Systematic review of time lag between antibiotic use and rise of resistant pathogens among hospitalized adults in Europe

Evidence for antimicrobial stewardship and reduced antimicrobial resistance in the Mid-West of Ireland, 2012 to 2023: findings from a One Health study

BackgroundEscherichia coli, a pathogen commonly infecting humans and bovines, is a prime sentinel indicator and predictor for antimicrobial resistance (AMR). Tracking epidemiological trends of AMR is essential to address this global One Health threat.AimTo perform a comprehensive retrospective epidemiological analysis of AMR trends in E. coli isolated from human urine and blood and bovine specimens, and compare with antimicrobial consumption or sales data for humans.MethodsAll E. coli isolates with susceptibility results from human urine (n = 122,419), blood (n = 2,373) and bovine specimens (n = 585) from 2012-23 in the Mid-West of Ireland were analysed. The resistance trends of nine commonly used antimicrobials were compared with their consumption by humans or sales in community and hospital settings.ResultsOver the 12-year period, resistance against common antimicrobials was lowest among the bovine isolates (range: 2-44%). Human urine isolates showed lower resistance (5-59%) than bloodstream isolates (12-69%). There was a downward trend in resistance to all antimicrobials between 2012 and 2023 in the human isolates (p < 0.001), except for piperacillin/tazobactam where resistance increased, in each case correlating with antimicrobial usage. Bovine isolates demonstrated reduced resistance to co-amoxiclav (p = 0.001), with no trend observed for other antimicrobials.ConclusionOur data showed reduced resistance to many antimicrobials for E. coli from human and bovine populations in our region. Increased use of 'preferred' antimicrobials in humans and reduced use of those 'to be avoided' was observed. The findings indicate the emerging effectiveness of AMR strategies and highlight the value of One Health AMR.

Comparison of Different Methods for Assaying the In Vitro Activity of Cefiderocol against Carbapenem-Resistant Pseudomonas aeruginosa Strains: Influence of Bacterial Inoculum

Carbapenem-resistant Pseudomonas aeruginosa infections represent a critical public health concern, highlighting the need for the development of effective antibiotics. Cefiderocol demonstrated potent in vitro activity against Pseudomonas aeruginosa, particularly in strains that are resistant to other drugs. However, concerns regarding the emergence of drug-resistant strains persist. This study, conducted with 109 carbapenem-resistant Pseudomonas aeruginosa strains from the Spanish Hospital (Dr. Balmis, Alicante). The study evaluated susceptibility to cefiderocol in comparison to alternative antibiotics and including their susceptibility to bacterial inoculum, while assessing various testing methods. Our findings revealed high susceptibility to cefiderocol against carbapenem-resistant strains, with only 2 of 109 strains exhibiting resistance. Comparative analysis demonstrated superiority of cefiderocol towards alternative antibiotics. Both the E-test and disk-diffusion methods showed 100% concordance with the microdilution method in classifying strains as susceptible or resistant. However, 4.6% (5/109) of disc zone diameters fell within the technical uncertainty zone, so the E-test technique was found to be more useful in routine clinical practice. Additionally, escalating bacterial inoculum correlated with decreases in vitro activity, so this parameter should be adjusted very carefully in in vivo studies. This study underscores cefiderocol's potential as a therapeutic option for carbapenem-resistant Pseudomonas aeruginosa infections. However, the emergence of drug-resistant strains emphasizes the critical need for a wise use of antibiotics and a continuous monitoring of resistance to antibiotics. Based on our in vitro data, further investigation concerning the impact of bacterial inoculum on drug efficacy is warranted in order to detect resistance mechanisms and optimize treatment strategies, thereby mitigating the risk of resistance.

Costs of antibiotic resistance genes depend on host strain and environment and can influence community composition

Antibiotic resistance genes (ARGs) benefit host bacteria in environments containing corresponding antibiotics, but it is less clear how they are maintained in environments where antibiotic selection is weak or sporadic. In particular, few studies have measured if the direct effect of ARGs on host fitness is fixed or if it depends on the host strain, perhaps marking some ARG-host combinations as selective refuges that can maintain ARGs in the absence of antibiotic selection. We quantified the fitness effects of six ARGs in 11 diverse Escherichia spp. strains. Three ARGs (blaTEM-116, cat and dfrA5, encoding resistance to β-lactams, chloramphenicol, and trimethoprim, respectively) imposed an overall cost, but all ARGs had an effect in at least one host strain, reflecting a significant strain interaction effect. A simulation predicts these interactions can cause the success of ARGs to depend on available host strains, and, to a lesser extent, can cause host strain success to depend on the ARGs present in a community. These results indicate the importance of considering ARG effects across different host strains, and especially the potential of refuge strains to allow resistance to persist in the absence of direct selection, in efforts to understand resistance dynamics.

Effect of different strategies for excluding duplicate cultures on the correlation between hospital resistance rates and antibiotic consumption

INTRODUCTION

Studies may underestimate the impact of antibiotics on bacterial resistance when correlating hospital antibiotic use with resistance rates (RRs) that exclude duplicate cultures as duplicates usually include more resistant isolates. Comparing correlations between antibiotic consumption and RRs resulting from different strategies for excluding duplicates could help explore how their exclusion affects such correlations.

METHODS

We obtained antibiotics consumption and Pseudomonas aeruginosa susceptibility data from 2017 to 2021 for seven antibiotics and for carbapenems as a group in a university hospital. We calculated RRs using seven different time criteria for excluding duplicates. We assessed the correlations of antibiotic consumption to the same-year and next-year RR rates for the three most distinct rates.

RESULTS

Duplicate cultures represented 53.45% of total cultures. RRs were higher when duplicates were included. We compared RRs resulting from excluding all duplicates, excluding duplicates monthly or admitting one culture per day. All antibiotics except meropenem showed a correlation with same-year RRs, either positive or negative, whereas all antibiotics showed a positive correlation with next-year RRs. For same-year and next-year correlations, the criteria with fewer duplicates (and therefore fewer resistant strains) found more correlations. However, the inclusion of duplicates taken at least 1 month apart found the most correlations. Admitting one culture per day found the fewest correlations.

CONCLUSIONS

Excluding duplicates from RRs affects the correlation of antibiotics consumption with RRs in P. aeruginosa. Including at least some duplicate cultures in correlation analyses, such as those taken 1 month apart, should be considered.

Examining pharmacoepidemiology of antibiotic use and resistance in first-line antibiotics: a self-controlled case series study of Escherichia coli in small companion animals

Background

Clinicians need to prescribe antibiotics in a way that adequately treats infections, while simultaneously limiting the development of antibiotic resistance (ABR). Although there are abundant guidelines on how to best treat infections, there is less understanding of how treatment durations and antibiotic types influence the development of ABR. This study adopts a self-controlled case study (SCCS) method to relate antibiotic exposure time to subsequent changes in resistance patterns. This SCCS approach uses antibiotic exposure as a risk factor, and the development of ABR as an incidence rate ratio (IRR), which can be considered as the multiplicative change in risk for bacteria to become or maintain resistance.

Aim

To investigate the IRR of extensive (more than 7 antibiotic classes), revert, persistent, and directed antibiotic resistance according to the duration and type of antibiotic exposures in Escherichia coli (E. coli).

Methods and material

We use anonymized veterinary clinical data from dog and cat patients older than 6 months between 2015 and 2020. Patients were considered suitable cases if they received antibiotics and had a minimum of two urinary antibiograms within a 12-month period (the first prior to antibiotics exposure and the second from 1 week to 6 months after exposure). The first antibiogram is conducted before antibiotic exposure (case n=20).

Findings

From 20 individuals and 42 paired antibiograms we found that the IRR = 2 for extensive drug resistance in patients who received short-course antibiotic treatment compared to longer treatments. In contrast, multi-drug resistance IRR = 2.6 for long-course compared to short-course antibiotic treatment. The ratio of E. coli isolates that reverted from resistant to sensitive was 5.4 times more likely in patients who received antibiotics for longer than 10 days.

Effects of a Primary Care Antimicrobial Stewardship Program on Meticillin-Resistant Staphylococcus aureus Strains across a Region of Catalunya (Spain) over 5 Years

Primary care antimicrobial stewardship program (ASP) interventions can reduce the over-prescription of unnecessary antibiotics, but the impact on the reduction in bacterial resistance is less known, and there is a lack of available data. We implemented a prolonged educational counseling ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, which was compared to a pre-intervention period, a significant reduction in antibiotic prescriptions occurred, particularly those associated with greater harmful effects and resistance selection. There was also a decrease in methicillin-resistant Staphylococcus aureus (MRSA) strains and in their co-resistance to other antibiotics, particularly those with an ecological impact.

Novel scores relevant to antimicrobial resistance and hospital-acquired infections developed with data from a multi-hospital consortium in the Parisian region of France

PURPOSE

Indicators for comparing and understanding differences in antimicrobial resistance (AMR) and healthcare-associated infections (HAIs) for benchmarking are essential to identify priorities for hospitals.

METHODS

This study measured the incidence of hospital-acquired or resistant Gram-negative bacilli bloodstream infections (GNB-BSIs) in a large public healthcare consortium in the Parisian region of France.

RESULTS

Within each hospital, there was a strong positive correlation between the incidence of GNB-BSIs due to resistant GNB and the incidence of hospital-acquired GNB-BSIs. Two scores measuring AMR and HAI rates by combining different GNB-BSI incidence rates were developed as indicators. These scores were highly variable within the hospital consortium. On multi-variate analysis, AMR and HAI scores were significantly associated with the proportion of surgical beds, staff absenteeism and the consumption of alcohol-based hand rub, with the latter two characteristics being amenable to interventions. Carbapenem use was also linked to AMR, but this may be because carbapenems are the preferred drug for treating resistant infections.

CONCLUSION

These results shed light on the incidence of HAIs and AMR in the study hospitals, and suggest possibilities for targeted interventions at healthcare facility level.

Impact of carbapenem-targeted antimicrobial stewardship interventions: an interrupted time-series analysis

BACKGROUND

The development of carbapenem-resistant Gram-negative bacilli (CR-GNB) is largely favoured by indiscriminate and prolonged carbapenem use, which is a significant contributing factor.

AIM

To evaluate the impact of two carbapenem antibiotic stewardship programme interventions on both carbapenem prescriptions and the clinical isolation rates of CR-GNBs, using interrupted time-series analysis.

METHODS

A time-series analysis was performed using data for carbapenem usage from a tertiary hospital in South Korea from January 2017 to July 2022. Two carbapenem antibiotic stewardship programme interventions were implemented sequentially: (i) a prospective audit and feedback (PAF) from November 2018 to April 2020 (intervention 1), and (ii) preauthorization from May 2020 to August 2020 (intervention 2). Monthly carbapenem usage and incidence of CR-GNB before and after each intervention were compared using an autoregressive integrated moving average model.

FINDINGS

Implementation of PAF resulted in a significant reduction in carbapenem consumption, followed by an additional decrease after the preauthorization was implemented. The incidence of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae increased after intervention 1, but there was a significant change from an increasing trend to a stationary trend after intervention 2. The incidence of carbapenem-resistant Pseudomonas aeruginosa, which had increased during the baseline period, became stationary after intervention 1. A significant decrease was observed in the incidence of carbapenem-resistant Acinetobacter baumannii during the implementation of intervention 1 and 2.

CONCLUSION

This study emphasizes the importance of adopting comprehensive antibiotic management and rigorous infection control to prevent infections caused by antibiotic-resistant bacteria.

The Diagnostic Value of Kinetics of NLR to Identify Secondary Pulmonary Bacterial Infection Among COVID-19 Patients at Single Tertiary Hospital in Indonesia

Purpose

Coronavirus disease 2019 (COVID-19) is a new respiratory tract infection caused by severe acute respiratory syndrome coronavirus-2. The presence of secondary pulmonary bacterial infection (SPBI) made COVID-19 difficult to treat. Neutrophil-lymphocyte count ratio (NLR) is a systemic inflammatory marker used in the diagnosis and prognosis of viral or bacterial infection. At the first 3-5 days after hyperinflammation, it occurs in relation to clinical outcome. Therefore, this study aimed to evaluate the diagnostic value of NLR based on leukocyte kinetics upon admission and after 72 hours among COVID-19 patients with or without SPBI.

Patients and Methods

This retrospective cross-sectional study analyzed medical records data of admitted patients with COVID-19 according to the International Classification of Disease 10th Revision (ICD-10) between January and December 2021. The list of patients was extracted and followed by a hand search to identify the inclusion or exclusion criteria and stratified into proven and non-proven SPBI based on clinical data. The study distinguished between SPBI by means of a cut-off value (COV) on the first (D1) and third day (D3), assessed using receiver operating characteristics (ROC), as well as determined the magnitude of sensitivity, specificity, and prevalence ratio.

Results

A screening process was conducted on 2902 COVID-19 patients, of which 236 were included, accounting for 8.1%. Among these patients, 87 (36.9%) were found to have proven SPBI. A considerable difference in NLR value between proven and non-proven SPBI was observed on both D1 (11.1 vs 4.2) and D3 (15.3 vs 5.2), with optimal COV of NLR on D1, D3 was found to be 5.29, 9.47, respectively (p < 0.001).

Conclusion

NLR on the D1 and D3 distinguished the occurrence of SPBI among COVID-19 patients. The application of NLR assisted in the early determination of bacterial infection and helped in controlling the empirical use of antibiotics.

Antimicrobial Resistant Coagulase-Negative Staphylococci Carried by House Flies (Musca domestica) Captured in Swine and Poultry Farms

House flies (Musca domestica) are very diffuse insects attracted by biological materials. They are abundantly present in farm environments and can frequently come in contact with animals, feed, manure, waste, surfaces, and fomites; consequently, these insects could be contaminated, carry, and disperse several microorganisms. The aim of this work was to evaluate the presence of antimicrobial-resistant staphylococci in house flies collected in poultry and swine farms. Thirty-five traps were placed in twenty-two farms; from each trap, 3 different kinds of samples were tested: attractant material present in the traps, the body surface of house flies and the body content of house flies. Staphylococci were detected in 72.72% of farms, 65.71% of traps and 43.81% of samples. Only coagulase-negative staphylococci (CoNS) were isolated, and 49 isolates were subjected to an antimicrobial susceptibility test. Most of the isolates were resistant to amikacin (65.31%), ampicillin (46.94%), rifampicin (44.90%), tetracycline (40.82%) and cefoxitin (40.82%). Minimum Inhibitory concentration assay allowed to confirm 11/49 (22.45%) staphylococci as methicillin-resistant; 4 of them (36.36%) carried the mecA gene. Furthermore, 53.06% of the isolates were classified as multidrug-resistant (MDR). Higher levels of resistance and multidrug resistance were detected in CoNS isolated from flies collected in poultry farms than in swine farms. Therefore, house flies could carry MDR and methicillin-resistant staphylococci, representing a possible source of infection for animals and humans.