Results from the Survey of Antibiotic Resistance (SOAR) 2012-14 in Thailand, India, South Korea and Singapore

Dispensing of antibiotics for tuberculosis patients using standardized patient approach at community pharmacies: results from a cross-sectional study in Pakistan

Background

Pakistan is among top countries for antibiotic consumption around the globe and patients often receive antibiotics directly from community pharmacies. Thus, our aim was to assess the drug dispensing practices of pharmacies for presumed and confirmed tuberculosis by using standardized patients' method in Pakistan.

Methods

In this cross-sectional study, we adopted two standardized patient cases in pharmacies of three cities of Punjab. The first case involved a presumed tuberculosis patient presenting with 2-3 weeks of cough and fever (Case-1), and the second case involved a confirmed tuberculosis patient carrying microbiologically confirmed tuberculosis results (Case-2). The ideal management for Cases-1 and Case-2 is referral of standardized patients to a healthcare provider without dispensing antibiotics or steroids, or both. The differences in antibiotic use, steroid use, and the number of medicines dispensed in referred and non-referred patients between Case-1 and Case-2 were analyzed using descriptive statistics.

Results

Between April 1, 2020, and July 31, 2020, standardized patients completed 575 out of 598 interactions among community pharmacies in Lahore, Rawalpindi, and Sialkot. We recorded ideal management in 115 (37.7%) of the 305 Case-1 interactions and 130 (48.1%) of the 270 Case-2 interactions. Antibiotic dispensing was higher in Case-1, with 71 out of 305 instances (23.3%), than in Case-2 interactions, with 27 out of 270 instances (10.0%). Anti-tuberculosis drugs were dispensed to 1 patient in Case-1 (0.3%) and to 19 patients (7.0%) in Case-2.

Conclusion

Slightly more than one-third of pharmacies in Punjab, Pakistan, ideally managed patients with presumed tuberculosis, but almost half of them ideally managed cases of confirmed tuberculosis. The presence of confirmed diagnosis slightly changes the behavior in the correct management of patients.

Invasive Pneumococcal Diseases in Korean Adults After the Introduction of Pneumococcal Vaccine into the National Immunization Program

Although Streptococcus pneumoniae has been one of the most common bacterial causes of disease in humans, its impact has been blunted by the broad use of vaccines. Since 2018, the incidence of invasive pneumococcal disease in Korea decreased with effective pneumococcal vaccines but is on the rise again recently. In this paper I will review the epidemiology, risk factors, and antibiotic resistance of invasive pneumococcal disease after the introduction of the pneumococcal vaccine in Korean adults.

Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study

As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32-38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39-47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23-31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27-32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35-43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15-22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized.

Bacterial Epidemiology and Antimicrobial Resistance Profiles of Respiratory Specimens of Children with Pneumonia in Hainan, China

Purpose

To investigate the bacterial species and antimicrobial susceptibility of respiratory specimens of children with pneumonia in Hainan, China.

Methods

A total of 5017 specimens, including 4986 sputum samples, 19 bronchoalveolar lavage fluid samples and 12 tracheal tube tip samples from hospitalized children with pneumonia from April 1, 2021 to March 31, 2022 were studied. All the bacterial isolates were identified and confirmed with the VITEK 2 system. Antimicrobial susceptibility of all isolates was determined using the Kirby-Bauer method or the VITEK 2 Compact automatic system, following the breakpoints recommended by the Clinical and Laboratory Standards Institute.

Results

A total of 996 bacterial isolates were collected and classified into 24 species. The top 10 most frequent species were Haemophilus influenzae (356 isolates, 35.7%), Streptococcus pneumoniae (128, 12.9%), Moraxella catarrhalis (114, 11.5%), Escherichia coli (89, 8.9%), Staphylococcus aureus (89, 8.9%), Klebsiella pneumoniae (82, 8.2%), Acinetobacter baumannii (31, 3.1%), Pseudomonas aeruginosa (28, 2.8%), Enterobacter cloacae (18, 1.8%), and Streptococcus agalactiae (13, 1.3%). 70.5% strains had the resistant (R) and/or intermediate (I) phenotypes to at least one of the tested drugs, with a large proportion (54.6%) showing resistance to two or more commonly used antibiotics. In addition, 60.5% (69/114) of M. catarrhalis strains and 42.9% (153/356) of H. influenzae strains produced β-lactamases while 19.1% (17/89) E. coli and 6.1% (5/82) K. pneumoniae strains produced extended-spectrum β-lactamases.

Conclusion

A diversity of pathogenic bacteria were isolated from the respiratory tract of children with pneumonia in Hainan, China. High-frequency resistance to first-line antimicrobial drugs was observed in Gram-negative and Gram-positive bacteria, including 544 isolates resistant to at least two antibiotics. Rapid identification and susceptibility testing should be implemented for children with bacterial pneumonia in Hainan before drug treatment is recommended.

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

Background

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

Objectives

To review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes.

Methods

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

Conclusions

Many initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Relevance of the Consensus Principles for Appropriate Antibiotic Prescribing in 2022

Background

In the late 1990s, as a response to rising antimicrobial resistance (AMR), an independent multinational, interdisciplinary group was formed specifically targeting primary care antibiotic prescribing for community-acquired respiratory tract infections (CA-RTIs). The group comprised senior clinicians from Canada, Israel, Spain, Sweden, UK and USA. The group’s objectives were to provide recommendations for antibiotic stewardship in the community because, whilst it was widely accepted that inappropriate antibiotic use was contributing to AMR, it remained difficult to change prescribing behaviour. The group aimed to identify principles underlying appropriate antibiotic prescribing and guideline formulation to reduce morbidity from CA-RTIs, limit therapeutic failure and, importantly, curb AMR emergence. The group published a report in 2002, which has become known as the Consensus Principles.

Objectives

(i) To consider the relevance of the Consensus Principles in 2022 by reviewing current global approaches to rising AMR. A wide range of factors, such as antibiotic overuse, most recently seen in COVID-19 patients, are still driving rising AMR even though there has been a high-level international response to the AMR threat; and (ii) as an introduction to this Supplement, which reports the findings of analyses of how AMR is being addressed in nine disparate countries (Brazil, India, Kuwait, Mexico, Pakistan, Russia, Saudi Arabia, Türkiye and Vietnam). Understanding how these initiatives are being pursued in different countries helps identify areas where more information is needed.

Conclusions

Adherence to the Consensus Principles remains as important now as it was in 2002. Achieving appropriate antibiotic prescribing is a vital objective in order that the right patient receives the right antibiotics at the right time to ensure optimal clinical outcomes while at the same time helping to limit further increases in AMR.

Distribution and Drug Resistance of Bacterial Pathogens Associated with Lower Respiratory Tract Infection in Children and the Effect of COVID-19 on the Distribution of Pathogens

By studying the distribution and drug resistance of bacterial pathogens associated with lower respiratory tract infection (LRTI) in children in Chengdu and the effect of the COVID-19 on the distribution of pathogens and by analyzing the epidemic trend and drug resistance changes of the main pathogens of LRTI, this research is supposed to provide a useful basis for the prevention of LRTI in children and the rational use of drugs in clinical practice. Hospitalized children clinically diagnosed with LRTI in Chengdu Women and Children's Central Hospital from 2011 to 2020 were selected as the study subjects. The pathogens of LRTI in children and the distribution of pathogens in different ages, genders, seasons, years, and departments and before and after the pandemic situation of COVID-19 were counted. The drug resistance distribution of the top six pathogens with the highest infection rate in the past three years and the trend of drug resistance in the past decade were analyzed. A total of 26,469 pathogens were isolated. Among them, 6240 strains (23.6%) were Gram-positive bacteria, 20152 strains (76.1%) were Gram-negative bacteria, and 73 strains (0.3%) were fungi. Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, and Staphylococcus aureus were highly isolated in the group of infants aged 0-1 (P < 0.01), Moraxella catarrhalis and Streptococcus pneumoniae were highly isolated in children aged 1–6 (P < 0.01), and Haemophilus influenzae was highly isolated in children over 1 (P < 0.01). The isolation rates of Enterobacteriaceae, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Staphylococcus aureus, and Candida albicans in the lower respiratory tract of 0-1 year-old male infants were higher than those of female infants (p < 0.05). Haemophilus influenzae was highly isolated in spring and summer, and Moraxella catarrhalis was highly isolated in autumn and winter, while the infection of Streptococcus pneumoniae was mainly concentrated in winter. This difference was statistically significant (P < 0.01). Affected by the COVID-19 pandemic, the isolation rates of Haemophilus influenzae and Streptococcus pneumoniae were significantly lower than those before the pandemic, and the isolation rate of Moraxella catarrhalis was significantly higher. The difference was statistically significant (P < 0.01). The proportion of isolated negative bacteria in NICU and PICU was higher than that in positive bacteria, and the infection rates of Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, and Acinetobacter baumannii were higher than those in other departments. The differences were statistically significant (P < 0.01). The results of drug sensitivity test showed that the drug resistance of Haemophilus influenzae and Moraxella catarrhalis was mainly concentrated in Ampicillin, First- and Second-generation cephalosporins, and Cotrimoxazole, with stable sensitivity to Third-generation cephalosporins, while the drug resistance of Streptococcus pneumoniae was concentrated in Macrolides, Sulfonamides, and Tetracyclines, with stable sensitivity to Penicillin. Staphylococcus aureus is highly resistant to penicillins and macrolides and susceptible to vancomycin. Enterobacteriaceae resistance is concentrated in cephalosporins, with a low rate of carbapenem resistance. From 2018 to 2020, 1557 strains of Staphylococcus aureus were isolated, of which 416 strains were MRSA, accounting for 27% of the isolates; 1064 strains of Escherichia coli were isolated, of which 423 strains were ESBL and 23 strains were CRE, accounting for 40% and 2% of the isolates, respectively; and 1400 strains of Klebsiella pneumoniae were isolated, of which 385 strains were ESBL and 402 strains were CRE, accounting for 28% and 29% of the isolates, respectively. Since 2011, the resistance of Escherichia coli and Klebsiella pneumoniae to Third-generation cephalosporins has increased, peaking in 2017, and has decreased after 2018, years after which carbapenem resistance has increased significantly, corresponding to an increase in the detection rate of Carbapenem-resistant Enterobacteriaceae CRE. Findings from this study revealed that there are significant differences in community-associated infectious pathogens before and after the COVID-19 pandemic, and there are significant age differences, seasonal epidemic trends, and high departmental correlation of pathogens related to lower respiratory tract disease infection in children. There was a significant gender difference in the isolation rate of pathogens associated with LRTI in infants under one year. Vaccination, implementation of isolation measures and social distance, strengthening of personal protective measures, aseptic operation of invasive medical treatment, hand hygiene, and environmental disinfection are beneficial to reducing community-associated pathogen infection, opportunistic pathogen infection, and an increase in resistant bacteria. The strengthening of bacterial culture of lower respiratory tract samples by pediatricians is conducive to the diagnosis of respiratory tract infections caused by different pathogens, contributing to the selection of effective drugs for treatment according to drug susceptibility results, which is important for the rational use of antibiotics and curbing bacterial resistance.

Point Prevalence Survey of Antimicrobial Utilization in a Tertiary Care Teaching Hospital and a Comprehensive Comparative Analysis of PPS across India

This study assessed antimicrobial prescription at our institute to promote rational antimicrobial use and implement customized antimicrobial stewardship programs. This study is a cross sectional point-prevalence survey on antimicrobial utilisation conducted at HAH Centenary hospital, New Delhi in April, 2019, over a period of 3 days. All in-patients were included in the analysis. However, neonates, emergency room patients and palliative care patients, orders for anti-viral, anti-fungal, anti-tubercular and anti-parasitic medications were excluded. SPSS version 13.0 was planned to be used for analysis of the statistical data. The number of patients admitted at the point of time of our survey was 217, out of which 101 (46.54%) patients were receiving antimicrobial agents (AMA) with 160 (73.73%) AMAs prescribed. 50 patients (49.5%) were prescribed AMAs for infections, whereas, 49 patients (48.51%) were prescribed AMAs prophylactically and 2 (1.98%) patients received AMAs for reasons not defined. The intensive care units exhibited 93.33% patients receiving antimicrobials. The most common indication was intra-abdominal infections (32.40%). The most commonly used antibiotics were beta-lactam antibiotics (60.62%). The study suggests a high rate of antimicrobial use and highlights areas for intervention for rational antimicrobial use. We propose to sensitise the government on initiating a national antimicrobial stewardship program such as the Global Point Prevalence Survey and facilitate evidence-based antimicrobial practice.

Results from the Survey of Antibiotic Resistance (SOAR) 2016-18 in Vietnam, Cambodia, Singapore and the Philippines: data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates collected from community-acquired respiratory tract infections (CA-RTIs) in 2016-18 in four Asian countries.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

In total, 260 S. pneumoniae and 258 H. influenzae isolates were tested. Pneumococci from Vietnam (n = 161) were the least susceptible, with rates of susceptibility >90% for fluoroquinolones by CLSI breakpoints, ∼60% for amoxicillin, amoxicillin/clavulanic acid and ceftriaxone but <14% for most other agents. Pneumococcal isolates from Cambodia (n = 48) and Singapore (n = 34) showed susceptibilities ranging from ∼30% for trimethoprim/sulfamethoxazole and oral penicillin to 100% for fluoroquinolones. Among isolates of H. influenzae from Cambodia (n = 30), the Philippines (n = 59) and Singapore (n = 80), rates of susceptibility using CLSI breakpoints were >90% for amoxicillin/clavulanic acid, cephalosporins [except cefaclor in Singapore (77.5%)], macrolides and fluoroquinolones; for isolates from Vietnam (n = 89) the rates of susceptibility were >85% only for amoxicillin/clavulanic acid (95.5%), ceftriaxone (100%) and macrolides (87.6%-89.9%). Susceptibility to other antibiotics ranged from 7.9% (trimethoprim/sulfamethoxazole) to 57.3%-59.6% (fluoroquinolones) and 70.8% (cefixime). The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified. A limitation of the study was the small sample sizes and only one or two sites participating per country; however, since susceptibility data are scarce in some of the participating countries any information concerning antibiotic susceptibility is of value.

CONCLUSIONS

Antibiotic susceptibility varied across countries and species, with isolates from Vietnam demonstrating the lowest susceptibility. Knowledge of resistance patterns can be helpful for clinicians when choosing empirical therapy options for CA-RTIs.

The Role of PK/PD Analysis in the Development and Evaluation of Antimicrobials

Pharmacokinetic/pharmacodynamic (PK/PD) analysis has proved to be very useful to establish rational dosage regimens of antimicrobial agents in human and veterinary medicine. Actually, PK/PD studies are included in the European Medicines Agency (EMA) guidelines for the evaluation of medicinal products. The PK/PD approach implies the use of in vitro, ex vivo, and in vivo models, as well as mathematical models to describe the relationship between the kinetics and the dynamic to determine the optimal dosing regimens of antimicrobials, but also to establish susceptibility breakpoints, and prevention of resistance. The final goal is to optimize therapy in order to maximize efficacy and minimize side effects and emergence of resistance. In this review, we revise the PK/PD principles and the models to investigate the relationship between the PK and the PD of antibiotics. Additionally, we highlight the outstanding role of the PK/PD analysis at different levels, from the development and evaluation of new antibiotics to the optimization of the dosage regimens of currently available drugs, both for human and animal use.

Antimicrobial Susceptibility Trends of Streptococcus pneumoniae by Age Groups Over Recent 10 Years in a Single Hospital in South Korea

PURPOSE

Streptococcus pneumoniae (S. pneumoniae) causes respiratory tract infections. Its non-vaccine serotypes and multidrug-resistant pneumococcal diseases have increased during the post-pneumococcal vaccination era. Therefore, it is important to understand the regional and age-related antimicrobial susceptibility of S. pneumoniae to select appropriate empirical antimicrobials.

MATERIALS AND METHODS

We retrospectively studied trends in the antimicrobial resistance of S. pneumoniae to commonly prescribed antibiotics in patient groups of various ages at a single teaching hospital in Jeju Island from 2009 to 2018.

RESULTS

In total, 1460 S. pneumoniae isolates were obtained during the study period. The overall antimicrobial resistance rates of S. pneumoniae to penicillin, erythromycin, ceftriaxone, levofloxacin, and vancomycin were 16.2%, 84.7%, 25.9%, 3.3%, and 0.0%, respectively, and the MDR rate was 6.7%. Erythromycin and ceftriaxone resistance rates increased by years; however, they were significantly reduced in adult groups. Levofloxacin resistance and MDR rates were also higher in adult groups. Overall, the MDR rate significantly increased during the recent 10 years, as well as in patients with a history of hospitalization within 90 days [odds ratio (OR)=3.58, 95% confidence interval (CI)=1.91-6.71] and sinusitis (OR=4.98, 95% CI=2.07-11.96).

CONCLUSION

Erythromycin and ceftriaxone resistance rates and the MDR rate of S. pneumoniae significantly increased during the recent 10 years; the trends in individual antimicrobial resistance rates significantly differed between the age groups. This study indicates the need for caution when using ceftriaxone as an empirical antimicrobial against pneumococcal infections.

Improved penicillin susceptibility of Streptococcus pneumoniae and increased penicillin consumption in Japan, 2013-18

OBJECTIVES

To examine the association between penicillin susceptibility of Streptococcus pneumoniae and penicillin consumption in Japan.

METHODS

We used Japan Nosocomial Infection Surveillance data on the susceptibility of S. pneumoniae and sales data obtained from IQVIA Services Japan K.K. for penicillin consumption. We analysed both sets of data by decomposing them into seasonality and chronological trend components. The cross-correlation function was checked using Spearman's rank correlation coefficient to examine the correlation between susceptibility and consumption.

RESULTS

After adjusting for seasonality, the susceptibility of S. pneumoniae to penicillins gradually improved (55.7% in 2013 and 60.6% in 2018, respectively) and penicillin consumption increased during the same period (0.76 defined daily doses per 1,000 inhabitants per day [DID] in 2013, and 0.89 DID in 2018). The results showed positive cross-correlation (coefficient 0.801, p-value < 0.001). In contrast, cephalosporin consumption decreased (3.91 DID in 2013 and 3.19 DID in 2018) and showed negative cross-correlation with susceptibility of S. pneumoniae to penicillins (coefficient -0.981, p-value < 0.001).

CONCLUSIONS

The rates of penicillin-susceptible S. pneumoniae isolates did not negatively correlate with penicillin consumption at the population level. Increased penicillin consumption might not impair the penicillin susceptibility of S. pneumoniae.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Russia

Objectives

To determine antibiotic susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from Russia.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

A total of 279 S. pneumoniae and 279 H. influenzae were collected. Overall, 67.0% of S. pneumoniae were penicillin susceptible by CLSI oral/EUCAST and 93.2% by CLSI intravenous (iv) breakpoints. All were fluoroquinolone susceptible, with amoxicillin, amoxicillin/clavulanic acid and ceftriaxone susceptibility ≥92.8% by CLSI and PK/PD breakpoints. Isolates showed lower susceptibility to cefuroxime, cefaclor, macrolides and trimethoprim/sulfamethoxazole by CLSI criteria: 85.0%, 76.7%, 68.8% and 67.7%, respectively. Generally, susceptibility was slightly lower by EUCAST criteria, except for cefaclor, for which the difference in susceptibility was much greater. Penicillin-resistant isolates had low susceptibility (≤60%) to all agents except fluoroquinolones. All 279 H. influenzae were ceftriaxone susceptible, 15.4% were β-lactamase positive and ≥97.5% were amoxicillin/clavulanic acid susceptible (CLSI, EUCAST and PK/PD breakpoints). Four isolates were fluoroquinolone non-susceptible by current EUCAST criteria. A major discrepancy was found with azithromycin susceptibility between CLSI (99.3%) and EUCAST and PK/PD (2.2%) breakpoints. Trimethoprim/sulfamethoxazole was poorly active (62.7% susceptible).

Conclusions

Susceptibility to penicillin (oral), macrolides and trimethoprim/sulfamethoxazole was low in S. pneumoniae from Russia. However, isolates were fully susceptible to fluoroquinolones and ≥92.8% were susceptible to amoxicillin, amoxicillin/clavulanic acid and ceftriaxone. Isolates of H. influenzae only showed reduced susceptibility to ampicillin, cefaclor, clarithromycin and trimethoprim/sulfamethoxazole. Some differences were detected between CLSI, EUCAST and PK/PD breakpoints, especially with cefaclor, cefuroxime and macrolides. These data suggest further efforts are required to harmonize international breakpoints.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Greece

Objectives

To determine antimicrobial susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from patients with community-acquired respiratory tract infections in Greece.

Methods

MICs were determined by CLSI broth microdilution and susceptibility assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

A total of 99 S. pneumoniae and 52 H. influenzae isolates were collected. Overall, 36.4% of S. pneumoniae were penicillin susceptible by CLSI oral/EUCAST and 88.9% by CLSI intravenous (iv) breakpoints. All were fluoroquinolone susceptible with ≥94% of isolates also susceptible to amoxicillin, amoxicillin/clavulanic acid and ceftriaxone by CLSI and PK/PD breakpoints. Trimethoprim/sulfamethoxazole, cefuroxime, cefaclor and macrolides were less active, with rates of susceptibility of 83.8%, 69.7%, 50.5% and 49.5%, respectively, by CLSI. Generally susceptibility was the same or slightly lower by EUCAST, but the cefaclor difference was much greater. Among H. influenzae, 15.4% of isolates were β-lactamase positive. Susceptibility to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime and the fluoroquinolones was seen in >95% of isolates by CLSI criteria. Susceptibility to azithromycin was seen in 94.2% of isolates using CLSI breakpoints, but clarithromycin susceptibility was lower (61.5%). However, susceptibility to both macrolides was seen in <5% of isolates by PK/PD and EUCAST criteria. Susceptibility to trimethoprim/sulfamethoxazole was seen in 71.2% of isolates.

Conclusions

Owing to the high prevalence of macrolide resistance among S. pneumoniae and the reduced activity of clarithromycin against H. influenzae, it appears that these agents are not appropriate as monotherapy for community-acquired pneumonia in Greece. Amoxicillin/clavulanic acid, on the other hand, maintained excellent in vitro activity and, as opposed to the similarly effective fluoroquinolones, is safe to use in paediatric patients.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Ukraine and the Slovak Republic

Objectives

To determine antibiotic susceptibility in isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from Ukraine and the Slovak Republic.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

S. pneumoniae isolates collected in Ukraine (n = 100) showed susceptibility rates ≥97% for amoxicillin, amoxicillin/clavulanic acid, penicillin [intravenous (iv) non-meningitis] and fluoroquinolones, between 83% and 86% for oral penicillin, macrolides and cefaclor, and 75% for trimethoprim/sulfamethoxazole. Susceptibility was substantially lower in the Slovak Republic (n = 95). All isolates were susceptible to the fluoroquinolones, but susceptibility to penicillin, amoxicillin, amoxicillin/clavulanic acid, cefuroxime and trimethoprim/sulfamethoxazole varied between 61% and 64%, with only 44% of isolates susceptible to the macrolides. Susceptibility of H. influenzae was more homogeneous, with susceptibility to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime, azithromycin and the fluoroquinolones seen in >90% of isolates by CLSI criteria in both countries. Much greater variability was seen across breakpoints, especially for azithromycin, cefaclor and cefuroxime. The β-lactamase rate was 5.1% (5/98) in the Slovak Republic and 7.3% (7/96) in Ukraine, but the Slovak Republic also had a relatively high rate of β-lactamase-negative-ampicillin-resistant (BLNAR) isolates (7.1%; 7/98).

Conclusions

The variability found across these two neighbouring countries illustrates the need to monitor and publish national and local resistance patterns. This information is not only critical for effective empirical therapy but can also be used to help shape and support antimicrobial stewardship efforts in order to limit antibiotic resistance.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in Bulgaria, Romania, Serbia and Croatia

Objectives

To determine antibiotic susceptibility of isolates of Streptococcus pneumoniae (n = 573) and Haemophilus influenzae (n = 345) collected in 2014-16 from Bulgaria, Romania, Serbia and Croatia.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

Among S. pneumoniae, susceptibility was generally lowest in Romania and Serbia and highest in Bulgaria. Rates of susceptibility to penicillin (CLSI oral or EUCAST) were 22.3% and 21.8% in Romania and Serbia respectively, 57% in Croatia and 86.6% in Bulgaria. Similarly, macrolide susceptibility using CLSI/EUCAST breakpoints was low in Romania and Serbia (∼28% and 34.5%, respectively), higher in Croatia (55.9%) and highest in Bulgaria (∼75%). Only fluoroquinolones were active against all isolates in all four countries. Susceptibility was higher and variability across countries less pronounced for H. influenzae. Susceptibility by CLSI criteria to amoxicillin/clavulanic acid, azithromycin, cefuroxime, ceftriaxone and fluoroquinolones was ≥98% in all countries. Ampicillin susceptibility ranged from 85.3% in Romania to 100% in Bulgaria. Much greater variability was seen across breakpoints. Susceptibility to azithromycin and cefuroxime using CLSI criteria was ≥98% in all four countries, but was 0%-1% by EUCAST criteria.

Conclusions

The variability in antimicrobial susceptibility using different breakpoints makes it difficult for clinicians to interpret antimicrobial resistance data, and efforts should be made to harmonize breakpoints. The variability found across the four neighbouring countries demonstrates the need to monitor and publish national and local resistance patterns. These findings provide information critical for the selection of appropriate antimicrobial agents for the treatment of S. pneumoniae and H. influenzae.

Results from the Survey of Antibiotic Resistance (SOAR) 2014-16 in the Czech Republic

Objectives

To determine the antibiotic susceptibility of isolates of Streptococcus pneumoniae and Haemophilus influenzae collected in 2014-16 from patients with community-acquired respiratory infections in the Czech Republic.

Methods

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

Results

S. pneumoniae isolates (n = 200) showed high rates of susceptibility (>95%) to amoxicillin, amoxicillin/clavulanic acid, penicillin [intravenous (iv) non-meningitis], ceftriaxone, cefuroxime and the fluoroquinolones using CLSI breakpoints. Susceptibility to cefaclor and trimethoprim/sulfamethoxazole was 94%-94.5%, to penicillin (oral) 91.5% and to the macrolides 89.5%. Susceptibility of H. influenzae (n = 197) to amoxicillin/clavulanic acid, ceftriaxone, cefuroxime, azithromycin and the fluoroquinolones was ≥98% by CLSI criteria. Rates of susceptibility to the remaining agents were ≥75% except for clarithromycin at 37.1%. Great variability was seen across breakpoints, especially for the macrolides, cefaclor and cefuroxime (oral), 98.0% of H. influenzae showing susceptibility to the latter by CLSI criteria, 69.5% by PK/PD and 1.5% by EUCAST standards. The β-lactamase rate was 13.7% with no β-lactamase-negative-ampicillin-resistant (BLNAR) isolates by CLSI criteria.

Conclusions

Antibiotic resistance among the two major respiratory pathogens remained low in the Czech Republic. These findings support local clinicians in continuing the historically restrictive use of antibiotics in the Czech Republic, with selection of narrower-spectrum agents for the empirical therapy of community-acquired respiratory tract infections. This highlights one of the great benefits of continuous surveillance of antimicrobial resistance: knowledge of current local resistance patterns reduces the need to choose broad-spectrum agents that contribute to increasing resistance worldwide.

HAMLET, a protein complex from human milk has bactericidal activity and enhances the activity of antibiotics against pathogenic Streptococci

HAMLET is a protein-lipid complex derived from human milk that was first described for its tumoricidal activity. Later studies showed that HAMLET also has direct bactericidal activity against select species of bacteria, with highest activity against Streptococcus pneumoniae Additionally, HAMLET in combination with various antimicrobial agents can make a broader range of antibiotic-resistant bacterial species sensitive to antibiotics. Here, we show that HAMLET has direct antibacterial activity not only against pneumococci, but also against Streptococcus pyogenes (GAS) and Streptococcus agalactiae (GBS). Analogous to pneumococci, HAMLET-treatment of GAS and GBS resulted in depolarization of the bacterial membrane followed by membrane permeabilization and death that could be inhibited by calcium and sodium transport inhibitors. Treatment of clinical antibiotic-resistant isolates of S. pneumoniae, GAS, and GBS with sublethal concentrations of HAMLET in combination with antibiotics decreased the minimal inhibitory concentrations of the respective antibiotic into the sensitive range. This effect could also be blocked by ion transport inhibitors, suggesting that HAMLET's bactericidal and combination treatment effects used similar mechanisms. Finally, we show that HAMLET potentiated the effects of erythromycin against erythromycin-resistant bacteria more effectively than it potentiated killing by penicillin G of bacteria resistant to penicillin G. These results show for the first time that HAMLET effectively kills three different species of pathogenic Streptococci using similar mechanisms and also potentiate the activity of macrolides and lincosamides more effectively than combination treatment with beta-lactams. These findings suggest a potential therapeutic role for HAMLET in repurposing antibiotics currently causing treatment failures in patients.

Antimicrobial susceptibility among Streptococcus pneumoniae and Haemophilus influenzae collected globally between 2015 and 2017 as part of the Tigecycline Evaluation and Surveillance Trial (TEST)

Purpose: In order to understand the prevalence of Streptococcus pneumoniae and Haemophilus influenzae globally and provide the basis for rational use of antimicrobials in clinical settings, in vitro activity of tigecycline and comparative agents was evaluated against 3929 S. pneumoniae and 4043 H. influenzae isolates obtained from 150 centers globally between 2015 and 2017 as a part of the Tigecycline Evaluation and Surveillance Trial (TEST).

Methods: Broth microdilution methods were performed to determine the minimum inhibitory concentration (MIC) of the isolates according to the guidelines of the Clinical and Laboratory Standards Institute (CLSI). The CLSI breakpoint was used to determine antimicrobial susceptibilities, except for that of tigecycline, for which the US Food and Drug Administration (FDA) breakpoints were used.

Results: More than 99% of S. pneumoniae isolates were susceptible to vancomycin (100%), linezolid (100%), tigecycline (99.9%), and levofloxacin (99.1%). Macrolides (erythromycin, azithromycin, and clarithromycin, 67.1–69.4% susceptibility globally) and penicillin (61.7% in globally) were the drugs with more resisitance to S. pneumoniae. Penicillin-intermediate and -resistant isolates were found in 24.8% and 13.6% of S. pneumoniae isolates. H. influenzae was highly susceptible (>98.7%) to all antibiotics tested except for ampicillin, for which susceptibility was 76.1%. The number of drugs with the lowest susceptibility calculated in Asia were far more than other regions, with 61.5% (8 in 13 drugs) in S. pneumoniae and 70.0% (7 in 10 drugs) in H. influenzae, respectively.

Conclusions: Vancomycin, linezolid, tigecycline, and levofloxacin can be used as the first choice in the empirical therapy of infection disease caused by S. pneumoniae. But macrolides and penicillin should be used prudently in treatment of the infection caused by S. pneumoniae, as well as ampicillin treat the infection caused by H. influenzae. Asia was the region with the most severe resistance in S. pneumoniae and H. influenzae.

Spread of ceftriaxone non-susceptible pneumococci in South Korea: Long-term care facilities as a potential reservoir

Despite the availability of a pneumococcal National Immunization Program, which provides free PPSV23 vaccination for older adults aged ≥65 years in South Korea, pneumococcal pneumonia remains one of the most common respiratory infections, with increasing antimicrobial resistance. From January to December in 2015, all pneumococcal isolates were collected from a 1,050-bed teaching hospital in South Korea. All isolates were analyzed for serotype, genotype, and antimicrobial susceptibility. Demographic, clinical and microbiological data were compared between ceftriaxone susceptible and non-susceptible cases. Among 92 microbiologically identified pneumococcal isolates, ceftriaxone non-susceptible pneumococci (CNSP) accounted for 32 cases (34.8%). Some of these cases also showed levofloxacin resistance (25%, 8/32 isolates) and all CNSP cases were multidrug resistant. Compared to patients with ceftriaxone susceptible pneumococci (CSP), long-term care facility residents (odds ratio [OR] 7.0, 95% confidence interval [CI] 0.8-62.1) and patients with chronic lung (OR 4.1, 95% CI 1.1-15.0) and renal diseases (OR 9.1, 95% CI 1.2-70.5) were more common among those with CNSP on multivariate analysis. PPSV23-unique serotypes not included in PCV13 were more common in CNSP than in CSP (34.4% versus 13.3%, p = 0.02). Regarding genotypes, ST320 (10 cases), ST166 (7 cases) and ST8279 (3 cases) were dominant in CNSP, and ST8279 was only detected in previous long-term care facility residents. Clonal expansion and spread of CNSP strains should be monitored among patients with chronic lung/renal diseases and residents of long-term care facilities.

Alternations in DNA gyrase genes in low-level fluoroquinolone-resistant Moraxella catarrhalis strains isolated in Poland

PURPOSE

The purpose of this study was to investigate the molecular mechanisms of fluoroquinolone resistance in Moraxella catarrhalis clinical strains isolated in Lublin, Poland.

MATERIALS AND METHODS

A total of 150 non-duplicate clinical strains of M. catarrhalis were obtained from individuals with signs of upper respiratory tract infection. Bacterial identification was corroborated on the basis of phenotypic and biochemical characteristics as well as with the use of molecular tests. The antimicrobial susceptibility of M. catarrhalis isolates was determined using the disk diffusion method and Etest. Mutations in the gyrase (gyrA and gyrB) and topoisomerase (parC and parE) genes were determined by polymerase chain reaction and sequencing.

RESULTS

It was observed that 16.7% of the studied isolates were drug resistant. Resistance to tetracycline was detected for 12% of the strains. Resistance to nalidixic acid, moxifloxacin, and levofloxacin was exhibited by 2.7% of the strains; 1.3% of the strains were resistant to trimethoprim/sulfamethoxazole and 0.7% to erythromycin. Minimum inhibitory concentration values of the four strains demonstrating fluoroquinolone resistance were: 6-12 mg/L for nalidixic acid, 1-1.5 mg/L for levofloxacin, 1 mg/L for moxifloxacin, and 0.25-0.5 mg/L for ciprofloxacin. The research resulted in the detection of mutations in 4 strains, in gyrase gyrA and gyrB genes. In gyrA gene, there occurred mutation G412C as well as four silent transition mutations. Within gyrB gene, there occurred mutation, substitution A1481G, as well as two identical silent mutations.

CONCLUSION

Our findings reveal that resistance to fluoroquinolones in M. catarrhalis is connected with amino acid substitutions in gyrA and gyrB genes. To our knowledge, this work is the first description of fluoroquinolone-resistant clinical strains of M. catarrhalis with described mutations in gyrA and gyrB genes isolated in Poland and in Europe.

Guideline for Antibiotic Use in Adults with Community-acquired Pneumonia

Community-acquired pneumonia is common and important infectious disease in adults. This work represents an update to 2009 treatment guideline for community-acquired pneumonia in Korea. The present clinical practice guideline provides revised recommendations on the appropriate diagnosis, treatment, and prevention of community-acquired pneumonia in adults aged 19 years or older, taking into account the current situation regarding community-acquired pneumonia in Korea. This guideline may help reduce the difference in the level of treatment between medical institutions and medical staff, and enable efficient treatment. It may also reduce antibiotic resistance by preventing antibiotic misuse against acute lower respiratory tract infection in Korea.

Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study

BACKGROUND

India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India.

METHODS

In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2-3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both.

FINDINGS

Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11-16) and 372 (62%) of 601 Case 2 interactions (95% CI 58-66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13-19) than in Case 1 (221 [37%] of 599, 95% CI 33-41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour.

INTERPRETATION

Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions.

FUNDING

Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.