Principles of good use of antibiotics in hospitals

Development of machine learning algorithms for scaling-up antibiotic stewardship

BACKGROUND

Antibiotic stewardship programs (ASP) aim to reduce inappropriate use of antibiotics, but their labor-intensive nature impedes their wide adoption. The present study introduces explainable machine learning (ML) models designed to prioritize inpatients who would benefit most from stewardship interventions.

METHODS

A cohort of inpatients who received systemic antibiotics and were monitored by a multidisciplinary ASP team at a tertiary hospital in the Republic of Korea was assembled. Data encompassing over 130,000 patient-days and comprising more than 160 features from multiple domains, including prescription records, laboratory, microbiology results, and patient conditions was collected.Outcome labels were generated using medication administration history: discontinuation, switching from intravenous to oral medication (IV to PO), and early or late de-escalation. The models were trained using Extreme Gradient Boosting (XGB) and light Gradient Boosting Machine (LGBM), with SHapley Additive exPlanations (SHAP) analysis used to explain the model's predictions.

RESULTS

The models demonstrated strong discrimination when evaluated on a hold-out test set(AUROC - IV to PO: 0.81, Early de-escalation: 0.78, Late de-escalation: 0.72, Discontinue: 0.80). The models identified 41%, 16%, 22%, and 17% more cases requiring discontinuation, IV to PO, early and late de-escalation, respectively, compared to the conventional length of therapy strategy, given that the same number of patients were reviewed by the ASP team. The SHAP results explain how each model makes their predictions, highlighting a unique set of important features that are well-aligned with the clinical intuitions of the ASP team.

CONCLUSIONS

The models are expected to improve the efficiency of ASP activities by prioritizing cases that would benefit from different types of ASP interventions along with detailed explanations.

Clinical Epidemiology, Risk Factors, and Control Strategies of Klebsiella pneumoniae Infection

Klebsiella species cause infections at multiple sites, including lung, urinary tract, bloodstream, wound or surgical site, and brain. These infections are more likely to occur in people with preexisting health conditions. Klebsiella pneumoniae (K. pneumoniae) has emerged as a major pathogen of international concern due to the increasing incidences of hypervirulent and carbapenem-resistant strains. It is imperative to understand risk factors, prevention strategies, and therapeutic avenues to treat multidrug-resistant Klebsiella infections. Here, we highlight the epidemiology, risk factors, and control strategies against K. pneumoniae infections to highlight the grave risk posed by this pathogen and currently available options to treat Klebsiella-associated diseases.

Phylogeny, Biofilm Production, and Antimicrobial Properties of Fecal Microbial Communities of Adi Tribes of Arunachal Pradesh, India

The fecal flora consists of trillions of bacteria influencing human health and several host factors. Such population-based fecal flora studies are critical to uplift the health status of ethnic tribes from Arunachal Pradesh. This study aimed to analyze the ethnic tribe's biofilm producing antibiotic resistant bacteria and their phyllogenetic analysis in 15 stool samples collected from Adi tribes of Arunachal Pradesh. Of the analyzed samples, 42.85% were Escherichia, 20% lactic acid bacteria, 20% Salmonella, and 17.14% Enterococcus. Escherichia coli, lactic acid bacteria, and Enterococcus sp. emerged as strong biofilm producers; however, Salmonella declined to exhibit characters for a strong biofilm producer. Tetracycline resistance dominated in all the gut bacterial profiles. The 16SrRNA amplified PCR product was used for sequencing, and a phylogenetic tree was constructed exhibiting the relationship between the isolates. The test sequences were compared with the non-redundant Gene bank collection of the database with the Basic Local Alignment Search Tool.

Adaptation of Lactobacillus plantarum to Ampicillin Involves Mechanisms That Maintain Protein Homeostasis

The widespread use of antibiotics has caused great concern in the biosafety of probiotics. In this study, we conducted a 12-month adaptive laboratory evolution (ALE) experiment to select for antibiotics-adapted Lactobacillus plantarum P-8, a dairy-originated probiotic bacterium. During the ALE process, the ampicillin MIC for the parental L. plantarum P-8 strain increased gradually and reached the maximum level of bacterial fitness. To elucidate the molecular mechanisms underlying the ampicillin-resistant phenotype, we comparatively analyzed the genomes and proteomes of the parental strain (L. plantarum P-8) and two adapted lines (L. plantarum 400g and L. plantarum 1600g). The adapted lines showed alterations in their carbon, amino acid, and cell surface-associated metabolic pathways. Then, gene disruption mutants were created to determine the role of six highly expressed genes in contributing to the enhanced ampicillin resistance. Inactivation of an ATP-dependent Clp protease/the ATP-binding subunit ClpL, a small heat shock protein, or a hypothetical protein resulted in partial but significant phenotypic reversion, confirming their necessary roles in the bacterial adaptation to ampicillin. Genomic analysis confirmed that none of the ampicillin-specific differential expressed genes were flanked by any mobile genetic elements; thus, even though long-term exposure to ampicillin upregulated their expression, there is low risk of spread of these genes and adapted drug resistance to other bacteria via horizontal gene transfer. Our study has provided evidence of the biosafety of probiotics even when used in the presence of antibiotics.IMPORTANCE Antibiotic resistance acquired by adaptation to certain antibiotics has led to growing public concerns. Here, a long-term evolution experiment was used together with proteomic analysis to identify genes/proteins responsible for the adaptive phenotype. This work has provided novel insights into the biosafety of new probiotics with high tolerance to antibiotics.

Cross-sectional study of the use of antimicrobials following common infections by rural residents in Anhui, China

OBJECTIVE

To describe help seeking behaviour from a medical doctor and antimicrobial use for common infections among rural residents of Anhui province, China.

DESIGN

A cross-sectional retrospective household survey.

SETTING

12 administrative villages from rural Anhui, China.

PARTICIPANTS

2760 rural residents selected through cluster-randomised sampling using an interviewer administered questionnaire.

METHOD

Logistic regression models were used to estimate associations between exposures (health insurance and antimicrobial-related knowledge), adjusted for confounders (sex, age and education), and help-seeking behaviour from a medical doctor and antimicrobial use following common infections, including acute respiratory tract infections (ARTIs), gastrointestinal tract infections (GTIs) and urinary tract infections (UTIs).

RESULTS

In total 2611 (94.6%) rural residents completed the questionnaire. Help seeking from a medical doctor was highest for ARTIs (59.4%) followed by GTIs (42.1%), and UTIs (27.8%). Around two-thirds (82.3% for ARTIs, 87.0% for GTIs and 66.0% for UTIs) of respondents sought help within 3 days following symptom onset and over three quarters (88% for ARTIs, 98% for GTIs and 77% for UTIs) reported complete recovery within 7 days. Of the help-seeking respondents, 94.5% with ARTI symptoms recalled being prescribed either oral or intravenous antimicrobials (GTIs 81.7% and UTIs 70.4%). Use of antimicrobials bought from medicine shops without prescriptions ranged from 8.8% for GTIs to 17.2% for ARTIs; while use of antimicrobials leftover from previous illnesses or given by a relative ranged from 7.6% for UTIs to 13.4% for ARTIs. Multivariate logistic regression analysis revealed that respondents with a higher antimicrobial-related knowledge score and lack of insurance were associated with lower levels of help-seeking for ARTIs; while respondents with a higher antimicrobial-related knowledge score were less likely to be prescribed either oral or intravenous antimicrobials.

CONCLUSIONS

Excessive antimicrobial use in the studied primary care settings is still prevalent.

Parental knowledge, attitudes and practices regarding antibiotic use for acute upper respiratory tract infections in children: a cross-sectional study in Palestine

BACKGROUND

In primary health care centres, upper respiratory tract infections (URTIs) in children are commonly encountered by physicians. Viruses cause most URTIs, but parents' attitudes often represent an important reason for antibiotic abuse, which leads to the development and spread of antimicrobial resistance. The goal of this study was to examine parents' knowledge, attitudes, and practices (KAP) about antibiotic use for children with URTIs in Palestine.

METHODS

A cross-sectional study was performed in primary health care centres in Nablus city from 1 June to 31 October 2012. A questionnaire was developed and administered to determine parents' KAP regarding antibiotic use for their children with URTIs.

RESULTS

Three hundred and eighty-five parents completed the questionnaire. A total of 79.7% of the parents were attentive to the truth that antibiotic misuse is responsible for bacterial resistance. Only 18.9% of parents thought that antibiotics did not have any harmful side effects. Fifty nine per cent of parents did not agree that URTIs are mostly viral in origin and are self-limited. Almost 73% of parents choose antibiotics as a treatment for URTIs, while earache (68%) and fever (64%) were the most common reasons for which parents expected antibiotics. However, more than 38% of the parents never asked the paediatrician to prescribe antibiotics, and only 6% congratulated their paediatricians for not prescribing antibiotics.

CONCLUSIONS

Although there is a trusted relationship between parents and paediatricians, Palestinian parents have insufficient knowledge related to antibiotic use for URTIs in children, which results in inappropriate attitudes and practices. Educational interventions for both parents and physicians will reduce unnecessary antibiotic use and resistance.

A novel chlorhexidine-releasing composite bone cement: Characterization of antimicrobial effectiveness and cement strength

The addition of calcium phosphate fillers or antimicrobials to bone cements seems to produce inferior materials. In this study, a two-solution bone cement composite was designed for high viscosity and high pseudoplasticity to improve injection and mitigate the risk of extravasation. By pre-mixing these cements, the fillers are incorporated into the matrix and should not detrimentally affect the performance properties. To expand the functionality of this cement system, the addition of bioactive and antimicrobial phases were explored. Brushite and chlorhexidine were used as calcium phosphate filler and the antimicrobial phase, respectively. By controlling the free radical quenching mechanism provided by the chlorhexidine molecule, it was possible to achieve high polymer conversion rates. This phenomenon led to cement strength retention while successfully preventing microbial proliferation in an environment exposed to the cement surface. Based on these results, two-solution cement composite prepared with high concentrations of brushite and chlorhexidine diacetate salt hydrate may provide an attractive bioactive and antimicrobial cement for load-bearing applications.

In silico analysis of antibiotic resistance genes in the gut microflora of individuals from diverse geographies and age-groups

The spread of antibiotic resistance, originating from the rampant and unrestrictive use of antibiotics in humans and livestock over the past few decades has emerged as a global health problem. This problem has been further compounded by recent reports implicating the gut microbial communities to act as reservoirs of antibiotic resistance. We have profiled the presence of probable antibiotic resistance genes in the gut flora of 275 individuals from eight different nationalities. For this purpose, available metagenomic data sets corresponding to 275 gut microbiomes were analyzed. Sequence similarity searches of the genomic fragments constituting each of these metagenomes were performed against genes conferring resistance to around 240 antibiotics. Potential antibiotic resistance genes conferring resistance against 53 different antibiotics were detected in the human gut microflora analysed in this study. In addition to several geography/country-specific patterns, four distinct clusters of gut microbiomes, referred to as ‘Resistotypes’, exhibiting similarities in their antibiotic resistance profiles, were identified. Groups of antibiotics having similarities in their resistance patterns within each of these clusters were also detected. Apart from this, mobile multi-drug resistance gene operons were detected in certain gut microbiomes. The study highlighted an alarmingly high abundance of antibiotic resistance genes in two infant gut microbiomes. The results obtained in the present study presents a holistic ‘big picture’ on the spectra of antibiotic resistance within our gut microbiota across different geographies. Such insights may help in implementation of new regulations and stringency on the existing ones.

A clinical pathway for community-acquired pneumonia: an observational cohort study

BACKGROUND

Six hospitals instituted a voluntary, system-wide, pathway for community acquired pneumonia (CAP). We proposed this study to determine the impact of pathway antibiotics on patient survival, hospital length of stay (LOS), and total hospital cost.

METHODS

Data were collected for adults from six U.S. hospitals with a principal CAP discharge diagnosis code, a chest infiltrate, and medical notes indicative of CAP from 2005-2007. Pathway and non-pathway cohorts were assigned according to antibiotics received within 48 hours of admission. Pathway antibiotics included levofloxacin 750 mg monotherapy or ceftriaxone 1000 mg plus azithromycin 500 mg daily. Multivariable regression models assessed 90-day mortality, hospital LOS, total hospital cost, and total pharmacy cost.

RESULTS

Overall, 792 patients met study criteria. Of these, 505 (64%) received pathway antibiotics and 287 (36%) received non-pathway antibiotics. Adjusted means and p-values were derived from Least Squares regression models that included Pneumonia Severity Index risk class, patient age, heart failure, chronic obstructive pulmonary disease, and admitting hospital as covariates. After adjustment, patients who received pathway antibiotics experienced lower adjusted 90-day mortality (p = 0.02), shorter mean hospital LOS (3.9 vs. 5.0 days, p < 0.01), lower mean hospital costs ($2,485 vs. $3,281, p = 0.02), and similar mean pharmacy costs ($356 vs. $442, p = 0.11).

CONCLUSIONS

Pathway antibiotics were associated with improved patient survival, hospital LOS, and total hospital cost for patients admitted to the hospital with CAP.

Does cyclical loading affect the elution of antibiotics from articulating cement knee spacers?

Two-stage revision surgery for infected total knee replacement offers the highest rate of success for the elimination of infection. The use of articulating antibiotic-laden cement spacers during the first stage to eradicate infection also allows protection of the soft tissues against excessive scarring and stiffness. We have investigated the effect of cyclical loading of cement spacers on the elution of antibiotics. Femoral and tibial spacers containing vancomycin at a constant concentration and tobramycin of varying concentrations were studied in vitro. The specimens were immersed and loaded cyclically to 250 N, with a flexion excursion of 45°, for 35 000 cycles. The buffered solution was sampled at set intervals and the antibiotic concentration was established so that the elution could be calculated. Unloaded samples were used as a control group for statistical comparison.

The elution of tobramycin increased proportionately with its concentration in cement and was significantly higher at all sampling times from five minutes to 1680 minutes in loaded components compared with the control group (p = 0.021 and p = 0.003, respectively). A similar trend was observed with elution of vancomycin, but this failed to reach statistical significance at five, 1320 and 1560 minutes (p = 0.0508, p = 0.067 and p = 0.347, respectively). However, cyclically loaded and control components showed an increased elution of vancomycin with increasing tobramycin concentration in the specimens, despite all components having the same vancomycin concentration. The concentration of tobramycin influences both tobramycin and vancomycin elution from bone cement. Cyclical loading of the cement spacers enhanced the elution of vancomycin and tobramycin.

Usage of antimicrobial agents in a private primary healthcare setting in South Africa

Objective

The aim of this study was to investigate the prescribing of antimicrobials in a private primary healthcare setting in South Africa.

Setting

A group of private primary healthcare clinics in South Africa.

Method

A retrospective, drug utilisation study was conducted on nine clinics that were randomly selected from 33 clinics situated in different geographical areas of South Africa, and whose data were electronically available. Data were obtained from the central database of the private primary healthcare provider and extracted for the period January 1, to December 31, 2001.

Key findings

The study population consisted of the total patient population (n = 83 655) who visited the clinics during this one-year period. The total number of medicine items prescribed was 515 976 at a total cost of R1 716 319 ($17 163). Of these, antimicrobials represented 18.69% (n = 96 421) of all medicine items prescribed at a cost of R1 045 108 ($10 451) (60.89%). Antimicrobials were prescribed during 72.72% of consultations at the nine clinics during the one-year period. The antimicrobials most frequently prescribed were penicillins (38.17%) followed by sulphonamides (22.49%), antiprotozoals (9.88%) and tetracyclines (9.34%). The most common diagnoses for which antimicrobials were prescribed were viral influenza, upper respiratory tract infections, hypertension, acute bronchitis, and common cold.

Conclusions

The high percentage of antimicrobial prescribing obtained in this study could indicate excessive use of antimicrobials in the private primary healthcare setting. The prescribing of antimicrobials in respiratory tract infections could indicate overuse and inappropriate use of these agents. This could have an effect on the health of the patients needing care, and the general budget for healthcare services. It is recommended that further investigations on the prescribing protocols of antimicrobial usage be done.

Impact of aminoglycoside cycling in six tertiary intensive care units: prospective longitudinal interventional study

AIM

To determine the effect of aminoglycoside cycling in six tertiary intensive care units (ICU) on the rates of sepsis, aminoglycoside resistance patterns, antibiotic consumption, and costs.

METHODS

This was a prospective longitudinal interventional study that measured the effect of change from first-line gentamicin usage (February 2002-February 2003) to amikacin usage (February 2003-February 2004) on the aminoglycoside resistance patterns, number of patients with gram-negative bacteremia, consumption of antibiotics, and the cost of antimicrobial drugs in 6 tertiary care ICUs in Zagreb, Croatia.

RESULTS

The change from first-line gentamicin to amikacin usage led to a decrease in the overall gentamicin resistance of gram-negative bacteria (GNB) from 42% to 26% (P<0.001; z-test of proportions) and netilmicin resistance from 33% to 20% (P<0.001), but amikacin resistance did not change significantly (P=0.462), except for Acinetobacter baumanni (P=0.014). Sepsis rate in ICUs was reduced from 3.6% to 2.2% (P<0.001; chi(2) test), with a decline in the number of nosocomial bloodstream infections from 55/100 patient-days to 26/100 patient-days (P=0.001, chi(2) test). Furthermore, amikacin use led to a 16% decrease in the overall antibiotic consumption and 0.1 euro/patient/d cost reduction.

CONCLUSION

Exclusive use of amikacin significantly reduced the resistance of GNB isolates to gentamicin and netilmicin, the number of GNB nosocomial bacteremias, and the cost of total antibiotic usage in ICUs.

Relation entre politique de bon usage et consommation des antibiotiques dans les établissements de santé

OBJECTIVE

The authors had for aim to study the relationship between antibiotic policies and antibiotic consumption in hospitals.

DESIGN

A component analysis was used to summarize the various measures of the antibiotic policies developed by hospitals. Antibiotics consumption was expressed as a number of Daily Defined Doses per 1,000 patient-days. The relation was studied by a multiple linear regression model with adjustment on hospital activity.

RESULTS

The first component illustrated an active program of antibiotic policies associating: a local antibiotic committee, an infectious diseases consultant, written local guidelines for prescriptions and restrictive measures before dispensing. The highest antibiotic consumption was associated with active policies, especially for carbapenems, glycopeptides, and aminoglycosides. However the relationship differed according to the type of hospital, with lower antibiotic consumption, especially for penicillins, in private hospitals that had more active policies.

CONCLUSION

The difference between public and private hospitals could be explained by the type of institution but also by the unit used to measure antibiotic consumption.

Antibiotic prescribing in primary care: first choice and restrictive prescribing are two different traits

OBJECTIVE

To investigate the quality of antibiotic prescribing in primary care using quality indicators and the relatedness of these indicators. To determine the influence of general practice and practice population characteristics on the indicator scores.

METHODS

Data on performance were collected during the Second National Survey of General Practice over 1 year between May 2000 and April 2002 in The Netherlands. The study was carried out in 104 computerised general practices, comprising 195 general practitioners and about 400,000 patients. From a preliminary set of quality indicators on antibiotic prescribing (n = 15), eight were selected covering various medical conditions. Indicator scores were derived. A factor analysis was performed to examine the relatedness of these indicators. Composite scores were calculated for the indicators loading on the same factor. The influence of general practice and practice population characteristics on the quality of antibiotic prescribing was investigated.

RESULTS

Considerable variation was found between indicator scores (32.8-94.2%) and between practices. The factor analysis discovered two interpretable factors-namely, "first choice prescribing" and "restrictive prescribing". The composite scores were 64% and 68%, respectively. No significant correlation was found between the two composite scores. Practice and population characteristics explained only a small proportion of the variance between practices.

CONCLUSIONS

Although different quality indicators on antibiotic prescribing are grouped together over several medical conditions, there is large variation between those indicators. General practices performing well on first choice prescribing do not automatically perform well on restrictive prescribing. There is room for improvement on both aspects of prescribing. The variation between practices is clearly present and should be further investigated.

A multicenter point-prevalence study: antimicrobial prescription frequencies in hospitalized patients in Turkey

Background

Accurate information about prescribing patterns in hospitals is valuable in improving the quality of antimicrobial prescriptions.

Methods

Data on the use of antimicrobial agents in eighteen tertiary care hospitals were collected on March 20th 2002.

Results

One or more antimicrobials were ordered in 2900 (30.6 %)of 9471 hospitalized patients. The reasons of hospitalization of the patients receiving antimicrobials were medical treatment (42.5 %), elective surgery (39.6 %), treatment of infectious disease (17.1 %) and emergent surgical procedures (10.4 %). The highest consumption frequencies were found in surgical (81.6 %) and medical (55.2 %) intensive care units. The 48.8 % of antimicrobials were given for treatment and 44.2 % for prophylactic use. The most common reasons for treatment were found as lower respiratory tract, urinary tract, surgical wound infections and febrile neutropenia. Antimicrobials were ordered empirically in 78.4 % of patients. The proven infection ratio was found as 30.7 %. The 56.4 % and 13.4 % of orders were evaluated as clinically and microbiologically appropriate respectively.

Conclusion

These results suggest that antimicrobial prescription and empirical treatment ratios were high and inappropriate at inpatient groups.

Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit

The purpose of this study was to assess the effect of reducing prescription of fluoroquinolones in an intensive care unit (ICU) upon bacterial resistance, particularly as regards Pseudomonas aeruginosa. For six months between January 2001 and June 2001, administration of fluoroquinolones was kept to a minimum. A bacteriological screening of patients was performed to assess the incidence of fluoroquinolone-resistant bacteria. There was a 75.8% restriction in prescriptions of fluoroquinolones. There was no significant change in bacterial ecology between the periods preceding (12 months) and following (12 months) restriction. There was a significant recovery of sensitivity of P. aeruginosa to ciprofloxacin (P<or=0.01), with a decrease in resistant strains from 71.3% in the pre-restriction period to 52.4% in the post-restriction period. Regarding clinical data, no significant differences were noted between the pre-restriction and the post-restriction periods, except for the number of cases of ventilator-associated pneumonia with P. aeruginosa resistant to ciprofloxacin. This study demonstrated the possibility of introducing rotation of antibiotics in an ICU.

Developing countries have their own characteristic problems with infection control

Infection control in developing countries differs markedly from that in the developed countries. It is important that both local and international authorities take these differences into account when formulating policies for use in developing countries. This review examines these issues and sets out some suggestions for improvements. The advantages of involving local experts in the development of such policies are emphasized.

Backgrounds of antibiotic-loaded bone cement and prosthesis-related infection

Antibiotic-loaded bone cement has been in use for over 30 years for the fixation of total joint arthroplasties, although its mechanism of action is still poorly understood. This review presents the backgrounds of bone cements, prosthesis-related infection and antibiotic-loaded bone cements. It is shown that antibiotic-loaded bone cement has a significant effect on bacteria, particularly in animal and clinical studies. However, recently, antimicrobial resistance among bacteria has been ascribed to the antibiotic-loaded bone cement. The unresolved issues both regarding the action of antibiotic-loaded bone cement and the nature of the antimicrobial resistance necessitate further research into the interaction of antibiotic-loaded bone cement and bacteria.