. At this stage, there is an urgent need for comprehensive statutory AB control rules, as well as measures for appropriate information, education, and surveillance throughout different groups of Bangladesh.

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.

Gastric troubles in Iran: The role of social and economic factors in Helicobacter pylori infection

Background

Helicobacter pylori infection is a major risk factor for gastric cancer in Iran, but the impact of socioeconomic factors on its prevalence is poorly understood. This study aimed to assess the socioeconomic inequalities and risk factors associated with H. pylori infection in Iran.

Methods

This cross-sectional study was conducted based on the PERSIAN cohort study. A total of 20460 individuals aged 35 to 70 years in Ardabil, Iran were included in the study. H. pylori infection was determined based on stool tests and clinical records. Multilevel logistic regression models with random intercepts at household and community levels were used to identify risk factors associated with H. pylori prevalence. The concentration index (CIn) and concentration curve (CC) were employed to assess socioeconomic-related inequality.

Results

In this study, 70.4% (CI 69.6-71.0) of the participants were infected with H. pylori, with a higher prevalence in women (71.2%) than men (69.6%). Age (OR: 1.37, CI: 1.17-1.61), sex (OR: 1.20, CI: 1.12-1.28), level of education (OR: 1.33, CI: 1.17-1.49), cardiac disease (OR: 1.32, CI:1.18-1.46), and BMI groups (OR: 2.49, CI: 1.11-5.58) were significantly associated with H. pylori infection based on the multivariable logistic regression. The results of the CIn and CC indicated that H. pylori were more prevalent among economically disadvantaged groups (CIn: -0.1065; [-0.1374 to -0.0755]).

Conclusion

The prevalence of H. pylori in Iran is higher than in other developing countries, and significant socioeconomic inequality exists between the poor and the rich. To reduce the rate of gastric cancer, socio-economic and demographic factors, especially the poor and people with low levels of education, should be considered.

Prescribing of Outpatient Antibiotics Commonly Used for Respiratory Infections Among Adults Before and During the Coronavirus Disease 2019 Pandemic in Brazil

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic may have impacted outpatient antibiotic prescribing in low- and middle-income countries such as Brazil. However, outpatient antibiotic prescribing in Brazil, particularly at the prescription level, is not well-described.

METHODS

We used the IQVIA MIDAS database to characterize changes in prescribing rates of antibiotics commonly prescribed for respiratory infections (azithromycin, amoxicillin-clavulanate, levofloxacin/moxifloxacin, cephalexin, and ceftriaxone) among adults in Brazil overall and stratified by age and sex, comparing prepandemic (January 2019-March 2020) and pandemic periods (April 2020-December 2021) using uni- and multivariate Poisson regression models. The most common prescribing provider specialties for these antibiotics were also identified.

RESULTS

In the pandemic period compared to the prepandemic period, outpatient azithromycin prescribing rates increased across all age-sex groups (incidence rate ratio [IRR] range, 1.474-3.619), with the greatest increase observed in males aged 65-74 years; meanwhile, prescribing rates for amoxicillin-clavulanate and respiratory fluoroquinolones mostly decreased, and changes in cephalosporin prescribing rates varied across age-sex groups (IRR range, 0.134-1.910). For all antibiotics, the interaction of age and sex with the pandemic in multivariable models was an independent predictor of prescribing changes comparing the pandemic versus prepandemic periods. General practitioners and gynecologists accounted for the majority of increases in azithromycin and ceftriaxone prescribing during the pandemic period.

CONCLUSIONS

Substantial increases in outpatient prescribing rates for azithromycin and ceftriaxone were observed in Brazil during the pandemic with prescribing rates being disproportionally different by age and sex. General practitioners and gynecologists were the most common prescribers of azithromycin and ceftriaxone during the pandemic, identifying them as potential specialties for antimicrobial stewardship interventions.

Assessing the appropriateness of community-based antibiotic prescribing in Alberta, Canada, 2017-2020, using ICD-9-CM codes: a cross-sectional study

BACKGROUND

Antimicrobial resistance is a rising threat to human health, and, with up to 90% of antibiotics prescribed in the community, it is critical to examine Canadian antibiotic stewardship practices in outpatient settings. We carried out a large-scale analysis of appropriateness in community-based prescribing of antibiotics to adults in Alberta, reporting on 3 years of data from physicians practising in the province.

METHODS

The study cohort was composed of all adult (age 18-65 yr) Alberta residents who filled at least 1 antibiotic prescription written by a community-based physician between Apr. 1, 2017, and Mar. 6, 2020. We linked diagnosis codes from the clinical modification of the International Classification of Diseases, 9th Revision (ICD-9-CM), as used for billing purposes by the province's fee-for-service community physicians, to drug dispensing records, as maintained in the province's pharmaceutical dispensing database. We included physicians practising in community medicine, general practice, generalist mental health, geriatric medicine and occupational medicine. Following an approach used in previous research, we linked diagnosis codes with antibiotic drug dispensations, classified across a spectrum of appropriateness (always, sometimes never, no diagnosis code).

RESULTS

We identified 3 114 400 antibiotic prescriptions dispensed to 1 351 193 adult patients by 5577 physicians. Of these prescriptions, 253 038 (8.1%) were "always appropriate," 1 168 131 (37.5%) were "potentially appropriate," 1 219 709 (39.2%) were "never appropriate," and 473 522 (15.2%) were not associated with an ICD-9-CM billing code. Among all dispensed antibiotic prescriptions, amoxicillin, azithromycin and clarithromycin were the most commonly prescribed drugs labelled "never appropriate."

INTERPRETATION

We found that nearly 40% of prescriptions dispensed to 1.35 million adult patients in Alberta's community-based settings over a 35-month period were inappropriate. This finding suggests that additional policies and programs to improve stewardship among physicians prescribing antibiotics for adult outpatients in Alberta may be warranted.

Circular Health: exploiting the SDG roadmap to fight AMR

Circular Health is a novel approach to address complex health issues that is based on the expansion of the One Health Paradigm. Circular health recognizes the need for a multidisciplinary convergence effort to complement the biomedical dimension of health. Antimicrobial resistance (AMR) is one of the greatest global concerns for public health that is likely on the rise, given the extensive use of antibiotics during the early Covid-19 years. Prior to the Covid-19 pandemic, an expert group chaired by Jim O'Neill published "The Review on Antimicrobial Resistance", which contains a final report and recommendations on how to tackle AMR. The report, for the first time, considers AMR from a multi-perspective viewpoint highlighting how it cannot be successfully addressed unless there is a converging approach encompassing many dimensions of the problem. In this perspective, we propose to include the recommendations from that seminal report and other more recent reviews which include the lessons learnt from the Covid-19 pandemic, into the operational framework of the sustainable development goals (SDGs). AMR represents a perfect case study to explore how the SDG roadmap has the potential of becoming the driving force and implementation tool to address complex health issues by pursuing the optimization of resources and actions via a convergent and multi-stakeholder approach. The implementation of health-related policies through the whole spectrum of the SDGs could be both a novel and a well-established framework to inform multi-dimensional policies for more sustainable health in the future.

Prevalence and Antibiotic Resistance Pattern of Streptococcus, Staphylococcus, Neisseria meningitidis and Enterobacteriaceae in Two Reference Hospitals of Yaoundé: An Overview before and during COVID-19 Pandemic Era

The COVID-19 pandemic led to tremendously use of antimicrobial due to the lack of proper treatment strategies, raising concerns about emergence of antimicrobial resistance (AMR). This study aimed at determining the prevalence and antibiotic resistance pattern of selected bacteria isolates in 02 referral health facilities in Yaoundé before and during the COVID-19 pandemic era. We conducted a retrospective study over a period of 03 years (from 1 January 2019 to 31 December 2021) in the bacteriology units of the Central and General Hospitals of Yaoundé, Cameroon. Data on bacteria genera (Streptococcus, Staphylococcus, Neisseria meningitidis and Enterobacteriaceae) as well as their corresponding specifics antibiotics: Cefixime, azythromycin and erythromycin were obtained from laboratory records. The global resistance rate of bacteria as well as their correlation with antibiotics according to COVID-19 pandemic era was determined and compared. For p < 0.05, the difference was statistically significant. In all, 426 bacterial strains were included. It appeared that the highest number of bacteria isolates and lowest rate of bacterial resistance were recorded during the pre-COVID-19 period in 2019 (160 isolates vs. 58.8% resistance rate). Conversely, lower bacteria strains but greater resistance burden were recorded during the pandemic era (2020 and 2021) with the lowest bacteria amount and peak of bacteria resistance registered in 2020, the year of COVID-19 onset (120 isolates vs. 70% resistance in 2020 and 146 isolates vs. 58.9% resistance in 2021). In contrast to almost all others groups of bacteria where the resistance burden was quite constant or decreasing over years, the Enterobacteriaceae exhibited greater resistance rate during the pandemic period [60% (48/80) in 2019 to 86.9% (60/69) in 2020 and 64.5% (61/95) in 2021)]. Concerning antibiotics, unlike erythromycin, azythromycin related resitance increased during the pandemic period and the resistance to Cefixim tends to decrease the year of the pandemic onset (2020) and re-increase one year therafter. A significant association was found between resistant Enterobacteriaceae strains and cefixime (R = 0.7; p = 0.0001) and also, between resistant Staphylococcus strains and erythromycin (R = 0.8; p = 0.0001). These retrospective data showed a herogeneous MDR bacteria rate and antibiotic resistance pattern over time before and during the COVID-19 pandemic era suggesting that antimicrobial resistance needs to be more closely monitored.

GENDER-RELATED VARIATIONS IN PATHOPHYSIOLOGICAL RESPONSES TO METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS PNEUMONIA AND SEPSIS

ABSTRACT

In preclinical studies, the protective effects of female sex hormones and the immunosuppressive effects of male sex hormones were demonstrated. However, gender-related differences in multiorgan failure and mortality in clinical trials have not been consistently explained. This study aims to investigate gender-related differences in the development and progression of sepsis using a clinically relevant ovine model of sepsis. Adult Merino male (n=7) and female (n=7) sheep were surgically prepared with multiple catheters before the study. To induce sepsis, bronchoscopy instilled methicillin-resistant Staphylococcus aureus into sheep's lungs. The time from the bacterial inoculation until the modified Quick Sequential Organ Failure Assessment (q-SOFA) score became positive was measured and analyzed primarily. We also compared the SOFA score between these male and female sheep over time. Survival, hemodynamic changes, the severity of pulmonary dysfunction, and microvascular hyperpermeability were also compared. The time from the onset of bacterial inoculation to the positive q-SOFA in male sheep was significantly shorter than in female sheep. Mortality was not different between these sheep (14% vs. 14%). There were no significant differences in hemodynamic changes and pulmonary function between the two groups at any time point. Similar changes in hematocrit, urine output, and fluid balance were observed between females and males. The present data indicate that the onset of multiple organ failure and progression of sepsis is faster in male sheep than in female sheep, even though the severity of cardiopulmonary function is comparable over time. Further studies are warranted to validate the above results.

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.

Sex-dependent obesogenic effect of tetracycline on Drosophila melanogaster deteriorated by dysrhythmia

Antibiotics have been identified as obesogens contributing to the prevalence of obesity. Moreover, their environmental toxicity shows sex dependence, which might also explain the sex-dependent obesity observed. Yet, the direct evidence for such a connection and the underlying mechanisms remain to be explored. In this study, the effects of tetracycline, which is a representative antibiotic found in both environmental and food samples, on Drosophila melanogaster were studied with consideration of both sex and circadian rhythms (represented by the eclosion rhythm). Results showed that in morning-eclosed adults, tetracycline significantly stimulated the body weight of females (AM females) at 0.1, 1.0, 10.0 and 100.0 µg/L, while tetracycline only stimulated the body weight of males (AM males) at 1.0 µg/L. In the afternoon-eclosed adults, tetracycline significantly stimulated the body weight of females (PM females) at 0.1, 1.0 and 100.0 µg/L, while it showed more significant stimulation in males (PM males) at all concentrations. Notably, the stimulation levels were the greatest in PM males among all the adults. The results showed the clear sex dependence of the obesogenic effects, which was diminished by dysrhythmia. Further biochemical assays and clustering analysis suggested that the sex- and rhythm-dependent obesogenic effects resulted from the bias toward lipogenesis against lipolysis. Moreover, they were closely related to the preference for the energy storage forms of lactate and glucose and also to the presence of excessive insulin, with the involvement of glucolipid metabolism. Such relationships indicated potential bridges between the obesogenic effects of pollutants and other diseases, e.g., cancer and diabetes.

Healthcare System Distrust and Non-Prescription Antibiotic Use: A Cross-Sectional Survey of Adult Antibiotic Users

Antibiotic resistance is a major public health concern driven by antibiotic overuse. Antibiotic stewardship programs are often limited to clinical settings and do little to address non-prescription antibiotic use in community settings. This study investigates the association between non-prescription antibiotic use and healthcare system distrust in the United States and Mexico. An online survey was deployed in the United States and Mexico with enhanced sampling through in-person recruiting in the border region. Non-prescription antibiotic use was defined as having bought or borrowed non-prescription oral or injectable antibiotics within the last 3 years. The survey included a previously validated 10-item scale to measure healthcare system distrust. Logistic regression was used to model the use of non-prescription antibiotics by the level of healthcare system distrust, adjusted for demographic characteristics and antibiotic knowledge. In total, 568 survey participants were included in the analysis, 48.6% of whom had used non-prescription oral or injectable antibiotics in the last 3 years. In the fully adjusted regression model, the odds of using non-prescription antibiotics were 3.2 (95% CI: 1.8, 6.1) times higher for those in the highest distrust quartile versus the lowest. These findings underscore the importance of community-based antibiotic stewardship and suggest that these programs are particularly critical for communities with high levels of healthcare system distrust.

Tackling AMR from a multidisciplinary perspective: a primer from education and psychology

Antimicrobial resistance (AMR) is currently one of the most concerning threats in public health. The efforts to tackle the problem require a global One Health approach, using multidisciplinary approaches and a thorough understanding of the topic both by the general public and the experts. Currently, the lack of a shared mental model of the problem, the absence of a sense of responsibility amongst the different actors and a deficient education on the topic burden the efforts to slow down the emergency and spread of antimicrobial resistant infections. We here propose a multidisciplinary approach to tackle the AMR problem, taking into consideration not only the input from the biological and medical sciences but also the input from the social sciences. Specifically, we suggest strategies from education and psychology to increase awareness about antimicrobial resistance and to implement more effective interventions. Finally, we advocate for a comprehensive and a solidaristic model as the only solution for a problem which knows no borders. As such, political will and international cooperation will be key to achieve the desired change in antibiotic resistance trend.

Antibiotic Prescriptions in Lung Cancer and Melanoma Populations: Differences With Potential Clinical Implications in the Immunotherapy Era

INTRODUCTION

Antibiotic exposure is associated with worse clinical outcomes in patients receiving immune checkpoint inhibitors (ICI). We analyzed antibiotic prescription patterns in lung cancer and melanoma, two malignancies in which ICI are used broadly across stages.

METHODS

We performed a retrospective cohort study of adults in the U.S. Veterans Affairs (VA) medical system diagnosed with lung cancer or melanoma from 2003 to 2016. We defined antibiotic exposure as receipt of a prescription for a systemic antibacterial agent between 6 months before and 6 months after cancer diagnosis. Demographics, clinical variables, prescriptions, and diagnostic codes were abstracted from the VA Corporate Data Warehouse. Antibiotic exposure was compared using t tests, Chi-square, and multivariate analyses.

RESULTS

A total of 310,321 patients (280,068 lung cancer, 30,253 melanoma) were included in the analysis. Antibiotic exposure was more common among patients with lung cancer (42% vs. 24% for melanoma; P < .001). Among antibiotic-exposed patients, those with lung cancer were more likely to receive prescriptions for multiple antibiotics (47% vs. 30% for melanoma; P < .001). In multivariate analyses, antibiotic exposure was associated with lung cancer diagnosis (HR 1.50; 95% CI, 1.46-1.55), comorbidity score (HR 1.08; 95% CI, 1.08-1.09), non-white race (HR 1.11; 95% CI, 1.06-1.17), and female gender (HR 1.31; 95% CI, 1.24-1.37).

CONCLUSION

Among cancer patients, antibiotics are prescribed frequently. Antibiotic exposure is more common in certain cancer types and patient populations. Given the negative effect antibiotic exposure has on immunotherapy outcomes, these observations may have clinical and healthy policy implications.

National Disparities in Antibiotic Prescribing by Race, Ethnicity, Age Group, and Sex in United States Ambulatory Care Visits, 2009 to 2016

While efforts have been made in the United States (US) to optimize antimicrobial use, few studies have explored antibiotic prescribing disparities that may drive future interventions. The objective of this study was to evaluate disparities in antibiotic prescribing among US ambulatory care visits by patient subgroups. This was a retrospective, cross-sectional study utilizing the National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was described as antibiotic visits per 1000 total patient visits. The appropriateness of antibiotic prescribing was determined by ICD-9 or ICD-10 codes assigned during the visit. Subgroup analyses were conducted by patient race, ethnicity, age group, and sex. Over 7.0 billion patient visits were included; 11.3% included an antibiotic prescription. Overall and inappropriate antibiotic prescription rates were highest in Black (122.2 and 78.0 per 1000) and Hispanic patients (138.6 and 79.8 per 1000). Additionally, overall antibiotic prescription rates were highest in patients less than 18 years (169.6 per 1000) and female patients (114.1 per 1000), while inappropriate antibiotic prescription rates were highest in patients 18 to 64 years (66.0 per 1000) and in males (64.8 per 1000). In this nationally representative study, antibiotic prescribing disparities were found by patient race, ethnicity, age group, and sex.

Bacterial infections epidemiology and factors associated with multidrug resistance in the northern region of Ghana

Bacterial infections caused by multidrug resistant organisms are a major global threat. There is still a knowledge gap on this situation in the Northern Region of Ghana. This study determined the prevalence and resistance profile of bacterial infections. It also identified factors associated with multidrug resistance in the study area. This was a retrospective cross-sectional design and it analyzed data from the samples received at the Tamale Zonal Public Health Reference Laboratory from June 2018 to May 2022. The data were analyzed using the R software version 4.2.0. Univariate and multivariable binary logistic regression analyses were used to determine the factors associated with multidrug resistance. The samples included all specimen types possible. The specimens were collected for the purpose of clinical bacteriology diagnostics. Overall a total of 1222 isolates were obtained. The three (3) main bacteria responsible for infections were: Klebsiella spp. (27%), Moraxella spp. (22%), Escherichia spp. (16%). High resistance levels were found against the tested antibiotics and about 41.60% of the bacterial strains isolated were multidrug resistant. Hospitalization was associated with multidrug resistance in univariate (COR 1.96; 95% CI 1.43-2.71; P-value < 0.001) and multivariable analyses (AOR 1.78; 95% CI 1.28-2.49; P-value < 0.001). There is the need for further research on the molecular epidemiology of antibiotic resistance genes in the study area to effectively control the spread of multidrug resistant pathogens. In addition, efforts to build the capacity of health professionals on infection prevention and control as well as diagnostic and antimicrobial stewardship needs urgent attention.

Trends in the Bacterial Prevalence and Antibiotic Resistance Patterns in the Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Hospitalized Patients in South India

Exacerbation due to antimicrobial-drug-resistant bacteria among chronic obstructive pulmonary disease (AECOPD) patients contributes to mortality and morbidity. We examined the prevalence of the bacterial organisms and trends in drug resistance in AECOPD. In this retrospective study, between January 2016 to December 2020, among 3027 AECOPD patients, 432 (14.3%) had bacteria isolated. The regression and generalized estimating equations (GEE) were used for trends in the resistance patterns over five years, adjusting for age, gender, and comorbidities. Klebsiella pneumoniae (32.4%), Pseudomonas aeruginosa (17.8%), Acinetobacter baumannii (14.4%), Escherichia coli (10.4%), and Staphylococcus aureus (2.5%) were common. We observed high levels of drug resistance in AECOPD patients admitted to ICU (87.8%) and non-ICU (86.5%). A Cox proportional hazard analysis, observed infection with Acinetobacter baumannii and female sex as independent predictors of mortality. Acinetobacter baumannii had 2.64 (95% confidence interval (CI): 1.08−6.43) higher odds of death, compared to Klebsiella pneumoniae. Females had 2.89 (95% CI: 1.47−5.70) higher odds of death, compared to males. A high proportion of bacterial AECOPD was due to drug-resistant bacteria. An increasing trend in drug resistance was observed among females.

Survey of the Knowledge, Attitudes and Practice towards Antibiotic Use among Prospective Antibiotic Prescribers in Serbia

The complex issue of antibacterial resistance (ABR) requires actions taken with the One Health approach, involving both human and veterinarian medicine. It can spread from animals to humans through the food chain or through direct contact. Health profession students, as the future antibiotic providers, can greatly impact antibiotic-related issues in the future. The study was conducted to evaluate knowledge, attitudes and practice of future antibiotic prescribers in relation to judicious use of antibiotics. This cross-sectional, questionnaire-based study was performed on 400 students of health professions who were allowed to prescribe antibiotics of the University of Novi Sad, Serbia. Students of medicine and students of dentistry showed a significantly higher knowledge score compared to students of veterinary medicine (p = 0.001). Multivariate regression identified predictors of adequate antibiotic knowledge: being a female student (B = 0.571; p = 0.020), higher grade average (B = 1.204; p = 0.001), students of medicine (B = 0.802; p = 0.006) and dentistry (B = 0.769; p = 0.026), and students who used a complete package of antibiotics during the last infection (B = 0.974; p = 0.001) or for the period recommended by the doctor (B = 1.964; p = 0.001). Out of the total sample, self-medication was reported among 42.8% of students. The identified predictors of self-medication were: more frequent (B = 0.587; p = 0.001) and irregular (B = 0.719; p = 0.007) antibiotic use, taking antibiotics until symptoms disappeared (B = 2.142; p = 0.001) or until the bottle was finished (B = 1.010; p = 0.001) during the last infection. It seems prudent to reevaluate the educational curricula regarding antibiotic use and ABR of prospective prescribers in Serbia.

Dispensación de antibióticos en un instituto de seguridad social universitario. Corrientes, Argentina. 2020

Objetivo Caracterizar la dispensa de antibiÓticos a pacientes ambulatorios en un instituto de seguridad social universitario durante el año 2020. Método Se realizó un estudio observacional, descriptivo-correlacional de utilización de medicamentos. Para cuantificar la dispensa, se utilizó la dosis diaria definida (DDD) por 1 000 habitantes por día (DHD) y la unidad de dosis, recomendadas por la Organización Mundial de la Salud (OMS), y el valor intrínseco terapéutico potencial como indicador cualitativo, según Laporte y Tognoni. Resultados Se incluyeron 4 748 dispensaciones ambulatorias. Edad promedio: 42 años; rango: 0-94 años, con predominio del sexo femenino (55%). La mayoría pertenecían al grupo de las penicilinas (51,3%) con predominio de amoxicilina en asociaciones a dosis fija o como monofármaco (48,3%), seguida por los macrólidos (21,0%) y las fluoroquinolonas (17,0%). Se pudo apreciar un consumo potencial de 7,7 DHD, lo cual implica que, en promedio, 7 de cada 1 000 afiliados de la institución estuvo expuesto a estos agentes diariamente, con predominio de amoxicilina asociada a ácido clavulánico (2,2 DHD). Conclusión La población general de universitarios estuvo expuesta a una prescripción alta de amoxicilina en asociaciones a dosis fijas, algunas de valor inaceptable o relativa, así como también a los nuevos macrólidos y fluoroquinolonas de segunda y tercera generación. Esto requiere especial atención, porque el consumo indiscriminado a nivel ambulatorio de antibióticos de amplio espectro podría convertirse en un factor de riesgo para el desarrollo de resistencia bacteriana; implica, además, un riesgo en la aparición de eventos adversos serios y un incremento en el gasto sanitario.

Outpatient Antibiotic Prescriptions in France: Patients and Providers Characteristics and Impact of the COVID-19 Pandemic

In France, despite several successive plans to control antimicrobial resistance, antibiotic use remains high in the outpatient setting. This study aims to better understand outpatient antibiotic use and prescription in order to identify tailored targets for future public health actions. Using data from the French National Health Data System, we described and compared the individual characteristics of patients with and without an antibiotic prescription. The prescribed antibiotics (ATC-J01) were detailed and compared between 2019 and 2020. Antibiotic prescribing indicators that take prescriber activity into account were estimated and compared. Patients who were female, advanced age, and the presence of comorbidities were associated with antibiotic prescriptions. The overall prescription rate was estimated at 134 per 1000 consultations and 326 per 1000 patients seen in 2019. General practitioners (GPs), dentists and paediatricians were associated with 78.0%, 12.2% and 2.2% of antibiotic prescriptions, respectively, with high prescription rates (391, 447, and 313 p. 1000 patients seen, respectively). In comparison with 2019, this rate decreased in 2020 for paediatricians (−30.4%) and GPs (−17.9%) whereas it increased among dentists (+17.9%). The reduction was twice as high among the male prescribers than among their female counterparts (−26.6 and −12.0, respectively). The reduction in prescriptions observed in 2020 (−18.2%) was more marked in children (−35.8%) but less so among individuals ≥65 years (−13.1%) and those with comorbidities (−12.5%). The decrease in penicillin prescriptions represents 67.3% of the overall reduction observed in 2020. The heterogeneous decrease in prescriptions by age and antibiotic class could be explained by the impact of COVID-19 control measures on the spread of respiratory viruses; thus, a substantial proportion of the prescriptions avoided in 2020 is likely inappropriate, particularly among children. In order to keep the rate of prescriptions comparable to that observed in 2020, male prescribers, paediatricians and GPs should be encouraged to maintain that level, while a campaign to raise awareness of the appropriate use of antibiotics should be aimed at dentists in particular.

Population-based assessment of factors influencing antibiotic prescribing for adults with dengue infection in Taiwan

Background

Antibiotic treatment for dengue is likely considerable and potentially avoidable but has not been well characterized. This study aimed to assess antibiotic prescribing for confirmed dengue cases in outpatient and inpatient settings and to identify associated patient, physician and contextual factors.

Methods

57,301 adult dengue cases reported in Taiwan between 2008–2015 were analyzed. We assessed both outpatient and inpatient claims data of dengue patients from a week before to a week after their dengue infections were confirmed under Taiwan’s National Health Insurance program. A multivariable logistic regression with generalized estimating equations was used to estimate the probability of antibiotic prescribing in dengue patients.

Results

Overall, 24.6% of dengue patients were prescribed an antibiotic during the 14 day-assessment period. Antibiotics were prescribed in 6.1% and 30.1% of outpatient visits and inpatient admissions, respectively. Antibiotic prescriptions were reduced by ~50% in epidemic years. Among inpatients, advanced age, females, and major comorbidities were risk factors for receipt of an antibiotic; antibiotics were used in 26.0% of inpatients after dengue was diagnosed. Significant differences in antibiotic prescribing practices were observed among physicians in outpatient settings but not in inpatient settings.

Conclusions

In addition to patient and physician demographic characteristics, contextual factors such as care setting and during epidemics significantly influenced prescription of antibiotics. Characterization of prescribing patterns should help direct programs to curb antibiotic prescribing.

Antimicrobial resistance is a growing global public health threat. The non-specific clinical manifestations of dengue overlap with signs and symptoms of other febrile illnesses common to tropical and subtropical zones making differential diagnosis between dengue and bacterial infections difficult, hence, leading to potentially unnecessary antibiotic prescribing. However, our understanding of factors underlying antibiotic prescribing for dengue is rather limited. Taiwan has experienced periodic dengue outbreaks and has a comprehensive national health insurance database including reliable infectious diseases surveillance and prescribing records. The findings in Taiwan show that other than commonly known patient characteristics, provider and contextual factors play a significant role. Physician’s age and practice setting were significant factors influencing the decision to prescribe antibiotics, particularly in outpatient visits. The likelihood of prescribing an antibiotic to dengue patients was reduced by more than 50% in medical visits occurring after the dengue infection was confirmed. Understanding patient, provider and contextual factors in antibiotics prescription for dengue infections can provide insights for improved antibiotic stewardship and unnecessary antibiotic treatment for dengue.

The Gut Microbiome in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS)

Myalgic encephalomyelitis (ME) or Chronic Fatigue Syndrome (CFS) is a neglected, debilitating multi-systemic disease without diagnostic marker or therapy. Despite evidence for neurological, immunological, infectious, muscular and endocrine pathophysiological abnormalities, the etiology and a clear pathophysiology remains unclear. The gut microbiome gained much attention in the last decade with manifold implications in health and disease. Here we review the current state of knowledge on the interplay between ME/CFS and the microbiome, to identify potential diagnostic or interventional approaches, and propose areas where further research is needed. We iteratively selected and elaborated on key theories about a correlation between microbiome state and ME/CFS pathology, developing further hypotheses. Based on the literature we hypothesize that antibiotic use throughout life favours an intestinal microbiota composition which might be a risk factor for ME/CFS. Main proposed pathomechanisms include gut dysbiosis, altered gut-brain axis activity, increased gut permeability with concomitant bacterial translocation and reduced levels of short-chain-fatty acids, D-lactic acidosis, an abnormal tryptophan metabolism and low activity of the kynurenine pathway. We review options for microbiome manipulation in ME/CFS patients including probiotic and dietary interventions as well as fecal microbiota transplantations. Beyond increasing gut permeability and bacterial translocation, specific dysbiosis may modify fermentation products, affecting peripheral mitochondria. Considering the gut-brain axis we strongly suspect that the microbiome may contribute to neurocognitive impairments of ME/CFS patients. Further larger studies are needed, above all to clarify whether D-lactic acidosis and early-life antibiotic use may be part of ME/CFS etiology and what role changes in the tryptophan metabolism might play. An association between the gut microbiome and the disease ME/CFS is plausible. As causality remains unclear, we recommend longitudinal studies. Activity levels, bedridden hours and disease progression should be compared to antibiotic exposure, drug intakes and alterations in the composition of the microbiota. The therapeutic potential of fecal microbiota transfer and of targeted dietary interventions should be systematically evaluated.

A systematic literature review and meta-analysis of community pharmacist-led interventions to optimise the use of antibiotics

Aims

The aim of this systematic review is to assess the effects of community pharmacist‐led interventions to optimise the use of antibiotics and identify which interventions are most effective.

Methods

This review was conducted according to the PRISMA guidelines (PROSPERO: CRD42020188552). PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for (randomised) controlled trials. Included interventions were required to target antibiotic use, be set in the community pharmacy context, and be pharmacist‐led. Primary outcomes were quality of antibiotic supply and adverse effects while secondary outcomes included patient‐reported outcomes. Risk of bias was assessed using the ‘Cochrane suggested risk of bias criteria’ and narrative synthesis of primary outcomes conducted.

Results

Seventeen studies were included covering in total 3822 patients (mean age 45.6 years, 61.9% female). Most studies used educational interventions. Three studies reported on primary outcomes, 12 on secondary outcomes and two on both. Three studies reported improvements in quality of dispensing, interventions led to more intensive symptom assessment (up to 30% more advice given) and a reduction of over‐the‐counter supply up to 53%. Three studies led to higher consumer satisfaction, effects on adherence from nine studies were mixed (risk difference 0.04 [−0.02, 0.10]). All studies had unclear or high risks of bias across at least one domain, with large heterogeneity between studies.

Conclusions

Our review suggests some positive results from pharmacist‐led interventions, but the interventions do not seem sufficiently effective as currently implemented. This review should be interpreted as exploratory research, as more high‐quality research is needed.

Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis

BACKGROUND

Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use.

METHODS

National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model.

RESULTS

Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden.

CONCLUSIONS

Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.

Antibiogram of clinical isolates from primary and secondary healthcare facilities: A step towards antimicrobial stewardship

Antibiogram development and use is a core element of antimicrobial stewardship practice, such data is scarce in healthcare settings in developing countries. The study aims to determine the epidemiology of clinical isolates and their antibiograms in secondary healthcare (SHC) and primary healthcare (PHC) facilities in Benin City, Nigeria. This was a retrospective study in three laboratories in SHC and PHC facilities. Microbial culture and susceptibility report over the past 4 years was collated. Ethical Clearance was obtained from the Edo State Ministry of Health and Benin City. Data were entered and analyzed using SPSS version 22. Of the 819 isolates, urine, semen and vagina swab were most represented (50.7%; 16.1%; 13.2%). S.aureus (60.6%) and coliform organism (31.9%) were commonly isolated. High resistance of 75%->90% was seen with penicillin, cephalosporin, macrolide, aminoglycoside and floroquinolone against S. aureus, Ps aeruginosa, coliform and E. coli. Resistance to all antimicrobials was observed in 11.7% of the isolates, multidrug resistance (MDR) was found to be 61.4%. MDR for Ps aeruginosa, coliform, E coli, and staph aureus were 95.5%, 67.3% 25.6% and 82.8% respectively. In the SHC, 15.4% of isolates were resistant to all antibacterial compared to none in the PHC. There was consistent yearly increase in resistance to more than six agents in both centers. Gender difference in antimicrobial resistance was observed. High MDR observed in this study emphasizes the need for routine antibiogram and its use in updating treatment guidelines to reflect the current resistance pattern to available antimicrobials.

Impact of treatment with immunomodulators and tumour necrosis factor antagonists on the incidence of infectious events in patients with inflammatory bowel disease

BACKGROUND

Corticosteroids, immunomodulators (IM) and tumour necrosis factor antagonists (anti-TNF) are commonly used in the treatment of inflammatory bowel disease (IBD) but they also supress the defence against infectious disease. The aim of this study was to analyse the incidence of infectious events in patients with IBD and the association to concomitant medical therapy.

METHODS

We performed a retrospective medical chart review of patients with IBD aged 18-65 years included in the Swedish Registry of Inflammatory Bowel Disease in the catchment area of Umeå University Hospital, Sweden. Data were collected from the period 01 January 2006, to 31 January 2019. An infectious event was defined as an outpatient prescription of antimicrobials or a positive diagnostic test for infection.

RESULTS

During a period of 5,120 observation-years, we observed 1,394 events in 593 patients. The mean number of infectious events per 100 person-years was 27.2 (standard deviation [SD]: 0.46). There were no differences in mean incidence rates between patients treated with no immunosuppression (23.0 events per 100 person-years, SD: 50.4), patients treated with IM monotherapy (27.6 events per 100 person-years, SD: 49.9), patients treated with anti-TNF monotherapy (34.3 events per 100 person-years, SD: 50.1) and patients on combination therapy (22.5 events per 100-person-years, SD: 44.2). In a multivariate logistic regression, female gender (adjusted odds ratio [AOR]: 2.24; 95% confidence interval [CI]: 1.49-3.37) and combination therapy (AOR: 3.46; 95% CI: 1.52-7.85) were associated with higher risks of infection (>32 events per 100 person years). Also, patients treated with any immunosuppression treatment for 25-75% (AOR: 2.29; 95% CI: 1.21-4.34) and for >75% (AOR: 1.93; 95% CI: 1.19-3.12) of the observation period were at higher risks compared to patients treated with immunosuppression <25% of the observation period.

CONCLUSION

We observed no significant difference in risk for infections between patients on monotherapy with IM or anti-TNF and patients with low use of immunosuppression, but there was a significant risk for combination therapy.

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.

Changes in the Framing of Antimicrobial Resistance in Print Media in Australia and the United Kingdom (2011-2020): A Comparative Qualitative Content and Trends Analysis

Educating the public about antimicrobial resistance (AMR) is considered a key part of an optimal public health response. In both media depictions and policy discourses around health risks, how a problem is framed underpins public awareness and understanding, while also guiding opinions on what actions can and should be taken. Using a mixed methods approach we analyse newspaper content in Australia and the United Kingdom (UK) from 2011 to 2020 to track how causes, consequences and solutions to AMR are represented in countries with different policy approaches. Analyses demonstrate greater variability in the frames used in UK newspapers reflecting large hospital and community outbreaks and a sustained period of policy reform mid-decade. Newspapers in Australia focus more on AMR causes and consequences, highlighting the importance of scientific discovery, whereas UK coverage has greater discussion of the social and economic drivers of AMR and their associated solutions. Variations in the trends of different frames around AMR in UK newspapers indicate greater levels of public deliberation and debate around immediate and actionable solutions; whereas AMR has not had the same health and political impacts in Australia resulting in a media framing that potentially encourages greater public complacency about the issue.

Pattern and Appropriateness of Antimicrobial Prescriptions for Upper Respiratory Tract and Dental Infections in Male Prisoners in Italy

BACKGROUND

This study explored the antimicrobial prescribing pattern for upper respiratory tract and dental infections in prisoners in Italy, with specific attention paid to the appropriateness of indication and its potential determinants.

METHODS

This investigation was conducted through the consultation of clinical records of adult male inmates in a prison in the south of Italy.

RESULTS

Prescription of antimicrobials for upper respiratory tract infections ranged from 41.9% in influenza diagnoses to 88% in pharyngitis diagnoses, with high prevalence also for bronchitis (73.5%) and common cold (57.7%), and those for dental infections ranged from 82% in pulp necrosis and symptomatic apical periodontitis/pulp necrosis and localized acute apical abscess diagnoses, to 85.7% in symptomatic irreversible pulpitis with or without symptomatic apical periodontitis diagnoses. The most frequently prescribed antimicrobial was amoxicillin and clavulanic acid (33.8%), followed by amoxicillin (26.5%), macrolides (19.8%) and third-generation cephalosporins (7.9%). The overall antimicrobial overprescription was 69.4%, whereas an antimicrobial prescription was provided in all 52 cases in which it was indicated. The inappropriate antimicrobial prescriptions were significantly less likely for bronchitis, influenza and symptomatic irreversible pulpitis with or without symptomatic apical periodontitis compared to common cold/pharyngitis/rhinosinusitis, and when the antimicrobial prescription was provided by medical specialists compared to prison physicians, whereas antimicrobial overprescriptions without indications were significantly more frequent in patients with underlying chronic clinical conditions.

CONCLUSIONS

A concerning widespread practice of inappropriate antimicrobial prescriptions in prisoners was found. Diagnoses-specific monitoring of antimicrobial use and prison-focused antimicrobial stewardship policies are strongly needed.

Unnecessary antibiotic treatment of children hospitalised with respiratory syncytial virus (RSV) bronchiolitis: risk factors and prescription patterns

OBJECTIVES

Respiratory syncytial virus (RSV) is a leading cause of respiratory tract infections, especially in young children. Antibiotics are often unnecessarily prescribed for the treatment of RSV. Such treatments affect antibiotic resistance in future bacterial infections of treated patients and the general population. This study aimed to understand risk factors for and patterns of unnecessary antibiotic prescription in children with RSV.

METHODS

In a single-centre, retrospective study in Israel, we obtained data for children aged ≤2 years (n = 1016) hospitalised for RSV bronchiolitis during 2008-2018 and ascertained not to have bacterial co-infections. Antibiotic misuse was defined as prescription of antibiotics during hospitalisation of the study population. Demographic and clinical variables were assessed as predictors of unnecessary antibiotic treatment in a multivariable logistic regression model.

RESULTS

The unnecessary antibiotic treatment rate of children infected with RSV and ascertained not to have a bacterial co-infection was estimated at 33.4% (95% CI 30.5-36.4%). An increased likelihood of antibiotic misuse was associated with drawing bacterial cultures and with variables indicative of a severe patient status such as lower oxygen saturation, higher body temperature, tachypnoea and prior recent emergency room visit. Older age and female sex were also associated with an increased likelihood of unnecessary antibiotic treatment.

CONCLUSIONS

Unnecessary antibiotic treatment in RSV patients was very common and may be largely attributed to physicians' perception of patients' severity. Improving prescription guidelines, implementing antibiotic stewardship programmes and utilising decision support systems may help achieve a better balance between prescribing and withholding antibiotic treatment.

Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.

A kiosk survey of perception, attitudes and knowledge (PAK) of Australians concerning microbes, antibiotics, probiotics and hygiene

Issues addressed

To obtain a baseline of public perception, attitudes and knowledge (PAK) of Australians about microbes, antibiotics and hygiene like hand washing and use of probiotics.

Methods

Using a kiosk‐based survey method at the American Museum of Natural History (AMNH), we remotely assayed PAK of Australians through their interaction with the kiosk. The surveys we used had five and seven multiple answer questions and were analysed using standard comparative approaches. We also made comparisons based on gender and on age group for many of the questions.

Results

Our analyses indicate that there is a lack of general understanding of the role of microbes in everyday life among Australians. In addition, we detected some basic misunderstandings about antibiotics. While 80% of the respondents identified penicillin as an antibiotic, up to 30% of the respondents wrongly identified aspirin, Tylenol, valium and Benadryl as antibiotics. We also detected a general lack of knowledge about hand washing hygiene and probiotic use.

Conclusions

Our results from around 700 Australian respondents can serve as a baseline for further PAK assessment of Australians. PAK of Australians with respect to microbes and hand washing hygiene is poor therefore public education is needed. This study should stimulate a better roadmap for public education about microbes, antibiotics, probiotics and hygiene.

So what?

With the recent spread of SARS‐Cov2 and the ensuing Covid19 pandemic and the continuing rise in antimicrobial resistance, the need for assessment PAK of microbes and infectious disease has become acute.

Assessment of prescribing patterns of antibiotics using National Treatment Guidelines and World Health Organization prescribing indicators at the Ghana Police Hospital: a pilot study

INTRODUCTION

irrational or inappropriate prescribing of antibiotics is a major problem in healthcare and leads to antibiotic resistance. There is the need to understand the prescribing patterns and antibiotic stewardship in health facilities to support appropriate antibiotic use. A study was carried out to evaluate prescribing pattern of antibiotics at the Ghana Police Hospital using National Standard Treatment Guidelines (STG) and World Health Organization (WHO) prescribing indicators.

METHODS

a cross-sectional descriptive study was conducted at the Ghana Police Hospital. Data on prescriptions of antibiotics for both out-patients and in-patients was collected between December 2019 and March 2020. A pretested self-designed tool was used for data collection. All sampled prescriptions were assessed for appropriateness using the STG of 2017 and WHO "AWaRe" classification. The criteria used in assessment included dose, frequency, duration of treatment and choice of antibiotic prescribed for disease condition. Descriptive statistics were used in data analysis.

RESULTS

a total of 184 patient prescriptions (286 antibiotics) were included in this study. Results showed that antibiotics were mostly prescribed for dental and dental-related conditions (20.7%) and obstetric post-delivery prophylaxis (18.1%). Appropriateness of indicators for antibiotics prescribed assessed ranged between 89.2% to 97.6%. The most frequently prescribed antibiotics were metronidazole (25.9%), amoxicillin with clavulanic acid (22.0%), amoxicillin (16.4%) and ciprofloxacin (10.1%). Based on WHO "AWaRe" classification, the "access" group of antibiotics (74%) was the most prescribed, followed by "watch" group (24%). There were no antibiotics prescribed from the "reserve" group of antibiotics and another 2% that was not part of AwaRe classification.

CONCLUSION

study revealed that the level of appropriateness for prescribing indicators assessed was relatively high and majority of prescribed antibiotics were from the "access" and "watch" group. These observations suggest responsible prescribing of antibiotics at the Ghana Police Hospital and effective antibiotic stewardship should be sustained and improved.

Impact of Social, Economic, and Healthcare Factors on the Regional Structure of Antibiotic Consumption in Primary Care in Poland (2013-2017)

Antibiotic resistance is one of the most important public health threats worldwide. Antimicrobial misuse and overuse are well-recognized risk factors for the resistance emergence and spread. Monitoring of antibiotic consumption (AC) is an important element in strategies to combat antibiotic resistance. As a result of AC surveillance in Poland, regional differences in AC levels were observed. This study aimed to characterize the regional AC in the period 2013–2017 in primary care in Poland and to assess the possible determinants that influence the AC at the regional level. The study analyzed relationships between AC and its factors (grouped in three different categories: demographic, economic, and related to the organization of healthcare). Data covered AC in primary care in 5 years period (2013–2017) from all 16 Polish voivodeships. The AC primary care data were sales data, expressed in defined daily doses (DDD) according to the WHO methodology. The yearly data on demographic, economic, and related healthcare factors were downloaded from the Central Statistical Office of Poland. Standard statistical parameters were used to characterize the AC. Non-standardized regression coefficients were used to estimate the quantitative dependence of variables. The strongest correlation was demonstrated with factors related to employment, female reproductive activity, mobility of the population, the number of outpatient consultations, and the number of dentists. A correlation was also found between population mobility and density. Recognized risk factors for increased AC should be a priority for interventions implementing and disseminating rational antibiotic policy.

Risk of Hospitalization for Adverse Drug Events in Women and Men: A Post Hoc Analysis of an Active Pharmacovigilance Study in Italian Emergency Departments

This post hoc analysis of an Italian active pharmacovigilance study describes pharmacological differences of ADEs leading to emergency department (ED) visits and hospitalization in women and men. During the study period (January 2007-December 2018), 61,855 reports of ADEs leading to ED visits were collected. Overall, 30.6% of ADEs resulted in hospitalization (30% in women and 31% in men). Multivariate logistic regression showed that, among women, drug classes significantly associated with an increased risk of hospitalization were heparins (ROR 1.41, CI 1.13-176), antidepressants (ROR 1.12, CI 1.03-1.23) and antidiabetics (ROR 1.13, CI 1.02-1.24). Among men, only vitamin K antagonists (ROR 1.28, CI 1.09-1.50), opioids (ROR 1.30, CI 1.06-1.60) and digitalis glycosides (ROR 1.32, CI 1.09-1.59) were associated with a higher risk of hospitalization. Overall, older age, multiple suspected drugs and the presence of comorbidities were significantly associated with a higher risk of hospitalization. A significantly reduced risk of hospitalization was observed in both women and men experiencing an adverse event following immunization (ROR 0.36, CI 0.27-0.48 and 0.83, 0.42-0.74, respectively) compared to drugs. Results obtained from this real-world analysis highlight important aspects of drug safety between sexes.

The infant gut resistome is associated with E. coli and early-life exposures

BACKGROUND

The human gut microbiome harbors a collection of bacterial antimicrobial resistance genes (ARGs) known as the resistome. The factors associated with establishment of the resistome in early life are not well understood. We investigated the early-life exposures and taxonomic signatures associated with resistome development over the first year of life in a large, prospective cohort in the United States. Shotgun metagenomic sequencing was used to profile both microbial composition and ARGs in stool samples collected at 6 weeks and 1 year of age from infants enrolled in the New Hampshire Birth Cohort Study. Negative binomial regression and statistical modeling were used to examine infant factors such as sex, delivery mode, feeding method, gestational age, antibiotic exposure, and infant gut microbiome composition in relation to the diversity and relative abundance of ARGs.

RESULTS

Metagenomic sequencing was performed on paired samples from 195 full term (at least 37 weeks' gestation) and 15 late preterm (33-36 weeks' gestation) infants. 6-week samples compared to 1-year samples had 4.37 times (95% CI: 3.54-5.39) the rate of harboring ARGs. The majority of ARGs that were at a greater relative abundance at 6 weeks (chi-squared p < 0.01) worked through the mechanism of antibiotic efflux. The overall relative abundance of the resistome was strongly correlated with Proteobacteria (Spearman correlation = 78.9%) and specifically Escherichia coli (62.2%) relative abundance in the gut microbiome. Among infant characteristics, delivery mode was most strongly associated with the diversity and relative abundance of ARGs. Infants born via cesarean delivery had a trend towards a higher risk of harboring unique ARGs [relative risk = 1.12 (95% CI: 0.97-1.29)] as well as having an increased risk for overall ARG relative abundance [relative risk = 1.43 (95% CI: 1.12-1.84)] at 1 year compared to infants born vaginally.

CONCLUSIONS

Our findings suggest that the developing infant gut resistome may be alterable by early-life exposures. Establishing the extent to which infant characteristics and early-life exposures impact the resistome can ultimately lead to interventions that decrease the transmission of ARGs and thus the risk of antibiotic resistant infections.

Sex disparities matter in cancer development and therapy

Curing cancer through precision medicine is the paramount aim of the new wave of molecular and genomic therapies. Currently, whether patients with non-reproductive cancers are male or female according to their sex chromosomes is not adequately considered in patient standard of care. This is a matter of consequence because there is growing evidence that these cancer types generally initiate earlier and are associated with higher overall incidence and rates of death in males compared with females. Gender, in contrast to sex, refers to a chosen sexual identity. Hazardous lifestyle choices (notably tobacco smoking) differ in prevalence between genders, aligned with disproportionate cancer risk. These add to underlying genetic predisposition and influences of sex steroid hormones. Together, these factors affect metabolism, immunity and inflammation, and ultimately the fidelity of the genetic code. To accurately understand how human defences against cancer erode, it is crucial to establish the influence of sex. Our Perspective highlights evidence from basic and translational research indicating that including genetic sex considerations in treatments for patients with cancer will improve outcomes. It is now time to adopt the challenge of overhauling cancer medicine based on optimized treatment strategies for females and males.