Antibiotic Utilization Patterns for Different Wound Types among Surgical Patients: Findings and Implications

Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post-operatively. However, there are concerns with the extent of prophylaxis post-operatively, especially in low- and middle-income countries (LMICs). This increases antimicrobial resistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study on 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. The identified variables included post-operative prophylactic antimicrobials given to all patients for all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures, and among these, the use of third-generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than the suggestions of the guidelines, with most patients prescribed antimicrobials until discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration need to be addressed. This includes appropriate interventions, such as antimicrobial stewardship programs, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and to reduce AMR.

Impact of Positive Culture Reports of E. coli or MSSA on De-Escalation of Antibiotic Use in a Teaching Hospital in Pakistan and the Implications

Background

Antibiotic de-escalation is a key element of antimicrobial stewardship programs that restrict the spread and emergence of resistance. This study was performed to evaluate the impact of positive culture sensitivity reports of E. coli or Methicillin sensitive Staphylococcus aureus (MSSA) on de-escalation of antibiotic therapy.

Methods

This prospective observational study was performed on 256 infected patients. The samples were obtained principally from the pus of infected sites for the identification of pathogens and culture-sensitivity testing. The data were collected from patient medical files, which included their demographic data, sample type, causative microbe and antimicrobial treatment as empiric or definitive treatment based on cultures. Data were analyzed using SPSS.

Results

Of 256 isolated microbes, 138 (53.9%) were MSSA and 118 were E. coli (46.1%). MSSA showed 100% sensitivity to cefoxitin, oxacillin, vancomycin, fosfomycin, colistin and more than 90% to linezolid (95.3%), tigecycline (93.1%), chloramphenicol (92.2%) and amikacin (90.2%). E. coli showed 100% sensitivity to only fosfomycin and more than 90% to colistin (96.7%), polymyxin-B (95.1%) and tigecycline (92.9%). The high use of cefoperazone+sulbactam (151), amikacin (149), ceftriaxone (33), metronidazole (30) and piperacillin + tazobactam (22) was seen with empiric prescribing. Following susceptibility testing, the most common antibiotics prescribed for E. coli were meropenem IV (34), amikacin (34), ciprofloxacin (29) and cefoperazone+sulbactam (25). For MSSA cases, linezolid (48), clindamycin (30), cefoperazone+ sulbactam IV (16) and amikacin (15) was used commonly. Overall, there was 23% reduction in antibiotic use in case of E. coli and 43% reduction in MSSA cases.

Conclusion

Culture sensitivity reports helped in the de-escalation of antimicrobial therapy, reducing the prescribing of especially broad-spectrum antibiotics. Consequently, it is recommended that local hospital guidelines be developed based on local antimicrobial susceptibility patterns while preventing the unnecessary use of broad-spectrum antibiotics for empiric treatment.

Dose optimization of vancomycin in obese patients: A systematic review

Background: Dose optimization of vancomycin plays a substantial role in drug pharmacokinetics because of the increased incidence of obesity worldwide. This systematic review was aimed to highlight the current dosing strategy of vancomycin among obese patients. Methods: This systematic review was in concordance with Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on various databases such as Scopus, PubMed/MEDLINE, ScienceDirect and EMBASE using Keywords and MeSH terms related to vancomycin dosing among obese patients. Google Scholar was also searched for additional articles. The English language articles published after January, 2000 were included in this study. The quality of the study was assessed using different assessment tools for cohort, and case reports. Results: A total of 1,029 records were identified. After screening, 18 studies were included for the final review. Of total, twelve studies are retrospective and remaining six are case-control studies. A total of eight studies were conducted in pediatrics while remaining studies were conducted in adult population. Most of the studies reported the dosing interval every 6-8 h. Differences in target trough concentration exist with respect to target ranges. The administration of loading dose (20-25 mg/kg) followed by maintenance dose (15-25 mg/kg) of vancomycin is recommended in adult patients to target therapeutic outcomes. Moreover, a dose of 40-60 mg/kg/day appears appropriate for pediatric patients. Conclusion: The initial dosing of vancomycin based on TBW could be better predictor of vancomycin trough concentration. However, the clinical significance is uncertain. Therefore, more studies are needed to evaluate the dosing strategy of vancomycin in overweight or obese patients.

Effects of reducing dietary amino acid density and stocking density on growth performance, carcass characteristics, meat quality, and occurrence of white striping in broiler chickens

A 49-day trial was conducted to determine the impact of dietary amino acid (AA) density and stocking density (SD) on growth performance, carcass traits, meat quality, and white striping (WS) occurrence in broiler chickens. Two hundred eighty-eight Ross 308 male broilers consisting of 6 replicate cages with 8 broilers per replicate were used. Treatments were arranged in a 3 × 2 factorial and consisted of 3 AA densities (normal, 10, or 20% lower than normal) and 2 different SD (high 35 kg/m² or low 26 kg/m²). Breasts were classified as normal, moderate, and severe for WS. Data were analyzed as a completely randomized design using the GLM procedure. Decreasing AA density decreased overall growth performance, carcass, breast yields, and fillet dimensions linearly, while leg and rib cage yields increased linearly (P < 0.01). High SD decreased hot carcass, breast, wings, and rib cage weights in birds fed normal AA diets (P < 0.05). High SD increased the length of breast fillet (P < 0.05). Cooking loss, breast lightness (L∗), and redness (a∗) at 48 h postmortem increased linearly with decreasing AA density, while ultimate breast pH (pH_u) and nitrogen content decreased linearly (P < 0.05). The occurrence of normal, moderate, and severe WS fillets was 45.3, 49.1, and 5.6%, respectively. As the dietary AA density decreased, the occurrence of no WS breast fillets increased linearly, whereas the occurrence of moderate WS fillets and mean WS score decreased linearly (P < 0.05). SD did not affect the occurrence of WS. Severe WS fillets were heavier and had higher cranial thickness, pH_u, and fat content and lower yellowness (P < 0.05), but water-holding capacity, nitrogen content, L∗, and a∗ value did not differ among different WS scores. Taken together, WS occurrence and severity increased with higher growth rate. Growth depression created by lowering dietary AA density regardless of SD resulted in a decrease in mean WS score, but it also compromised the growth and meat quality.

Role of selenium in male reproduction - a review

The role of Se and various selenoproteins in male reproductive performance is reviewed. Development of male reproductive tissue requires an optimal level of Se in testis, and a small deviation, either deficiency or excess, leads to abnormal development. Selenium is a constituent of selenoproteins including GPx1, GPx3, mGPx4, cGPx4, and GPx5 that protect against oxidative damage to spermatozoa throughout the process of sperm maturation, whereas selenoproteins, such as mGPx4 and snGPx4, serve as structural components of mature spermatozoa. Thus Se and selenoproteins ensure viability of spermatozoa as well as providing protection against reactive oxygen species. Gene knock-out studies of selenoproteins revealed that their absence during spermatogenesis results in abnormal spermatozoa, which in turn affects semen quality and fertility. Deviation from the optimal quantities of dietary Se, both above or below, may cause multiple abnormalities of spermatozoa and affect motility and fertility. Libido may also be increased by Se. Dietary Se should be in optimal quantity to maintain reproductive function in males and to avoid infertility.