Enforcing surveillance of antimicrobial resistance and antibiotic use to drive stewardship: experience in a paediatric setting

BACKGROUND

Antibiotic stewardship (AS) interventions in paediatrics are still not standardized regarding methodology, metrics, and outcomes. We report the results of an AS intervention in the paediatric area based on education and guideline provision via an electronic App.

MATERIALS AND METHODS

The AS intervention was conducted in 2021 through observation, education, audit and feedback and provision of an electronic App (Firstline.org) to support antibiotic prescription based on local susceptibility data. The primary outcome was the antibiotic consumption in the 12 months following the intervention (year 2022) compared with a historical 12-month control (year 2019) via an interrupted time series analysis. Secondary outcomes were appropriateness of therapy, length of stay, 30-day readmission, transfers to the paediatric intensive care unit, in-hospital mortality, and prevalence of antimicrobial resistance (AMR).

RESULTS

During the post-intervention phase, 29 cross-sectional audits and feedback were conducted including 467 patients. Prescriptions were appropriate according to the guidelines in 85.7% of cases, with a stable trend over time. A significant decrease in antibiotic consumption was measured in terms of defined daily doses per 1000 patient days (-222.13; P<0.001) and days of therapy per 1000 patient days (-452.49; P<0.001) in the post-intervention period with a clear inversion of the Access to Watch ratio (from 0.7 to 1.7). Length of stay, in-hospital mortality, intensive care unit transfers, and incidence of AMR infections remained stable, while 30-day readmission decreased from 4.9 per 100 admissions to 2.8 per 100 admissions (P<0.001).

CONCLUSIONS

The intervention was associated with a significant reduction in antimicrobial consumption and an increase in the appropriateness of prescriptions. Electronic tools can be of value in promoting adherence to guidelines and ensuring the sustainability of results.

Antimicrobial Prophylaxis in Neonates and Children Undergoing Dental, Maxillo-Facial or Ear-Nose-Throat (ENT) Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in surgical procedures, mainly because clean/contaminated surgery involves organs that are normally colonized by bacteria. Dental, maxillo-facial and ear-nose-throat (ENT) surgeries are among those that carry a risk of SSIs because the mouth and the first respiratory tracts are normally colonized by a bacterial flora. The aim of this consensus document was to provide clinicians with recommendations on surgical antimicrobial prophylaxis in neonates (<28 days of chronological age) and pediatric patients (within the age range of 29 days−18 years) undergoing dental, maxillo-facial or ENT surgical procedures. These included: (1) dental surgery; (2) maxilla-facial surgery following trauma with fracture; (3) temporo-mandibular surgery; (4) cleft palate and cleft lip repair; (5) ear surgery; (6) endoscopic paranasal cavity surgery and septoplasty; (7) clean head and neck surgery; (8) clean/contaminated head and neck surgery and (9) tonsillectomy and adenoidectomy. Due to the lack of pediatric data for the majority of dental, maxillo-facial and ENT surgeries and the fact that the recommendations for adults are currently used, there is a need for ad hoc studies to be rapidly planned for the most deficient areas. This seems even more urgent for interventions such as those involving the first airways since the different composition of the respiratory microbiota in children compared to adults implies the possibility that surgical antibiotic prophylaxis schemes that are ideal for adults may not be equally effective in children.

Surgical Antimicrobial Prophylaxis in Patients of Neonatal and Pediatric Age Undergoing Orthopedic and Hand Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication in any type of surgery and can occur up to one year after the procedure in the case of implant placement. In the field of orthopedic and hand surgery, the rate of SSIs is a relevant issue, considering the need for the placement of synthesis devices and the type of some interventions (e.g., exposed fractures). This work aims to provide guidance on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing orthopedic and hand surgery in order to standardize the management of patients and to reduce, on the one hand, the risk of SSI and, on the other, the development of antimicrobial resistance. The following scenarios were considered: (1) bloodless fracture reduction; (2) reduction of unexposed fracture and grade I and II exposed fracture; (3) reduction of grade III exposed fracture or traumatic amputation; (4) cruel fracture reduction with percutaneous synthesis; (5) non-traumatic amputation; (6) emergency intact skin trauma surgery and elective surgery without synthetic media placement; (7) elective orthopedic surgery with prosthetic and/or synthetic media placement and spinal surgery; (8) clean elective hand surgery with and without bone involvement, without use of synthetic means; (9) surgery of the hand on an elective basis with bone involvement and/or with use of synthetic means. This manuscript has been made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies and represents, in our opinion, the most complete and up-to-date collection of recommendations regarding the behavior to be adopted in the peri-operative setting in neonatal and pediatric orthopedic and hand surgery. The specific scenarios developed are aimed at guiding the healthcare professional in practice to ensure the better and standardized management of neonatal and pediatric patients, together with an easy consultation.

Phase I/II trial of multicycle high-dose chemotherapy with peripheral blood stem cell support for treatment of advanced ovarian cancer

Ovarian cancer is chemosensitive, but most patients with advanced disease die from tumor progression. As 25% of the patients can be cured by chemotherapy, it is reasonable to evaluate high-dose chemotherapy (HDCT). Forty-eight patients with untreated ovarian cancer were entered in a multicenter phase I/II trial of multicycle HDCT. Median age was 46 (19-59 years); International Federation of Gynecology and Obstetrics-stage was III in 79% and IV in 21%; 31% had residual disease >1 cm after surgery. Two courses of induction/mobilization therapy with cyclophosphamide (250 mg/m2) and paclitaxel (250 mg/m2) were used to collect peripheral blood stem cells. HDCT consisted of two courses of carboplatin (area under curve (AUC) 18-22) and paclitaxel followed by one course of carboplatin and melphalan (140 mg/m2) with or without etoposide (1600 mg/m2). Main toxicity was gastrointestinal. Limiting carboplatin to AUC 20 and eliminating etoposide resulted in manageable toxicity (69% without grade 3/4 toxicity). One patient died from treatment-related pneumonitis. At 8 years median follow-up, median progression-free-survival (PFS) and overall survival (OS) is 13.3 and 37.0 months. Five-years PFS and OS is 18 and 33%. Multicycle HDCT is feasible in a multicenter setting. A European phase III trial based on this regimen is evaluating the efficacy of HDCT.

Therapy of metastatic breast cancer with humanized antibodies against the HER2 receptor protein

The HER2 protein, a member of the epidermal growth factor family, is encoded by the protooncogene c-erbB-2. Its overexpression, occurring in approximately one-third of all breast carcinomas, is associated with a poor prognosis. A humanized mouse antibody against HER2 has been developed by genetic engineering. Here an unspecific human IgG was connected to the recognizing mouse IgG fragment. The allergization typical for allogeneic antibodies does not take place in this context. The effectiveness of this antibody has been confirmed by two international prospective phase III trials that tested it alone and combined with chemotherapy. Both modes of application increased the response rates and the time to progression. Side-effects were rare except for a high rate of cardiac dysfunction when the antibody was combined with anthracyclines. The effectiveness and negligible side-effects of the chimeric antibody against HER2 (Herceptin) render it a valuable tool in the treatment of breast cancer.

[Rectal resection within the scope of multi-visceral interdisciplinary resection in the pelvis]

Multivisceral resectioning is the only curative treatment for progressive carcinomas extending beyond the organ. The results of 25 consecutively operated patients are presented in this prospective observational study. Twelve patients underwent surgery for a primary tumor and 13 for a recurrence. Radical resectioning was achieved in 5 of 12 and in 3 of 13 patients. Restoration of continuity obtained in 11 of 12 and in 7 of 13 patients. Morbidity was 33% and 62%. None of the patients died from complications. An aggressive surgical approach is justifiable on account of the acceptable morbidity and mortality as well as the high rate of preserved continence through modern reconstruction procedures.

Congenital cystic adenomatoid malformation of the lung and fetal hydrops--a case with favourable outcome

We present a case of congenital cystic adenomatoid malformation of the lung (CCAM) diagnosed at 23 weeks of gestation with concomitant fetal hydrops. The sonographical picture of CCAM disappeared in the third trimester of pregnancy and fetal hydrops resolved under medication with digitalis to the mother. The neonate showed mild dyspnea; the prenatal diagnosis of CCAM was confirmed by chest X-ray and computed tomography. The affected lung segments were dissected at 5 days of age. The diagnosis of CCAM type III was confirmed histologically.

Differentiation of breast lesions by measurements under craniocaudal and lateromedial compression using a new sonographic method

RATIONALE AND OBJECTIVES

The authors differentiate breast lesions on sonography by measurements in two compression states that are perpendicular to each other.

METHODS

Diameters of 100 breast lesions were measured preoperatively under lateromedial and craniocaudal compression with a new sonographic method. This method uses mammography-identical positioning of the breast and a reference structure for detection of changes of sound amplitude and velocity by through transmission of lesions. Sizes parallel to sound propagation were corrected for abridgement by increased velocity within some lesions. For each lesion, an average length and breadth was calculated by adding sizes parallel and perpendicular to sound propagation in the two compression states and dividing it by 2. An average ratio was calculated for each lesion by dividing the average size perpendicular to sound propagation by the corrected average size along sound propagation. After obtaining histopathologic results, a threshold of ratios and other features that might help differentiate benign from malignant lesions were studied.

RESULTS

Ninety-six percent of the malignant lesions appeared with ratios < or = 1.2, whereas 92% of the benign lesions had a ratio > 1.2. Further differentiation is possible by observation of velocity in lesions with ratios > 1.2.

CONCLUSIONS

Examination of lesions in two compression states that are perpendicular to each other allows discrimination of benign and malignant masses by measurements in most patients.

[Insulin-like-growth-factor-binding-protein 1 (IGFBP-1) and fetal fibronectin in diagnosis of premature rupture of fetal membranes]

The diagnosis of a premature rupture of membranes presents no problem in the vast majority of cases. However, a reliable diagnosis is clinically not possible in about 10%. Most methods available lack the necessary sensitivity and specificity. Since the clinical consequences of a false diagnosis are considerable (overtreatment for false-positive and risk of infection for false-negative results), it is essential to clinically establish new, minimally invasive methods with higher predictive powers. In the present study we compared: the AMNI Check for detection of insulin-like growth-factor binding protein 1 (IGFBP-1); a membrane immunoassay for detection of fetal fibronectin (fFn); pH indicator paper; and, to verify a rupture of membranes in unclear cases, amniocentesis with installation of indigo carmine. The examination was performed in a group of 75 patients, 35 with and 40 without rupture of the membranes. The best results were obtained for the AMNI Check (sensitivity and negative correctness 100%, specificity and positive correctness 83%). With the same sensitivity and negative correctness, the membrane immunoassay for fFn achieved a specificity of 70% and a positive correctness of 74%. The pH indicator paper had the lowest predictive value (sensitivity 94%, negative correctness 93%, specificity 63%, positive correctness 69%). Both the AMNI Check and the test for detection of fetal fibronectin can be recommended for reliable exclusion of premature rupture of membranes. Amniocentesis should however be performed in uncertain cases with a positive test result. Nevertheless, considerable reduction of this invasive method is possible.

[137 local recurrences after breast carcinoma--a retrospective study]

A retrospective study was performed to follow up the course of the disease in 137 female premenopausal and postmenopausal patients in whom local recurrence of carcinoma of the breast had occurred. Particular attention was given to the dependence of the recurrence-free interval on the tumorobiological parameters of the primary tumour. In 23% of the cases the local recurrence was an expression of generalisation of the tumour with simultaneous occurrence of distant metastases. The average recurrence-free interval was four years, but more than half of the recurrences were seen during the first two postoperative years. For the following parameters we found a statistically significant correlation with the recurrence-free interval: size of the primary tumour (p = 0.0003), the nodal status (p = 0.0006) and in this connection also the number of the metastatically involved lymphatic node level (p = 0.00001). There was also a significant correlation between the duration of the recurrence-free interval and the immunohistochemical oestrogen and progesterone receptor status (p = 0.0005) and the growth fraction (p = 0.0106) determined with the monoclonal antibody Ki67. However, although there was no correlation between recurrence-free survival and the kind of surgical primary therapy that had been employed, adjuvant therapy did exercise a decisive influence: there was significant later incidence of local recurrences (p = 0.00001) subsequent to adjuvant radiotherapy.

Successful emergency splenectomy during pregnancy in a patient with life-threatening idiopathic thrombocytopenia. Case report

Thrombocytopenia can be a pathophysiological feature of pregnancy. In the case reported, the thrombocyte count was reduced to 1% of normal (1 x 10(9) thrombocytes/l) at 28 weeks of gestation. In chronological order, the patient showed epistaxis, macrohematuria and gingival, conjunctival, intracerebral and pulmonary bleeding. The latter was life-threatening. An emergency splenectomy was undertaken, without complications. The operation was followed by a massive increase in the thrombocyte count, reaching 200 x 10(9)/l four days later. Unfortunately, a premature rupture of the membranes, with signs of amnion infection, occurred on the seventh day. A Cesarean section was undertaken (30 weeks of gestation), without complications. Both mother and baby are in good health 10 months later. The newborn had a normal thrombocyte count at delivery and thereafter. The life-threatening hemorrhage of the mother, the delivery of an unaffected baby and the relatively quick remission after splenectomy suggest an upregulated destruction of thrombocytes by the maternal spleen. The increased level of Macrophage-Colony Stimulating Factor (M-CSF), a normal feature of pregnancy, has the potential to augment thrombocyte destruction by activating macrophages. The production of anti-thrombocyte antibodies, especially if localized in the spleen, could result in increased thrombocyte sequestration by macrophages with severe effects focused on the mother.

[Colpohysterectomy. A contribution to gynecologic geriatric surgery]

From 1983 to 1992 we performed 70 interventions because of a total genital prolapse: 51 vaginal hysterectomies and four removals of the cervical stump, both combined with vaginectomy and fifteen vaginectomies of the prolapsed vaginal vault. Two patients underwent another procedure during the same anesthesia: mastectomy and treatment of an inguinal hernia respectively. The youngest patient was 59 years old and the oldest 89. Fifty-four patients were aged between 71 and 82. Thirteen women had worn a pessary before the operation. Fifty-one interventions took less than 75 minutes. Serious postoperative complications included myocardial infarction on postoperative day eight in one patient and bronchopneumonia and cardiovascular decompensation in a second patient. No case of relapsing prolapse has come to our knowledge so far. We hold hysterectomy combined with vaginectomy to be the treatment method of choice in women with total genital prolapse and no further desire of cohabitation. When performed by an experienced surgeon it is the method with the lowest potential of recurrence and therefore to be preferred to other procedures.

Local therapy of malignant pleural effusion with mitoxantrone

Twelve patients received intrapleural instilments of the cytostatic agent mitoxantrone in a total dosage of 30 mg for locoregional palliative therapy of malignant pleural effusion. Effusion could be stopped for a mean period of 3.2 months in 11 patients.

[Cytologic cancer prevention with smears of the uterine cervix and endocervical canal in pregnancy]

This study was performed to evaluate the importance of obtaining prepartum Papanicolaou smears routinely. 1,417 patients receiving pregnancy care had normal prenatal Pap smears. 88 (5.85%) had abnormal prepartum Pap smears. Thirteen (14.8%) of the abnormal smears showed squamous dysplasia, 2 (2.3%) showed an adenocarcinoma or squamous invasive carcinoma. The results of this study support the practice of performing Pap smears during prenatal care.

Mammary mycoses

Since 1969 we have had at our hospital a special consulting room for mammary gland diseases in which we have so far seen more than 17,000 patients. Mycoses are a rare disease of the mammary glands. We are reporting below on the incidence of this disease, the mode of infection and the diagnostic possibilities within the framework of our special clinic.

[Relevance of CEA in benign breast disease (author's transl)]

Serum CEA-concentrations were measured in patients with various benign breast tumors; in addition, CEA levels were determined in the fluid of mammary cysts present. Patients with proliferating mastopathia with and without atypia had CEA values exceeding 25 ng/ml in the cystic fluid (= 46). No significant correlation existed between serum and cystic fluid concentrations. CEA determination allows for a differentiation between simple and proliferating mastopathias.

[HCG-determinations in serum and mammary cyst aspirates in women with benign breast tumors (author's transl)]

Results of HCG-determinations in human serum and cystfluid of benign mammary tumors are presented. HCG was determined gy RIA in 40 samples from 30 patients with different forms of fibro-cystic mastitis. In 60% of the cases positive results were obtained. It is still unclear, whether the demonstrated substance is native HCG, a free beta-subunit, a mixture of both or a different substance with immunologic properties similar to those of HCG.