The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings

Treatment of Helicobacter Pylori İnfection and the Colonization of the Gastrointestinal System by Resistant Bacteria

BACKGROUND AND AIMS

Helicobacter pylori (H. pylori) infections are widely treated with antibiotic regimens such as "Amoxicillin 1 gr 2 × 1 tablet, Clarithromycin 500 mg 2 × 1 tablet, and Lansoprazole 30 mg 2 × 1 tablet" for 14 days. We conducted a prospective observational study to explore whether this treatment protocol serves as a predisposing factor for the colonization of resistant gastrointestinal microflora, namely vancomycin-resistant enterococci (VRE), extended-spectrum beta-lactamase Enterobacterales (ESBL-E), and carbapenem-resistant Enterobacterales (CRE).

MATERIALS AND METHODS

Pre- and post-treatment stool samples from 75 patients diagnosed with H. pylori, without a prior treatment history, were cultured and evaluated based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria.

RESULTS

Of the 75 evaluated patients, a pronounced surge in ESBL-E positivity was observed. Before initiating antibiotic treatment, 12 patients (16%) had ESBL-E-positive strains in their gastrointestinal tract. Notably, this number surged to 24 patients (32%) after the conclusion of the 14-day treatment regimen. The change was statistically significant, with a P value of less than 0.002, indicating a clear association between treatment for H. pylori and heightened ESBL-E colonization. Notably, VRE and CRE remained undetected in patients throughout the study, suggesting that the treatment regimen may specifically amplify the risk of ESBL-E colonization without affecting VRE and CRE prevalence.

CONCLUSIONS

As the inaugural report from Turkey on this issue, our study suggests that antibiotic regimens for H. pylori eradication contribute to the increased risk of ESBL-positive bacterial colonization in the gastrointestinal tract.

Assessing the conversion of electronic medical record data into antibiotic stewardship indicators

BACKGROUND

Measuring the appropriateness of antibiotic use is crucial for antibiotic stewardship (ABS) programmes to identify targets for interventions.

OBJECTIVES

To assess the technical feasibility of converting electronic medical record (EMR) data into ABS indicators.

METHODS

In this observational feasibility study covering a period of 2 years, the EMRs of patients hospitalized at a large non-university hospital network and receiving at least one dose of a systemic antibiotic were included. ABS indicators measuring steps in the process of antibiotic prescription proposed by the literature were collected and rephrased or defined more specifically to be calculable if needed. Algorithms were programmed in R to convert EMR data into ABS indicators. The indicators were visualized in an interactive dashboard and the plausibility of each output value was assessed.

RESULTS

In total, data from 25 337 hospitalizations from 20 723 individual patients were analysed and visualized in an interactive dashboard. Algorithms could be programmed to compute 89% (25/28) of all pre-selected indicators assessing treatment decisions automatically out of EMR data, with good data quality for 46% (13/28) of these indicators. According to the data quality observed, the most important issues were (i) missing or meaningless information on indication (e.g. 'mild infection') and (ii) data processing issues such as insufficiently categorized metadata.

CONCLUSIONS

The calculation of indicators assessing treatment decisions from EMRs was feasible. However, better data structure and processing within EMR systems are crucial for improving the validity of the results.

Identification of antibiotic consumption targets for the management of Clostridioides difficile infection in hospitals- a threshold logistic modelling approach

BACKGROUND

This study aims to demonstrate the utility of a threshold logistic approach to identifying thresholds for specific antibiotic use associated with Clostridioides difficile infection (CDI) in an English teaching hospital.

METHODS

A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-onset, healthcare-associated (HOHA) CDI cases.

RESULTS

Using a threshold logistic regression approach, an incidence greater than 0.2645 cases/1000 occupied bed-days (OBD; 85th percentile) was determined as the cutoff rate to define a critical (high) incidence rate of HOHA CDI. Fluoroquinolones and piperacillin-tazobactam were found to have thresholds at 84.8 and 54 defined daily doses (DDD)/1000 OBD, respectively. Analysis of data allowed calculating risk scores for HOHA CDI incidence rates exceeding the 85th percentile, i.e. entering critical incidence level. The threshold-logistic model also facilitated performing 'what-if scenarios' on future values of fluoroquinolones and piperacillin-tazobactam use to understand how HOHA CDI incidence rates may be affected.

CONCLUSION

Using threshold logistic analysis, critical incidence levels and antibiotic use targets to control HOHA CDI were determined. Threshold logistic models can be used to inform and enhance the effective design and implementation of antimicrobial stewardship programs.

Molecular characterization and comparative genomic analysis of Acinetobacter baumannii isolated from the community and the hospital: an epidemiological study in Segamat, Malaysia

Acinetobacter baumannii is a common cause of multidrug-resistant (MDR) nosocomial infections around the world. However, little is known about the persistence and dynamics of A. baumannii in a healthy community. This study investigated the role of the community as a prospective reservoir for A. baumannii and explored possible links between hospital and community isolates. A total of 12 independent A. baumannii strains were isolated from human faecal samples from the community in Segamat, Malaysia, in 2018 and 2019. Another 15 were obtained in 2020 from patients at the co-located tertiary public hospital. The antimicrobial resistance profile and biofilm formation ability were analysed, and the relatedness of community and hospital isolates was determined using whole-genome sequencing (WGS). Antibiotic profile analysis revealed that 12 out of 15 hospital isolates were MDR, but none of the community isolates were MDR. However, phylogenetic analysis based on single-nucleotide polymorphisms (SNPs) and a pangenome analysis of core genes showed clustering between four community and two hospital strains. Such clustering of strains from two different settings based on their genomes suggests that these strains could persist in both. WGS revealed 41 potential resistance genes on average in the hospital strains, but fewer (n=32) were detected in the community strains. In contrast, 68 virulence genes were commonly seen in strains from both sources. This study highlights the possible transmission threat to public health posed by virulent A. baumannii present in the gut of asymptomatic individuals in the community.

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

Background

Antimicrobial resistance (AMR) causes substantial health and economic burden to individuals, healthcare systems and societies globally. Understanding the temporal relationship between antibiotic consumption and antibiotic resistance in hospitalized patients can better inform antibiotic stewardship activities and the time frame for their evaluation.

Objectives

This systematic review examined the temporal relationship between antibiotic use and development of antibiotic resistance for 42 pre-defined antibiotic and pathogen combinations in hospitalized adults in Europe.

Methods

Searches in MEDLINE, Embase, Cochrane Library and NIHR Centre for Reviews and Dissemination were undertaken from 2000 to August 2021. Pathogens of interest were Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecium, CoNS, Pseudomonas aeruginosa and Acinetobacter baumannii complex.

Results

Twenty-eight ecological studies and one individual-level study were included. Ecological studies were predominantly retrospective in design (19 studies) and of reasonable (20 studies) to high (8 studies) methodological quality. Of the eight pathogens of interest, no relevant data were identified for S. pneumoniae and CoNS. Across all pathogens, the time-lag data from the 28 ecological studies showed a similar pattern, with the majority of studies reporting lags ranging from 0 to 6 months.

Conclusions

Development of antibiotic resistance for the investigated antibiotic/pathogen combinations tends to occur over 0 to 6 months following exposure within European hospitals. This information could inform planning of antibiotic stewardship activities in hospital settings.

Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications

The COVID-19 pandemic has significantly influenced antimicrobial use in hospitals, raising concerns regarding increased antimicrobial resistance (AMR) through their overuse. The objective of this study was to assess patterns of antimicrobial prescribing during the current COVID-19 pandemic among hospitals in Pakistan, including the prevalence of COVID-19. A point prevalence survey (PPS) was performed among 11 different hospitals from November 2020 to January 2021. The study included all hospitalized patients receiving an antibiotic on the day of the PPS. The Global-PPS web-based application was used for data entry and analysis. Out of 1024 hospitalized patients, 662 (64.64%) received antimicrobials. The top three most common indications for antimicrobial use were pneumonia (13.3%), central nervous system infections (10.4%) and gastrointestinal indications (10.4%). Ceftriaxone (26.6%), metronidazole (9.7%) and vancomycin (7.9%) were the top three most commonly prescribed antimicrobials among surveyed patients, with the majority of antibiotics administered empirically (97.9%). Most antimicrobials for surgical prophylaxis were given for more than one day, which is a concern. Overall, a high percentage of antimicrobial use, including broad-spectrums, was seen among the different hospitals in Pakistan during the current COVID-19 pandemic. Multifaceted interventions are needed to enhance rational antimicrobial prescribing including limiting their prescribing post-operatively for surgical prophylaxis.

Identifying Antibiotic Use Targets for the Management of Antibiotic Resistance Using an Extended-Spectrum β-Lactamase-Producing Escherichia coli Case: A Threshold Logistic Modeling Approach

The aim of this study was to develop a logistic modeling concept to improve understanding of the relationship between antibiotic use thresholds and the incidence of resistant pathogens. A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-level incidence rates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli). Threshold logistic models identified thresholds for fluoroquinolones (61.1 DDD/1000 occupied bed days (OBD)) and third-generation cephalosporins (9.2 DDD/1000 OBD) to control hospital ESBL-producing E. coli incidence. The 60th percentile of ESBL-producing E. coli was determined as the cutoff for defining high incidence rates. Threshold logistic analysis showed that for every one-unit increase in fluoroquinolones and third-generation cephalosporins above 61.1 and 9.2 DDD/1000 OBD levels, the average odds of the ESBL-producing E. coli incidence rate being ≥60th percentile of historical levels increased by 4.5% and 12%, respectively. Threshold logistic models estimated the risk scores of exceeding the 60th percentile of a historical ESBL-producing E. coli incidence rate. Threshold logistic models can help hospitals in defining critical levels of antibiotic use and resistant pathogen incidence and provide targets for antibiotic consumption and a near real-time performance monitoring feedback system.

Conceptual framework of antibiotic stewardship programs in reducing ESBL-producing Enterobacteriaceae: a systematic review and meta-analysis

Today, the phenomenon of antibiotic resistance has become one of the main concerns of health system around the world. Antimicrobial stewardship programs (ASPs) are considered as the most important strategy in optimizing antibiotic consumption, which in turn reduce the emergence of multidrug/extensively drug-resistant (MDR/XDR) microorganisms, as well as reducing mortality and healthcare costs. However, the effectiveness of APSs in controlling the spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae has not been investigated. The pooled odds ratio for the effectiveness of ASPs in reducing ESBL-producing Enterobacteriaceae was 0.82 (95% CI: 0.70-0.98; P value: 0.03); our results showed that in group with implemented ASPs, the prevalence of infection associated with these bacteria had been reduced by 11.8%. Overall, antimicrobial stewardship strategies are significantly effective in reducing ESBL-producing Enterobacteriaceae infections. The present study concluded that a comprehensive stewardship program will certainly reduce the mortality rate, as well as hospitalization stay and treatment costs. In general, our findings strongly support the performance of ASPs in healthcare centers.

Comparison between antimicrobial stewardship program and intervention by infection control team for managing antibiotic use in neurogenic bladder-related urinary tract infection patients: A retrospective chart audit

BACKGROUND

Antimicrobial prescriptions are relatively common in urologic outpatients. Therefore, it is necessary to investigate the impact of antimicrobial stewardship program (ASP) interventions.

METHODS

In urology outpatients, antimicrobial use density (AUD), antimicrobial agent costs, isolation of urinary tract infection (UTI)-causing organisms and their antimicrobial susceptibilities were compared between intervention by infection control team (ICT) era (pre-2014) and ASP era (post-2014) in 2739 patients with lower urinary tract symptoms, including neurogenic bladder patients with UTI or suspected UTI, from 2011 to 2020.

RESULTS

In the ASP, overall AUD (P<.001), cefotiam (CTM) (P=.0013), 2nd-generation cephalosporins (P=.026), cefdinir (CFDN) (P<.001), levofloxacin (LVFX) (P<.001), sitafloxacin (STFX) (P=.0016), and tosufloxacin (TFLX) (P=.0044) showed a significant decrease, but cefaclor (P=.019) showed a significant increase. Regarding antimicrobial agent costs, overall (P=.016), CTM (P=.021), 2nd-generation cephalosporins (P=.033), CFDN (P=.016), LVFX (P=.016), STFX (P=.033), and TFLX (P=.033) showed a significant decrease in the ASP. UTI-causing antimicrobial susceptibilities, CTM (P=.035), LVFX (P=.026) and sulfamethoxazole/trimethoprim (P=.048) in E. coli, and minocycline (P=.026) in K. pneumoniae showed a significant improve in the ASP.

CONCLUSION

ASP contributed to decrease AUD and antimicrobial agent costs, and to improve antimicrobial susceptibilities of E. coli and K. pneumoniae to several antibiotics, compared to ICT. Further prospective studies are necessary for definitive conclusions.

The impact of public health interventions on the future prevalence of ESBL-producing Klebsiella pneumoniae: a population based mathematical modelling study

Background

Future prevalence of colonization with extended-spectrum betalactamase (ESBL-) producing K. pneumoniae in humans and the potential of public health interventions against the spread of these resistant bacteria remain uncertain.

Methods

Based on antimicrobial consumption and susceptibility data recorded during > 13 years in a Swiss region, we developed a mathematical model to assess the comparative effect of different interventions on the prevalence of colonization.

Results

Simulated prevalence stabilized in the near future when rates of antimicrobial consumption and in-hospital transmission were assumed to remain stable (2025 prevalence: 6.8% (95CI%:5.4–8.8%) in hospitals, 3.5% (2.5–5.0%) in the community versus 6.1% (5.0–7.5%) and 3.2% (2.3–4.2%) in 2019, respectively). When overall antimicrobial consumption was set to decrease by 50%, 2025 prevalence declined by 75% in hospitals and by 64% in the community. A 50% decline in in-hospital transmission rate led to a reduction in 2025 prevalence of 31% in hospitals and no reduction in the community. The best model fit estimated that 49% (6–100%) of observed colonizations could be attributable to sources other than human-to-human transmission within the geographical setting.

Conclusions

Projections suggests that overall antimicrobial consumption will be, by far, the most powerful driver of prevalence and that a large fraction of colonizations could be attributed to non-local transmissions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07441-z.

A Nonlinear Time-Series Analysis to Identify the Thresholds in Relationships Between Antimicrobial Consumption and Resistance in a Chinese Tertiary Hospital

Introduction

Balancing the benefits and risks of antimicrobials in health care requires an understanding of their effects on antimicrobial resistance at the population scale. Therefore, we aimed to investigate the association between the population antibiotics use and resistance rates and further identify their critical thresholds.

Methods

Data for monthly consumption of six antibiotics (daily defined doses [DDDs]/1000 inpatient-days) and the number of cases caused by five common drug-resistant bacteria (occupied bed days [OBDs]/10,000 inpatient-days) from inpatients during 2009–2020 were retrieved from the electronic prescription system at Nanjing Drum Tower Hospital, a tertiary hospital in Jiangsu Province, China. Then, a nonlinear time series analysis method, named generalized additive models (GAM), was applied to analyze the pairwise relationships and thresholds of these antibiotic consumption and resistance.

Results

The incidence densities of carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Klebsiella pneumoniae (CRKP), and aminoglycoside-resistant Pseudomonas aeruginosa were all strongly synchronized with recent hospital use of carbapenems and glycopeptides. Besides, the prevalence of carbapenem-resistant Escherichia coli was also highly connected the consumption of carbapenems and fluoroquinolones. To lessen resistance, we determined a threshold for carbapenem and glycopeptide usage, where the maximum consumption should not exceed 31.042 and 25.152 DDDs per 1000 OBDs, respectively; however, the thresholds of fluoroquinolones, third-generation cephalosporin, aminoglycosides, and β-lactams have not been identified.

Conclusions

The inappropriate usage of carbapenems and glycopeptides was proved to drive the incidence of common drug-resistant bacteria in hospitals. Nonlinear time series analysis provided an efficient and simple way to determine the thresholds of these antibiotics, which could provide population-specific quantitative targets for antibiotic stewardship.

An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns

Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide. Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes. Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections. Conclusion:  It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.

Antibiotic consumption at community pharmacies: A multicenter repeated prevalence surveillance using WHO methodology

Background:

Antibiotics are losing their effectiveness because of the rapid emergence of resistant bacteria. Unnecessary antimicrobial use increases antimicrobial resistance (AMR). There are currently no published data on antibiotic consumption in Pakistan at the community level. This is a concern given high levels of self-purchasing of antibiotics in Pakistan and variable knowledge regarding antibiotics and AMR among physicians and pharmacists.

Objective:

The objective of this repeated prevalence survey was to assess the pattern of antibiotic consumption data among different community pharmacies to provide a baseline for developing future pertinent initiatives.

Methods:

A multicenter repeated prevalence survey conducted among community pharmacies in Lahore, a metropolitan city with a population of approximately 10 million people, from October to December 2017 using the World Health Organization (WHO) methodology for a global program on surveillance of antimicrobial consumption.

Results:

The total number of defined daily doses (DDDs) dispensed per patient ranged from 0.1 to 50.0. In most cases, two DDDs per patient were dispensed from pharmacies. Co-amoxiclav was the most commonly dispensed antibiotic with a total number of DDDs at 1018.15. Co-amoxiclav was followed by ciprofloxacin with a total number of 486.6 DDDs and azithromycin with a total number of 472.66 DDDs. The least consumed antibiotics were cefadroxil, cefotaxime, amikacin, and ofloxacin, with overall consumption highest in December.

Conclusion:

The study indicated high antibiotic usage among community pharmacies in Lahore, Pakistan particularly broad-spectrum antibiotics, which were mostly dispensed inappropriately. The National action plan of Pakistan on AMR should be implemented by policymakers including restrictions on the dispensing of antimicrobials.

A systematic review of in-patients’ antimicrobial prescriptions and status of antimicrobial stewardship programmes in Nigerian hospitals

Background

Antimicrobial resistance is a major consequence of irrational antimicrobial prescriptions and consumptions, but this can be prevented by antimicrobial stewardship. The study systematically reviewed available evidence on antimicrobial prescriptions and antimicrobial stewardship (AMS) programmes in Nigerian hospitals. This will provide insight to the extent of required interventions, for improved healthcare.

Main body

Published research from January 1 2010 to March 31 2021 from PubMed, Scopus, Web of Science, African Journals Online and Google scholar databases was reviewed using Preferred Regulatory Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2009. Studies that reported antimicrobial use and antimicrobial stewardship programmes in Nigerian hospitals within the period in focus were assessed for eligibility. The National Heart, Lung and Blood Institute (NHLBI) quality assessment tool was used to assess quality of included studies. Among 15 studies included based on inclusion criteria, 12 reported on antimicrobial prescriptions and 3 reported on status of antimicrobial stewardship programmes in Nigerian hospitals. Most studies reported high prevalence of antimicrobials prescriptions with broad spectrum antimicrobials, majority of which were inappropriate. Empirical antimicrobial prescribing was common, and this was mostly done with less cognisance to existing guidelines. Only few hospitals were observed to have formal AMS teams in Nigeria.

Conclusion

Inappropriate prescribing of antimicrobials was common among prescribers in Nigeria. Although there was paucity of studies on status of AMS, the available few showed very low prevalence of AMS teams in hospitals. There is urgent need for implementation of AMS in Nigerian hospitals, to enhance rational antimicrobial use. Meanwhile more research on AMS in Nigerian hospitals is needed.

Impact of an antimicrobial stewardship programme on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitals in Jordan

OBJECTIVES

To evaluate the impact of an antimicrobial stewardship programme (ASP) on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitalized patients.

METHODS

The study was a retrospective, ecological assessment in a tertiary teaching hospital over 6 years (January 2014 to December 2019). The intervention involved the implementation of an ASP in February 2018, which remains in effect today. This ASP consists of several components, including education, antibiotic guidelines, antibiotic restriction policy with prior approval, audit of compliance to the restriction policy and feedback. Restricted antibiotics were imipenem/cilastatin, ertapenem, meropenem, vancomycin, teicoplanin, tigecycline, colistin, amikacin, piperacillin/tazobactam, levofloxacin and ciprofloxacin. The intervention was evaluated by time-series methods.

RESULTS

Statistically significant decreases in the level of antibiotic use, after the introduction of the ASP, were observed for the following antibiotics: imipenem/cilastatin (P = 0.0008), all carbapenems (P = 0.0001), vancomycin (P = 0.0006), colistin (P = 0.0016) and third-generation cephalosporins (P = 0.0004). A statistically significant decrease in the slope, after the introduction of the ASP, for ertapenem (P = 0.0044) and ciprofloxacin (P = 0.0117) was observed. For piperacillin/tazobactam, there was a significant increasing trend (P = 0.0208) before the introduction of the ASP. However, this increased trend was halted post-introduction of the ASP (P = 0.4574). The introduction of the ASP was associated with a significant impact on reducing the levels of CRAb (P = 0.0237).

CONCLUSIONS

The introduced antimicrobial stewardship interventions contributed to a reduction in the use of several broad-spectrum antibiotics, reversed the trends of increasing use of other antibiotics and were associated with a significant reduction in CRAb.

Community pharmacists' management of self-limiting infections: a simulation study in Akwa Ibom State, South-South Nigeria

BACKGROUND

Inappropriate use of antibiotics, especially for treatment of self-limiting infections remains one of the major drivers of antibiotic resistance (ABR). Community pharmacists can contribute to reducing ABR by ensuring antibiotics are dispensed only when necessary.

OBJECTIVE

To assess community pharmacists' management of self-limiting infections.

METHODS

A purposive sample of 75 pharmacies participated in the study. Each pharmacy was visited by an investigator and a trained simulated patient who mimicked symptoms of common cold and acute diarrhoea, respectively. Interactions between the simulated patient and pharmacist were recorded by the investigator in a data collection form after each visit. Descriptive statistical analysis was carried out. Ethics approval was obtained from the state Ministry of Health Research Ethics Committee.

RESULTS

For common cold, 68% (51/75) of pharmacists recommended an antibiotic. Azithromycin, amoxicillin/clavulanic acid, and sulphamethoxazole/trimethoprim (43%, 24%, 20%, respectively) were the most frequently dispensed agents. For acute diarrhoea, 72% (54/75) of pharmacists dispensed one antibiotic, while 15% dispensed more than one antibiotic. The most frequently dispensed agent was metronidazole (82%), which was dispensed in addition to amoxicillin or tetracycline among pharmacists who dispensed more than one agent. In both infection scenarios, advice on dispensed antibiotics was ofered in 73% and 87% of the interactions, respectively.

CONCLUSION

This study shows high rate of inappropriate antibiotics dispensing among community pharmacists. There is need for improved awareness of antibiotic resistance through continuing education and training of community pharmacists. Furthermore, the inclusion of antibiotic resistance and stewardship in undergraduate pharmacy curriculum is needed.

Compared with Cotrimoxazole Nitroxoline Seems to Be a Better Option for the Treatment and Prophylaxis of Urinary Tract Infections Caused by Multidrug-Resistant Uropathogens: An In Vitro Study

The resistance of uropathogens to various antibiotics is increasing, but nitroxoline remains active in vitro against some relevant multidrug resistant uropathogenic bacteria. E. coli strains, which are among the most common uropathogens, are unanimously susceptible. Thus, nitroxoline is an option for the therapy of urinary tract infections caused by multiresistant bacteria. Since nitroxoline is active against bacteria in biofilms, it will also be effective in patients with indwelling catheters or foreign bodies in the urinary tract. Cotrimoxazole, on the other hand, which, in principle, can also act on bacteria in biofilms, is frequently inactive against multiresistant uropathogens. Based on phenotypic resistance data from a large number of urine isolates, structural characterisation of an MDR plasmid of a recent ST131 uropathogenic E. coli isolate, and publicly available genomic data of resistant enterobacteria, we show that nitroxoline could be used instead of cotrimoxazole for intervention against MDR uropathogens. Particularly in uropathogenic E. coli, but also in other enterobacterial uropathogens, the frequent parallel resistance to different antibiotics due to the accumulation of multiple antibiotic resistance determinants on mobile genetic elements argues for greater consideration of nitroxoline in the treatment of uncomplicated urinary tract infections.

Does Fluoroquinolones and Third-Generation Cephalosporins Restriction Reverse Extended-Spectrum β-Lactamases Klebsiella pneumoniae Resistance Rates?

Aim: To decrease the incidence and resistance rates of extended-spectrum β-lactamases (ESBL) Klebsiella pneumoniae (KP) by restriction of the use of third-generation cephalosporins (3GCs) and fluoroquinolones. Methods: Consumption of 3GCs, fluoroquinolones, and carbapenems in association with ertapenem and fluoroquinolone-resistant KP isolates, were analyzed in 21 months by autoregressive integrated moving average models. A follow-up analysis was performed 5 years later. Results: Consumption of 3GCs decreased significantly during the postintervention period. Their restriction was associated with a decrease in ertapenem-resistant KP isolates by 17.5%. Fluoroquinolone, 3GCs, and carbapenem use did not significantly predict the percentage of ertapenem-resistant KP isolates. Fluoroquinolone, but not cephalosporin use, significantly predicted the percentage of fluoroquinolone-resistant isolates, with an increase of 1 defined daily dose (DDD) of fluoroquinolone/100 occupied bed-days (OBDs) corresponding to a 0.32% increase of fluoroquinolone-resistant isolates (p = 0.008). A decrease of 1 DDD of carbapenem/100 OBD was associated with a 16.94% increase of fluoroquinolone-resistant isolates (p = 0.007). Five years later, the consumption of all three antimicrobial classes increased significantly compared with the 2011-2013 period, whereas ertapenem-resistant KP rates significantly decreased. Conclusion: This study may bring a valuable contribution to the understanding of the intricate association between antibiotic consumption and bacterial resistance. Reporting a spectrum of different results could present a useful basis for more profound research of various interventions' effects.

Risk factors for fecal carriage of extended-spectrum beta-lactamase-producing and carbapenem-resistant Escherichia coli and Klebsiella pneumoniae strains among patients at hospital admission

AIM

Extended-spectrum beta-lactamase (ESBL)-producing and carbapenem-resistant (CR) Enterobacteriaceae are substantial problems in hospital-acquired infections worldwide. We analyzed the risk factors for fecal carriage of ESBL-positive and/or CR E. coli and K. pneumoniae (EcKp) strains in a hospital in Turkey, an endemic country for both resistances.

MATERIALS AND METHODS

A prospective cross-sectional study including the rectal swab samples of 168 patients, obtained at the day of admission, was conducted. ESBL-producing and CR EcKp were investigated with phenotypic tests and PCR, and the clonal relatedness of isolates was studied. Risk analysis was performed with logistic regression method.

RESULTS

A total of 67 (39.8%) and 21 (12.5%) patient samples tested positive for ESBL-producing and CR EcKp, respectively. CTX-M (n = 27) and OXA-48 (n = 12) were the dominant ESBL and carbapenemase types, and 4.5%-10.7% of the isolates were clonally-related. Among 15 potential risk factors studied, longer lengths of hospital stay and antimicrobial use, and receiving total parenteral nutrition in the last 6 months were determined as independent risk factors for fecal carriage of ESBL-producing and/or CR EcKp, while prior antimicrobial treatment was only a risk factor for ESBL producers.

CONCLUSION

Certain conditions in patients' medical backgrounds may be associated with increased likelihood of resistant bacterial colonization. Notably, questioning these situations at admission can help to identify potential carriers and proactively administer appropriate infection control measures.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

Review of antimicrobial resistance control strategies: low impact of prospective audit with feedback on bacterial antibiotic resistance within hospital settings

BACKGROUND

Antimicrobial stewardship constitutes an essential element of any concerted effort to tackle bacterial resistance, a rising public health threat both in community as well as hospital settings. The term comprises variable strategies which aim to optimise prescribing practices through either antibiotic restrictions or prospective audits of prescriptions with subsequent feedback to clinicians. Although highly debated, the actual effects of the latter on the antimicrobial susceptibility patterns of hospital flora are uncertain. The present study aims to review and evaluate the literature concerning the impact of persuasive stewardship strategies on antimicrobial resistance within hospitals.

MATERIALS AND METHODS

A literature review covering the period to 1st April 2020 was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases.

RESULTS

Fifteen studies were retrieved, including twelve simple before-and-after, and three interrupted time-series studies. Audit frequency and compliance rates varied broadly. The rationale of treatment optimisation is not clear in most cases. Overall, surveillance of sentinel microorganisms through antibiograms indicates ambiguous results, with uncertainty as to whether the few successes are due to a causal effect, random incidence fluctuations, or confounding. The most informative approach targeted solely fluoroquinolones, reporting improvements in relevant Pseudomonas susceptibilities and MRSA, but without sufficient data on other effects of the strategy to assess its overall utility in clinical practice.

CONCLUSION

Higher standard research is needed to address the actual effects of persuasive stewardship strategies on antimicrobial susceptibility patterns. At present, they seem inadequate to play a decisive role in bacterial resistance control within hospitals.

Advocacy for Increased International Efforts for Antimicrobial Stewardship Actions in Low-and Middle-Income Countries on Behalf of Alliance for the Prudent Use of Antimicrobials (APUA), Under the Auspices of the International Society of Antimicrobial Chemotherapy (ISAC)

Antimicrobial stewardship (AMS) is a set of coordinated strategies to improve the use of antimicrobials, to enhance patient outcomes, reduce antimicrobial resistance, and decrease unnecessary costs. The pioneer years of AMS were restricted to high-income countries (HIC), where overconsumption of antibiotics was associated with emergence of multidrug-resistant (MDR) bacteria. AMS in low- and middle-income countries (LMIC) is also necessary. However, programs effective in HIC may not perform as well in LMIC, because (i) While decreased consumption of antibiotics may be an appropriate target in overconsuming HIC, this may be dangerous in LMIC, where many patients die from the lack of access to antibiotics; (ii) although AMS programs in HIC can be designed and monitored through laboratory surveillance of resistance, surveillance programs are not available in many LMIC; (iii) the heterogeneity of health care systems implies that AMS programs must be carefully contextualized. Despite the need to individually tailor AMS programs in LMIC, international collaborations remain highly valuable, through the dissemination of high-quality documents and educational material, that may be shared, adapted where needed, and adopted worldwide. This process, facilitated by modern communication tools, combines many benefits, including: (i) saving time, a precious dimension for health care workers, by avoiding the duplication of similar works in different settings; (ii) taking advantage of colleagues skills, and initiatives, through open access to the work performed in other parts of the world; (iii) sharing experiences, so that we all learn from each others' successes and failures.

Antimicrobial resistance and molecular detection of extended spectrum β-lactamase producing Escherichia coli isolates from raw meat in Greater Accra region, Ghana

BACKGROUND

Typically, raw meat can be contaminated with antibiotic resistant pathogens at unhygienic slaughter and sale points. Consumption of meat contaminated with antibiotic resistant E. coli is associated with grave health care consequences. The aim of this study was to determine the microbial quality of raw meat, the antimicrobial susceptibility and Extended Spectrum Beta Lactamase (ESBL) production in E. coli isolates from raw meat.

RESULTS

Total Plate Counts exceeded the acceptable limit of 5.0 log CFU/ cm² in 60.5% (124/205) of raw meat samples. Total Coliform Counts in 70.7% (145/205) of samples were in excess of the acceptable limit of 2.5 log CFU/cm². E. coli was detected in about half of raw meat samples (48%), ranging from 9.5-79.0% among the slaughter sites. Isolates were susceptible to meropenem (100%), ceftriaxone (99%), cefotaxime (98%), chloramphenicol (97%), gentamycin (97%), ciprofloxacin (92%) and amikacin (92%), but resistant to ampicillin (57%), tetracycline (45%), sulfamethoxazole-trimethoprim (21%) and cefuroxime (17%). Multi-drug resistance (MDR) was identified in 22% of the isolates. The bla_{TEM gene} was detected in 4% (4/98) of E. coli isolates in this study.

CONCLUSION

The levels of microbial contamination of raw meat in this study were unacceptable. Meat handlers and consumers are at risk of foodborne infections from E. coli including ESBL producing E. coli that are resistant to most antibiotics in use. We recommend an enhanced surveillance for antibiotic resistance in food products for the early detection of emerging resistant bacteria species in the food chain.

Implementation of antimicrobial stewardship programmes in African countries: a systematic literature review

OBJECTIVE

Antimicrobial stewardship is one of the strategic objectives of the WHO global action plan on antimicrobial resistance. This paper sought to review the extent of implementation of antimicrobial stewardship programmes (ASPs) in African countries and the reported outcomes.

METHODS

We searched five electronic databases, including PubMed, Scopus, Cochrane library, African Journal Online, CINAHL and Google scholar for papers published between 1990 and March 2019. We combined the names of countries in the five regions of Africa with antimicrobial stewardship terms. Studies of any design, employing any stewardship strategies were included. The quality of included studies was assessed using the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool for before and after studies.

RESULTS

Of 1752 titles identified, 13 studies met the criteria for inclusion. Seven of the studies were conducted in South Africa, three in Kenya and one each in Sudan, Tanzania and Egypt. Eleven studies were of high quality with low risk of bias. The included studies mainly assessed the outcome using process measures and these were associated with improved compliance with antibiotic guidelines, appropriateness of prescribing, reduction in antibiotic use and cost savings. Decrease in rate of surgical site infections and nonsignificant change in mortality and 30-day readmission rate were reported in two studies respectively.

CONCLUSION

Findings of this review show the paucity of data on implementation of ASPs in African countries. Although the continent is faced with challenges which impact on effective implementation of ASPs, the successes reported in the included studies show that other African countries can implement these programmes.

Household carriage and acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae: A systematic review

OBJECTIVE

The epidemiology of ESBL-producing Enterobacteriaceae (ESBL-PE) has been extensively studied in hospitals, but data on community transmission are scarce. We investigated ESBL-PE cocarriage and acquisition in households using a systematic literature review.

METHODS

We conducted a systematic literature search to retrieve cross-sectional or cohort studies published between 1990 and 2018 evaluating cocarriage proportions and/or acquisition rates of ESBL-PE among household members, without language restriction. We excluded studies focusing on animal-to-human transmission or conducted in nonhousehold settings. The main outcomes were ESBL-PE cocarriage proportions and acquisition rates, stratified according to phenotypic or genotypic assessment of strain relatedness. Cocarriage proportions of clonally related ESBL-PE were transformed using the double-arcsine method and were pooled using a random-effects model. Potential biases were assessed manually.

RESULTS

We included 13 studies. Among 863 household members of ESBL-PE positive index cases, prevalence of ESBL-PE cocarriage ranged from 8% to 37%. Overall, 12% (95% confidence interval [CI], 8%-16%) of subjects had a clonally related strain. Those proportions were higher for Klebsiella pneumoniae (20%-25%) than for Escherichia coli (10%-20%). Acquisition rates of clonally related ESBL-PE among 180 initially ESBL-PE-free household members of a previously identified carrier ranged between 1.56 and 2.03 events per 1,000 person weeks of follow-up. We identified multiple sources of bias and high heterogeneity (I2, 70%) between studies.

CONCLUSIONS

ESBL-PE household cocarriage is frequent, suggesting intrafamilial acquisition. Further research is needed to evaluate the risk and control of ESBL-PE household transmission.

Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis

BACKGROUND

There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use.

METHODS

We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples.

FINDINGS

The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012-13 and an intervention period of 2014-17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect -15·9%, 95% CI -23·9 to -8·0) and cephalosporins (-22·6%, -35·9 to -9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by -0·028 cases per 1000 inhabitants (95% CI -0·034 to -0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of -65·6% (-68·2 to -63·0) 4 years later.

INTERPRETATION

Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care.

FUNDING

Instituto de Salud Carlos III, Spanish Government (PI14/01523).

Role of antimicrobial restrictions in bacterial resistance control: a systematic literature review

BACKGROUND

Antimicrobial stewardship is considered as one of the most fundamental aspects of bacterial resistance control. Among the multitude of initiatives, restrictive strategies have been widely practiced in hospital settings. However, data concerning their potential effectiveness have not been methodically collected and evaluated to date.

AIM

To identify, collect and evaluate the available evidence regarding the impact of restrictive policies on bacterial resistance in hospital settings.

METHODS

A systematic literature review was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases.

FINDINGS

In total, 5555 papers were retrieved in the search process, and 29 studies were included in the final analysis. There were no randomized studies, and the inherent limitations of the observational designs employed impede the deduction of safe conclusions. Seemingly beneficial interventions encompass the restriction of broad-spectrum cephalosporins in favour of beta-lactam/lactamase inhibitor combinations as well as the restriction of fluoroquinolones. Antimicrobial restrictions might also play a role in the control of vancomycin-resistant enterococci, while carbapenem stewardship in the form of the preferred use of ertapenem did not produce the anticipated results. Complex restrictions are not offered for informative comparative analyses. Hospital-wide policies could perhaps be superior to those confined to high-risk departments. Carbapenem-resistant Acinetobacter baumannii might be difficult to control through solely formulary interventions.

CONCLUSION

The presumably effective restrictive strategies rely mainly on inadequately tested hypotheses and low-quality evidence. Therefore, systematic, high-quality research is needed to confirm and expand comprehension of the subject so that the most successful policies are employed in the field.

A 2-Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes

OBJECTIVES

To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group.

DESIGN

Two-year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group).

SETTING

A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate.

PARTICIPANTS

Nursing staff and medical care providers in the participating NHs.

INTERVENTION

Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit.

MEASUREMENTS

Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections.

RESULTS

Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69-0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65-0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92-0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2-year implementation costs per NH, exclusive of medical provider time, ranged from $354 to $3653.

CONCLUSIONS

Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success. J Am Geriatr Soc 68:46-54, 2019.

Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings

This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.

Influence of primary care antibiotic prescribing on incidence rates of multidrug-resistant Gram-negative bacteria in hospitalised patients

PURPOSE

Use of antibiotics can give rise to the selection of resistant bacteria. It remains unclear whether antibiotic use in primary care can influence bacterial resistance incidence in patients when hospitalised. The aim of this study is to explore the impact of prior community antibiotic usage on hospital-detected multidrug-resistant Gram-negative (MRGN) incidence rate.

METHODS

This pharmacoepidemiological study was case-control in design, and was carried out in the Antrim Area Hospital (N. Ireland) in two phases. In phase 1, the controls were matched according to: age, gender, admission ward, date of admission, and age-adjusted Charlson co-morbidity index score. During the second phase, controls were selected randomly from the total population of admissions to the hospital over the 2-year study period.

RESULTS

In phase 1, multivariate analysis revealed that prior exposure to the second- and third-generation cephalosporins (p = 0.004) and fluoroquinolones (p = 0.023) in primary care was associated with an increased likelihood of MRGN detection in inpatients. In phase 2, an independent relationship between an increased risk of identification of MRGN, while hospitalised was associated with: prolonged hospitalisation (p < 0.001), being elderly (p < 0.001), being female (p = 0.007), and having genitourinary disease (p < 0.001).

CONCLUSION

This study provides clear evidence which supports the need to optimise antibiotic use in primary care to help reduce MRGN incidence in hospitalised patients.

Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party

The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use.

A nonlinear time-series analysis approach to identify thresholds in associations between population antibiotic use and rates of resistance

Balancing access to antibiotics with the control of antibiotic resistance is a global public health priority. At present, antibiotic stewardship is informed by a 'use it and lose it' principle, in which antibiotic use by the population is linearly related to resistance rates. However, theoretical and mathematical models suggest that use-resistance relationships are nonlinear. One explanation for this is that resistance genes are commonly associated with 'fitness costs' that impair the replication or transmissibility of the pathogen. Therefore, resistant genes and pathogens may only gain a survival advantage where antibiotic selection pressures exceed critical thresholds. These thresholds may provide quantitative targets for stewardship-optimizing the control of resistance while avoiding over-restriction of antibiotics. Here, we evaluated the generalizability of a nonlinear time-series analysis approach for identifying thresholds using historical prescribing and microbiological data from five populations in Europe. We identified minimum thresholds in temporal relationships between the use of selected antibiotics and incidence rates of carbapenem-resistant Acinetobacter baumannii (Hungary), extended-spectrum β-lactamase-producing Escherichia coli (Spain), cefepime-resistant E. coli (Spain), gentamicin-resistant Pseudomonas aeruginosa (France) and methicillin-resistant Staphylococcus aureus (Northern Ireland) in different epidemiological phases. Using routinely generated data, our approach can identify context-specific quantitative targets for rationalizing population antibiotic use and controlling resistance. Prospective intervention studies that restrict antibiotic consumption are needed to validate these thresholds.

A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction

In a Policy Forum, Alison Holmes and colleagues discuss coordinated approaches to antimicrobial stewardship.

A multicenter point prevalence survey of antibiotic use in Punjab, Pakistan: findings and implications

OBJECTIVES

In line with the recent global action plan for antimicrobial resistance, this is the first time such a comprehensive antimicrobial point prevalence survey has been undertaken in Pakistan, the sixth most populous country.

METHODS

This point prevalence survey (PPS) was conducted in 13 hospitals among 7 different cities of Pakistan. The survey included all inpatients receiving an antibiotic on the day of PPS. A web-based application was used for data entry, validation, and reporting as designed by the University of Antwerp (www.global-pps.com).

RESULTS

Out of 1954 patients, 1516 (77.6%) were treated with antibiotics. The top three most reported indications for antibiotic use were prophylaxis for obstetrics or gynaecological indications (16.5%), gastrointestinal indications (12.6%) and lower respiratory tract infections (12.0%). The top three most commonly prescribed antibiotics were ceftriaxone (35.0%), metronidazole (16.0%) and ciprofloxacin (6.0%). Out of the total indications, 34.2% of antibiotics were prescribed for community-acquired infections (CAI), 5.9% for healthcare-associated infections (HAI), and 57.4% for either surgical or medical prophylaxis. Of the total use for surgical prophylaxis, 97.4% of antibiotics were given for more than one day.

CONCLUSIONS

Unnecessary prophylactic antibiotic use is extremely high, and broad-spectrum prescribing is common among hospitals in Pakistan. There is an urgent need to work on the  national action plan of Pakistan on antibiotic resistance to address this.

Are third-generation cephalosporins associated with a better prognosis than amoxicillin-clavulanate in patients hospitalized in the medical ward for community-onset pneumonia?

OBJECTIVES

We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin-clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia.

METHODS

We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin-clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other β-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin-clavulanate.

RESULTS

1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin-clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9-12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4-5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3-15.7)), do-not-resuscitate order (aOR 8.7 (5.2-14.6)) and fluid therapy (aOR 6.3 (2.5-15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin-clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7-3.0)).

CONCLUSION

In the largest study aiming to compare amoxicillin-clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin-clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin-clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

Delafloxacin: Place in Therapy and Review of Microbiologic, Clinical and Pharmacologic Properties

Delafloxacin (formerly WQ-3034, ABT492, RX-3341) is a novel fluoroquinolone chemically distinct from currently marketed fluoroquinolones with the absence of a protonatable substituent conferring a weakly acidic character to the molecule. This property results in increased intracellular penetration and enhanced bactericidal activity under acidic conditions that characterize the infectious milieu at a number of sites. The enhanced potency and penetration in low pH environments contrast what has been observed for other zwitterionic fluoroquinolones, which tend to lose antibacterial potency under acidic conditions, and may be particularly advantageous against methicillin-resistant Staphylococcus aureus, for which the significance of the intracellular mode of survival is increasingly being recognized. Delafloxacin is also unique in its balanced target enzyme inhibition, a property that likely explains the very low frequencies of spontaneous mutations in vitro. Delafloxacin recently received US Food and Drug Administration approval for the treatment of acute bacterial skin and skin structure infections and is currently being evaluated in a phase 3 trial among patients with community-acquired pneumonia. In the current era of a heightened awareness pertaining to collateral ecologic damage, safety issues and antimicrobial stewardship principles, it is critical to describe the unique properties of delafloxacin and define its potential role in therapy. The purpose of this article is to review available data pertaining to delafloxacin’s biochemistry, pharmacokinetic/pharmacodynamics characteristics, in vitro activity and potential for resistance selection as well as current progress in clinical trials to ultimately assist clinicians in selecting patients who will benefit most from the distinctive properties of this agent.

Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention

PURPOSE OF REVIEW

Fluoroquinolones are a commonly prescribed antibiotic class that has come under scrutiny in recent years due to mounting evidence of association between adverse drug events, C. difficile infection and isolation of antibiotic-resistant bacteria.

RECENT FINDINGS

Inpatient antimicrobial stewardship (AMS) programs have a toolbox of potential interventions to curb inappropriate antibiotic use, prevent antibiotic-associated adverse drug events, and avoid unnecessary costs of care. Fluoroquinolone restriction policies in the acute care setting have demonstrated beneficial effects, including decreased rates of C. difficile infection and ESBL-producing Enterobacteriaceae. However, a simple blanket restriction policy may "squeeze the antibiotic balloon" and will likely be insufficient if not implemented in conjunction with other AMS interventions. There is a growing body of evidence to support formulary restriction of fluoroquinolones in the acute care setting to decrease rates of C. difficile infection and development of ESBL-producing organisms. Data on how to best implement these restrictions or how to implement outside of acute care settings is limited.

Is There an Association Between Use of Amoxicillin-Clavulanate and Resistance to Third-Generation Cephalosporins in Klebsiella pneumoniae and Escherichia coli at the Hospital Level?

AIMS

Amoxicillin-clavulanate is extensively used in European hospitals. Whether the hospital use of amoxicillin-clavulanate is associated with nonsusceptibility to third-generation cephalosporins (3GC) in Klebsiella pneumoniae is unknown. Our aim was to assess the relationship between the hospital use of amoxicillin-clavulanate and 3GC nonsusceptibility in K. pneumoniae and Escherichia coli.

METHODS

Yearly data of antibiotic use and 3GC nonsusceptibility in K. pneumoniae and E. coli were obtained from 33 French hospitals between 2011 and 2016. Decreased susceptibility to 3GC and Extended-Spectrum Beta-Lactamase (ESBL) production were modelled from antibiotic use with linear mixed models on years 2011 to 2015, and validated on year 2016.

RESULTS

Nonsusceptibility to 3GC increased in K. pneumoniae and E. coli. In a multivariable model that included year and use of 3GC and fluoroquinolones as explanatory variables, amoxicillin-clavulanate use was protective against 3GC nonsusceptibility in K. pneumoniae (incidence rate ratio [IRR], 0.992 [0.988-0.997]), and with ESBL production in K. pneumoniae (IRR, 0.989 [0.985-0.992]). The correlation coefficient between observed and predicted numbers of 3GC-nonsusceptible K. pneumoniae in 2016 was 0.95 (95% confidence interval, 0.89-0.98). There was no significant association between amoxicillin-clavulanate use and 3GC nonsusceptibility in E. coli.

CONCLUSION

Amoxicillin-clavulanate hospital use was protective against nonsusceptibility to 3GC in K. pneumoniae. Conversely, it was not associated with susceptibility to 3GC in E. coli. To decrease the hospital use of 3GC and fluoroquinolones, and 3GC nonsusceptibility in K. pneumoniae, it may be acceptable to increase the hospital use of amoxicillin-clavulanate. Interventional studies are necessary to confirm this hypothesis.

Antibiotics-From There to Where?: How the antibiotic miracle is threatened by resistance and a broken market and what we can do about it

To fully appreciate the importance of antibiotics to everyday life, we must step back to the edge of the pre-antibiotic era when these lifesaving drugs were first introduced into clinical use.

A systematic review of inpatient antimicrobial stewardship programmes involving clinical pharmacists in small-to-medium-sized hospitals

Objective

Antimicrobial stewardship programmes (ASPs) have been widely implemented in large hospitals but little is known regarding small-to-medium-sized hospitals. This literature review evaluates outcomes described for ASPs participated in by clinical pharmacists and implemented in small-to-medium-sized hospitals (<500 beds).

Methods

Following PRISMA principles, PubMed and Cochrane Library databases were searched in early 2016 for English language articles describing implementation and outcomes for inpatient ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. Each included study was required to include at least one of the following outcomes: microbiological outcomes, quality of care and clinical outcomes or antimicrobial use and cost outcomes.

Results

We included 28 studies from 26 hospitals, mostly American or Canadian. Most cases (23 studies) consisted of time-series comparisons of pre-and post-intervention periods. Of the 28 studies analysed, 8 reported microbiological outcomes, 21 reported quality of care and clinical outcomes, and 27 reported antimicrobial use and cost outcomes. Interventions were not generally associated with significant changes in mortality or readmission rates but were associated with substantial cost savings, mainly due to reduced use of antibiotics or the use of cheaper antibiotics.

Conclusion

As far as we are aware, ours is the first systematic review that evaluates ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. ASPs appear to be an effective strategy for reducing antimicrobial use and cost. However, the limited association with better microbiological, care quality and clinical outcomes would highlight the need for further studies and for standardised methods for evaluating ASP outcomes.

Trend and seasonality of community-acquired Escherichia coli antimicrobial resistance and its dynamic relationship with antimicrobial use assessed by ARIMA models

INTRODUCTION

We studied the trend and seasonality of community-acquired Escherichia coli resistance and quantified its correlation with the previous use of certain antibiotics.

METHODS

A time series study of resistant community-acquired E. coli isolates and their association with antibiotic use was conducted in a Primary Health Care Area from 2008 to 2012. A Poisson regression model was constructed to estimate the trend and seasonality of E. coli resistance.

RESULTS

A significant increasing trend in mean E. coli resistance to cephalosporins, aminoglycosides and nitrofurantoin was observed. Seasonal resistance to ciprofloxacin and amoxicillin-clavulanic acid was significantly higher in autumn-winter. There was a delay of 7, 10 and 12 months between the use of cotrimoxazole (P<0.038), fosfomycin (P<0.024) and amoxicillin-clavulanic acid (P<0.015), respectively, and the occurrence of E. coli resistance.

CONCLUSIONS

An average delay of 10 months between the previous use of amoxicillin-clavulanic acid, cotrimoxazole and fosfomycin and the appearance of resistant community-acquired E. coli strains was detected.

Impact of clinical pharmacist intervention on antimicrobial use in a small 164-bed hospital

Objectives

To study the impact of clinical pharmacist interventions (PIs) on antimicrobial prescriptions in terms of physician acceptance rates, clinical benefits and antimicrobial use/cost outcomes.

Methods

This study retrospectively analysed the impact of antimicrobial PIs over a 2-year period (October 2012 to October 2014) in a private non-teaching 164-bed hospital without a formal antimicrobial stewardship programme. Excluded from the study were outpatients and patients admitted to the intensive care unit or the emergency department. The PIs focused on appropriate indication and appropriate dosage; drug adverse events, allergies, intolerance and interactions; sequential therapy; therapeutic de-escalation; excessive duration of treatment and therapeutic drug monitoring. Carbapenems and linezolid were classified as special-vigilance drugs. Amoxicillin-clavulanic, piperacillin-tazobactam and vancomycin were classified as preferred drugs. Clinical benefits evaluated in accordance with internal guidelines, were classified as enhancing appropriate antimicrobial prescription or potentially reducing toxicity. Antimicrobial use and expenditure were compared with that of the previous 2-year period.

Results

386 PIs were implemented in 303 patients. The overall acceptance rate was 83.4%. The acceptance rate for appropriate prescription PIs was significantly lower than for toxicity PIs (73.7% vs 90.9%; p<0.0001). Significant reductions in the use of special-vigilance drugs (from 39.9 (22.2-86.0) to 28.0 (6.0-43.4) defined daily doses (DDD)/1000 patient-days; p=0.0003) were seen and increases in the use of piperacillin-tazobactam (from 13.2 (0-22.9) to 17.2 (6.9-44.8) DDD/1000 patient-days; p=0.007) and of cephalosporins (from 123.5 (61.8-196.6) to 149.1 (80.3-228.2) DDD/1000 patient-days; p=0.027). Overall cost savings were 5.1%.

Conclusions

PIs on antimicrobial prescriptions may be effective in enhancing appropriate use of antimicrobials, reducing their toxicity, reducing the use of special-vigilance drugs and reducing overall antimicrobial cost.

The Impact of Antibiotic Stewardship Programs in Combating Quinolone Resistance: A Systematic Review and Recommendations for More Efficient Interventions

Quinolones are among the most commonly prescribed antibiotics worldwide. A clear relationship has been demonstrated between excessive quinolone use and the steady increase in the incidence of quinolone-resistant bacterial pathogens, both in hospital and community sites. In addition, exposure to quinolones has been associated with colonization and infection with healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus and Clostridium difficile in hospitalized patients. Therefore, the management of quinolone prescribing in hospitals through antibiotic stewardship programs is considered crucial. Although suggestions have been made by previous studies on the positive impact of stewardship programs concerning the emergence and spread of multidrug-resistant bacteria at hospital level, the association of quinolone-targeted interventions with reduction of quinolone resistance is vague. The purpose of this article was to evaluate the impact of stewardship interventions on quinolone resistance rates and healthcare-associated infections, through a literature review using systematic methods to identify and select the appropriate studies. Recommendations for improvements in quinolone-targeted stewardship programs are also proposed. Efforts in battling quinolone resistance should combine various interventions such as restriction formulary policies, prospective audits with feedback to prescribers, infection prevention and control measures, prompt detection of low-level resistance, educational programs, and guidelines for optimal quinolone usage. However, the effectiveness of such strategies should be assessed by properly designed and conducted clinical trials. Finally, novel approaches in diagnostic stewardship for rapidly detecting bacterial resistance, including PCR-based techniques, mass spectrometry, microarrays, and whole-genome sequencing as well as the prompt investigation on the clonality of quinolone-resistant strains, will strengthen our ability to personalize quinolone prescribing to individual patients.

Antimicrobial-resistant Escherichia coli in hospitalised companion animals and their hospital environment

INTRODUCTION

Antimicrobial resistance is a growing concern with implications for animal health. This study investigated the prevalence of antimicrobial resistance among commensal and environmental Escherichia coli isolated from animals sampled in referral hospitals in the UK.

MATERIALS AND METHODS

Resistant Escherichia coli isolated from animal faeces and practice environments were tested for susceptibility to antimicrobial agents. PCR and sequencing techniques were used to identify extended spectrum beta-lactamase and AmpC-producer genotypes.

RESULTS

In total, 333 faecal and 257 environmental samples were collected. Multi-drug resistant Escherichia coli were found in 13·1% of faecal and 8·9% of environmental samples. Extended spectrum beta-lactamase and AmpC genes were identified 14% and 7·7% of faecal samples and 8·6% and 8·6% of environmental samples, respectively. The most common extended spectrum beta-lactamase gene type detected was blaCTX-M -15 , although blaTEM-158 was detected in faecal and environmental samples from one practice.

CLINICAL SIGNIFICANCE

Escherichia coli resistant to key antimicrobials were isolated from hospitalised animals and the practice environment. We identified the emergence of the inhibitor resistant and extended spectrum beta-lactamase blaTEM-158 in companion animals. Further investigation to determine risk factors for colonisation with antimicrobial-resistant bacteria is needed to provide evidence for antimicrobial stewardship and infection control programmes.

Comparison of rates of fecal colonization with extended-spectrum beta-lactamase-producing enterobacteria among patients in different wards, outpatients and medical students

Because asymptomatic carriage of extended-spectrum beta-lactamase (ESBL) producers is a risk factor for infection, data on colonization dynamics are important when planning infection control. This study investigated fecal colonization with ESBL producers among inpatients, outpatients and medical students and compares the characteristics of ESBL producers among these groups. Carriage rates were investigated in 5581 fecal samples; 4343 from inpatients (330, 1397, 619 and 1864 from adult ICUs [intensive care units], adult non-ICUs, pediatric ICUs and pediatric non-ICUs, respectively), 814 from outpatients and 424 from screening of medical students. ESBL producers were characterized by co-resistance, integrons carried, and aminoglycoside resistance and ESBL genes. Dynamic regression models were built to identify relationships between combinations of time series of monthly antibiotic consumption, prevalence of carriers and infected subjects. Inpatients, ICU patients and adults showed higher prevalence than outpatients, non-ICU patients or children (7.4%, 9.3% and 12.0% vs. 3.1%, 6.1% and 4.1%, respectively). Klebsiella pneumoniae was more frequent in ICU patients; dominance of CTX-M-15 producers was more marked in adult than in pediatric inpatients. ESBL carriage was shown to be a consequence of infection in adults in the time-series analysis; antibiotic consumption had little effect. The epidemiology of colonization with ESBL producers differed between pediatric ICU, adult ICU and adult non-ICU patients. In adults, carriage of ESBL producers seems to be the consequence of infection, especially in ICU patients; the main source of colonization is nosocomial acquisition. In contrast, children are less likely to acquire colonizer strains in hospitals; importation of ESBL producers by colonized children seems to be significant.

Prevalence of antibiotic susceptibility and resistance of Escherichia coli in acute uncomplicated cystitis in Korea: Systematic review and meta-analysis

BACKGROUND

The aim of this study is to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli Escherichia coli (E coli) in female uncomplicated cystitis in Korea using meta-analysis.

METHODS

A cross-search of the literature was performed with MEDLINE for all relevant data published before October 2015 and EMBASE from 1980 to 2015, the Cochrane Library, KoreaMed, RISS, KISS, and DBPia were also searched. Observational or prospective studies that reported the prevalence of antimicrobial susceptibility and resistance of E coli were selected for inclusion. No language or time restrictions were applied. We performed a meta-analysis using a random effects model to quantify the prevalence of antimicrobial susceptibility and resistance of E coli.

RESULTS

Ten studies were eligible for the meta-analysis, which together included a total of 2305 women with uncomplicated cystitis. The overall resistance rate to antibiotics was 0.28 (95% confidence interval [CI]: 0.25, 0.32). The pooled resistance rates were 0.08 (95% CI: 0.06, 0.11) for cephalosporin, 0.22 (95% CI: 0.18, 0.25) for fluoroquinolone (FQ), and 0.43 (95% CI: 0.35, 0.51) for trimethoprim/sulfamethoxazole (TMP/SMX). Regression analysis showed that resistance to FQ is increasing (P = 0.014) and resistance to TMP/SMX is decreasing (P = 0.043) by year. The generation of cephalosporin was not a significant moderator of differences in resistance rate.

CONCLUSION

The resistance rate of FQ in Korea is over 20% and is gradually increasing. Although the resistance rate of TMP/SMX is over 40%, its tendency is in decreasing state. Antibiotic strategies used for the treatment of uncomplicated cystitis in Korea have to be modified.