Longitudinal trends and cross-sectional analysis of English national hospital antibacterial use over 5 years (2008-13): working towards hospital prescribing quality measures

OBJECTIVES

There is global concern that antimicrobial resistance is a major threat to healthcare. Antimicrobial use is a primary driver of resistance but little information exists about the variation in antimicrobial use in individual hospitals in England over time or comparative use between hospitals. The objective of this study was to collate, analyse and report issue data from pharmacy records of 158 National Health Service (NHS) acute hospitals.

METHODS

This was a cohort study of inpatient antibacterial use in acute hospitals in England analysed over 5 years through a data warehouse from IMS Health, a leading provider of information, services and technology for the healthcare industry. Around 98% of NHS hospitals were included in a country with a population of 50 million residents.

RESULTS

There was a dramatic change in the usage of different groups of antibacterials between 2009 and 2013 with a marked reduction in the use of first-generation cephalosporins by 24.7% and second-generation cephalosporins by 41%, but little change in the use of third-generation cephalosporins (+5.7%) and fluoroquinolones (+1.6%). In contrast, use of co-amoxiclav, carbapenems and piperacillin/tazobactam increased by 60.1%, 61.4% and 94.8%, respectively. There was wide variation in the total and relative amounts of antibacterials used between individual hospitals.

CONCLUSIONS

Longitudinal analysis of antibacterial use demonstrated remarkable changes in NHS hospitals, probably reflecting governmental and professional guidance to mitigate the risk of Clostridium difficile infection. The wide variation in usage between individual hospitals suggests potential for quality improvement and benchmarking. Quality measures of optimal hospital antimicrobial prescribing need urgent development and validation to support antimicrobial stewardship initiatives.

Antibiotic resistance in the intensive care unit setting

Antibiotic resistance is an important factor influencing clinical outcome for patients in intensive care units. It is also associated with increased healthcare costs resulting from prolonged patient stays. The problem of antibiotic resistance is particularly acute in intensive care units because they house seriously ill patients who are predisposed to infection, as a result of which, antibiotic use is extremely common. Strategies for controlling resistance in intensive care units have focused on attempting to reduce unnecessary antibiotic use, while at the same time ensuring adequate antibiotic cover is provided. The formulation of policies for the effective use of antibiotics in individual intensive care units requires a multidisciplinary approach, entailing regular epidemiological surveillance, together with input from critical care specialists, infectious disease specialists and pharmacists.

Systematic analysis of funding awarded for antimicrobial resistance research to institutions in the UK, 1997-2010

Objectives

To assess the level of research funding awarded to UK institutions specifically for antimicrobial resistance-related research and how closely the topics funded relate to the clinical and public health burden of resistance.

Methods

Databases and web sites were systematically searched for information on how infectious disease research studies were funded for the period 1997–2010. Studies specifically related to antimicrobial resistance, including bacteriology, virology, mycology and parasitology research, were identified and categorized in terms of funding by pathogen and disease and by a research and development value chain describing the type of science.

Results

The overall dataset included 6165 studies receiving a total investment of £2.6 billion, of which £102 million was directed towards antimicrobial resistance research (5.5% of total studies, 3.9% of total spend). Of 337 resistance-related projects, 175 studies focused on bacteriology (40.2% of total resistance-related spending), 42 focused on antiviral resistance (17.2% of funding) and 51 focused on parasitology (27.4% of funding). Mean annual funding ranged from £1.9 million in 1997 to £22.1 million in 2009.

Conclusions

Despite the fact that the emergence of antimicrobial resistance threatens our future ability to treat many infections, the proportion of the UK infection-research spend targeting this important area is small. There are encouraging signs of increased investment in this area, but it is important that this is sustained and targeted at areas of projected greatest burden. Two areas of particular concern requiring more investment are tuberculosis and multidrug-resistant Gram-negative bacteria.

Community-acquired, healthcare-associated and hospital-acquired bloodstream infection definitions in children: a systematic review demonstrating inconsistent criteria

BACKGROUND

Historically, bacterial infections were categorized as either community-acquired (CA) or hospital-acquired (HA). However, the CA/HA dichotomy no longer adequately reflects patterns of emerging healthcare-associated (HCA) infections in complex patients managed between hospital and the community. Studies trying to define this evolving epidemiology often excluded children.

AIM

To identify what criteria have been used to distinguish between CA, HCA and HA bloodstream infections (BSIs) in children, and the proportional distribution of CA, HCA and HA among total BSIs and by organism.

METHODS

We systematically reviewed published literature from PubMed, UK Department of Health and US Centers for Disease Control and Prevention websites.

FINDINGS

Results from 23 studies and the websites highlighted the use of inconsistent criteria. There were 13 and 15 criteria variations for CA and HA BSI respectively, although a 48h cut-off for cultures sampled post admission was most commonly reported. Five studies used variable clinical criteria to define HCA. The mean proportion of paediatric CA BSI in nine studies was 50%. Only four BSI organisms from five studies were predominantly CA (Streptococcus pneumoniae, Salmonella spp.) or HA (coagulase-negative staphylococci, Enterococcus spp.), whereas Pseudomonas spp., Klebsiella spp. and Enterobacter spp. did not clearly fit into either category.

CONCLUSIONS

Our study reveals inconsistent use of criteria, and a lack of evidence upon which to base them, to distinguish between CA, HCA and HA BSI in children. Criteria for CA, HCA and HA BSI need to be developed using population-based studies that consider patients' clinical characteristics, recent healthcare exposure as well as isolated organism species.

Improving antimicrobial stewardship: AmWeb, a tool for helping microbiologists in England to 'Start Smart' when advising on antibiotic treatment

As part of an antimicrobial stewardship programme, healthcare organizations should have local antibiotic treatment guidelines in place that take account of local antibiotic resistance patterns. The current issue of JAC reports the development of an interactive web tool, called AmWeb, for the local surveillance of resistance by hospital laboratories in England. The application of AmWeb should help to both optimize the management of patients with infection and contribute to efforts to prolong the active life of antibiotics currently available for use.

Global spread of antibiotic resistance: the example of New Delhi metallo-β-lactamase (NDM)-mediated carbapenem resistance

The rapidity with which new types of antibiotic resistance can disseminate globally following their initial emergence or recognition is exemplified by the novel carbapenemase New Delhi metallo-β-lactamase (NDM). The first documented case of infection caused by bacteria producing NDM occurred in 2008, although retrospective analyses of stored cultures have identified the gene encoding this enzyme (blaNDM) in Enterobacteriaceae isolated in 2006. Since its first description, NDM carbapenemase has been reported from 40 countries worldwide, encompassing all continents except South America and Antarctica. The spread of NDM has a complex epidemiology involving the spread of a variety of species of NDM-positive bacteria and the inter-strain, inter-species and inter-genus transmission of diverse plasmids containing blaNDM, with the latter mechanism having played a more prominent role to date. The spread of NDM illustrates that antibiotic resistance is a public health problem that transcends national borders and will require international cooperation between health authorities if it is to be controlled.

Exploring the Epidemiology of Hospital-Acquired Bloodstream Infections in Children in England (January 2009-March 2010) by Linkage of National Hospital Admissions and Microbiological Databases

BACKGROUND

Hospital-acquired bloodstream infection (HA-BSI) requires immediate effective antibiotic treatment. However, there are no published national data for England that describe the pathogen profile and antibiotic resistance rates of HA-BSI in children.

METHODS

Probabilistic matching methods were used to link national data on microbiologically confirmed BSI to hospital in-patient admissions data for the period of January 2009-March 2010. HA-BSI was defined as a positive blood culture drawn from a child aged 1 month-18 years 2 or more days after admission (and before discharge).

RESULTS

A total of 8718 episodes of BSI was reported during the study period. Linkage allowed 82% of records to be matched, of which 23% (1734) were HA-BSI, giving a rate of 4.74 per 1000 admissions. The median age of infection was 1 year, and 54% of infections were in males. Methicillin resistance was seen in 83% and 17% of coagulase-negative staphylococci and Staphylococcus aureus, respectively. Penicillin resistance was rare in pyogenic streptococci but more common in viridans streptococci (39%). Among Gram-positive organisms, only 3% were vancomycin-resistant. The overall proportion of Gram-negative bacteria resistant to recommended empirical antibiotics (meropenem or piperacillin/tazobactam) was 5% and 16%, respectively, but <4% of isolates were resistant when either of these drugs were combined with gentamicin.

CONCLUSIONS

This study provides the first national estimates of the proportion of pediatric BSI that is hospital-acquired and describes the antimicrobial resistance of organisms causing infection. Pediatric HA-BSI remains unacceptably high; interventions must focus on identifying effective means of preventing HA-BSI, fostering antibiotic stewardship, and improving surveillance.

A combinatorial in silico and cellular approach to identify a new class of compounds that target VEGFR2 receptor tyrosine kinase activity and angiogenesis

BACKGROUND AND PURPOSE

Vascular endothelial growth factor receptor 2 (VEGFR2) is an attractive therapeutic target for the treatment of diseases such as cancer. Small-molecule VEGFR2 inhibitors of a variety of chemical classes are currently under development or in clinical use. In this study, we describe the de novo design of a new generation pyrazole-based molecule (JK-P3) that targets VEGFR2 kinase activity and angiogenesis.

EXPERIMENTAL APPROACH

JK-P compound series were designed using de novo structure-based identification methods. Compounds were tested in an in vitro VEGFR2 kinase assay. Using primary endothelial cells, JK-P compounds were assessed for their ability to inhibit VEGF-A-stimulated VEGFR2 activation and intracellular signalling. We tested these compounds in cell migration, proliferation and angiogenesis assays.

KEY RESULTS

JK-P3 and JK-P5 were predicted to bind the VEGFR2 kinase domain with high affinity, and both compounds showed pronounced inhibition of endogenous VEGFR2 kinase activity in primary human endothelial cells. Only JK-P3 inhibited VEGF-A-stimulated VEGFR2 activation and intracellular signalling. Interestingly, JK-P3 inhibited endothelial monolayer wound closure and angiogenesis but not endothelial cell proliferation. Both compounds inhibited fibroblast growth factor receptor kinase activity in vitro, but not basic fibroblast growth factor-mediated signalling in endothelial cells.

CONCLUSIONS AND IMPLICATIONS

This is the first report that describes an anti-angiogenic inhibitor based on such a pyrazole core. Using a de novo structure-based identification approach is an attractive method to aid such drug discovery. These results thus provide an important basis for the development of multi-tyrosine kinase inhibitors for clinical use in the near future.

[An interesting experience on the use of information and population data bases]

INTRODUCTION

In order to support decisions and analyze outcomes, the Spanish Health System has shown a great interest in developing data bases and high quality information systems. Nevertheless the use of these data bases are limited, not very systematized and, some times, their accessibility may be difficult.

MATERIAL AND METHODS

We describe in this review the experience in using the Institute for Clinical Evaluative Science (ICES, Ontario, Canada) as an efficient model to improve the usefulness of these data bases.

RESULTS

Under restrictive conditions of confidentiality and privacy, the ICES has the legal capacity to use several population based data bases, for research projects and reports. ICES's functional structure (with an administrative and scientific level) is an interesting framework since it guarantees its independent and economic assessment.

DISCUSSION

To date, its scientific production has been high in many areas of knowledge and open to those interested, with points of view of many health care professionals (including management), for whom the quality of research is of the ultimate importance, to be able to access these resources.

Indolinones and anilinophthalazines differentially target VEGF-A- and basic fibroblast growth factor-mediated responses in primary human endothelial cells

BACKGROUND AND PURPOSE

The potent pro-angiogenic growth factors VEGF-A and basic fibroblast growth factor (bFGF) exert their effects by binding VEGF receptor 2 and FGF receptor tyrosine kinases, respectively. Indolinones (e.g. SU5416 and Sutent) and anilinophthalazines (e.g. PTK787) are potent small molecule inhibitors of VEGFR2 and other tyrosine kinases, but their effects on VEGF-A- and bFGF-stimulated endothelial responses are unclear. Here we assess the ability of these compounds to inhibit pro-angiogenic responses through perturbation of receptor activity and endothelial function(s).

EXPERIMENTAL APPROACH

We used in silico modelling, in vitro tyrosine kinase assays, biochemistry and microscopy to evaluate the effects of small molecules on receptor tyrosine kinase activation and intracellular signalling. Primary human endothelial cells were used to assess intracellular signalling, cell migration, proliferation and tubulogenesis.

KEY RESULTS

We predicted that the anilinophthalazine PTK787 binds the tyrosine kinase activation loop whereas indolinones are predicted to bind within the hinge region of the split kinase domain. Sutent is a potent inhibitor of both VEGFR2 and FGFR1 tyrosine kinase activity in vitro. The compounds inhibit both ligand-dependent and -independent VEGFR2 trafficking events, are not selective for endothelial cell responses and inhibit both VEGF-A- and bFGF-mediated migration, wound healing and tubulogenesis at low concentrations. CONCLUSIONS AND IMPLICATIONS; We propose that these compounds have novel properties including inhibition of bFGF-mediated endothelial responses and perturbation of VEGFR2 trafficking. Differential inhibitor binding to receptor tyrosine kinases translates into more potent inhibition of bFGF- and VEGF-A-mediated intracellular signalling, cell migration and tubulogenesis. Indolinones and anilinophthalazines thus belong to a class of multi-kinase inhibitors that show clinical efficacy in disease therapy.

Outcome of Cushing's disease following transsphenoidal surgery in a single center over 20 years

CONTEXT

Historically, Cushing's disease (CD) was associated with a 5-yr survival of just 50%. Although advances in CD management have seen mortality rates improve, outcome from transsphenoidal surgery (TSS), the current first-line treatment, varies significantly between centers.

OBJECTIVES

The aim of the study was to define outcome including mortality in a cohort of CD patients treated with TSS over 20 yr.

DESIGN

We conducted a retrospective cohort study of 80 patients who underwent TSS to treat CD between 1988 and 2009. In 72 cases, data on clinical features and outcomes were collected from medical records. In eight patients, records were unavailable, but in all cases mortality data were obtained from National Health Service (NHS) registries and recorded as standardized mortality ratio.

SETTING

The study was conducted in a United Kingdom tertiary referral center.

PATIENTS OR OTHER PARTICIPANTS

Adult patients confirmed to have CD participated in the study.

INTERVENTIONS

All patients underwent TSS.

MAIN OUTCOME MEASURE

Patients were subdivided into groups based on disease response after initial treatment. Mortality according to subgroup was also assessed.

RESULTS

Median follow-up for clinical data was 4.6 yr. Three outcome groups were identified: cure, 72% (52 of 72); persistent disease, 17% (12 of 72); and disease recurrence, 11% (eight of 72). Median time to recurrence after initial remission was 2.1 yr (interquartile range, 1.3-3.1 yr). Mean follow-up for mortality was 10.9 yr. Thirteen of 80 patients had died: five of 52 in the cure group, two of eight in the disease recurrence group, two of 12 with persistent disease, and four of eight of those followed up by NHS registry search only. Overall, the standardized mortality ratio was 3.17 [95% confidence interval (CI), 1.70-5.43], whereas in the cure group it was 2.47 (95% CI, 0.80-5.77), and it was 4.12 (95% CI, 1.12-10.54) for disease recurrence/persistent disease groups.

CONCLUSIONS

We report long-term cure rates in excess of 70%. Mortality is increased in CD and may be higher in patients with persistent/recurrent disease compared to patients cured after initial treatment.

Using antibiotics responsibly: right drug, right time, right dose, right duration

Everyone prescribing antibiotics should consider both their clinical and public health responsibilities. The objective should be to provide optimal patient care while at the same time seeking to minimize selective pressure that may result in the emergence and spread of antibiotic resistance. To this end, in 2008 the European Centre for Disease Control initiated the annual European Antibiotic Awareness Day (EAAD) to take place on 18 November, when Europe-wide activities are undertaken to highlight the critical importance of prudent antibiotic prescribing. This year activities in England will focus on the optimal management of infections in secondary care, and will have two inter-related aims. The first is to improve the quality of the initial decision to prescribe an antibiotic (including making an informed choice of empirical drug and dose) in particular ensuring rapid prescribing and administration in presumed sepsis. This is deliberately combined with a second focus on the critical importance of formally reviewing antibiotic therapy at 48 h, based on the patient's clinical response and the availability of microbiology test results. This should lead to a clear decision to stop, switch to oral, switch to outpatient antibiotic therapy (OPAT) or change antibiotic, if possible to a narrower spectrum. The EAAD campaign in England will highlight the need to 'Start Smart-Then Focus'. The aim is that patients receiving antibiotics should receive the right drug at the right time at the right dose for the right duration.

Methicillin-resistant Staphylococcus aureus: the European landscape

Pan-European surveillance of bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA) shows it to be a problem affecting all European countries, although there is marked geographical variation in prevalence. Although the proportion of S. aureus bacteraemia due to MRSA is declining in many countries, data from the European Antimicrobial Resistance Surveillance System (EARSS) for 2008 showed that in more than one-third of countries the proportion remained >25%. In contrast to bacteraemia, community-associated MRSA infection in Europe remains relatively uncommon. However, there appears to be an increasing problem involving transmission of MRSA (particularly sequence type 398) from colonized livestock, particularly pigs, to farm workers, abattoir workers and veterinarians who are in contact with such animals. Molecular analysis of isolates of MRSA has shown that there has been spread of only a limited number of MRSA clones in Europe and that many of these clones show geographical clustering due to dissemination through regional healthcare networks. Despite our increasing understanding of the epidemiology of MRSA in Europe, MRSA infections continue to pose a significant public health challenge.

Empirical treatment of influenza-associated pneumonia in primary care: a descriptive study of the antimicrobial susceptibility of lower respiratory tract bacteria (England, Wales and Northern Ireland, January 2007-March 2010)

OBJECTIVES

To determine the susceptibility of lower respiratory tract (LRT) isolates of Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae to antimicrobial agents recommended by UK guidelines for treatment of pneumonia associated with influenza-like illness.

METHODS

Analysis of antimicrobial susceptibility data from sentinel microbiology laboratories in England, Wales and Northern Ireland was carried out. Subjects comprised patients who had an LRT specimen taken in a general practitioner surgery or hospital outpatient setting between January 2007 and March 2010. The main outcome measurements were antimicrobial susceptibility trends of LRT isolates over time, between patient age groups and in different geographical regions.

RESULTS

Susceptibility to tetracyclines or co-amoxiclav was high. Of the 70,288 and 45,288 isolates with susceptibility results for tetracyclines or co-amoxiclav, 96% and 92%, respectively, were susceptible. Overall susceptibility to ciprofloxacin, ampicillin/amoxicillin and macrolides was lower than for tetracyclines or co-amoxiclav and varied markedly by organism. There were few clinically relevant variations in susceptibility to doxycycline or co-amoxiclav over time, geographically or between age groups.

CONCLUSIONS

The data support the use of doxycycline or co-amoxiclav as appropriate empiric treatment for LRT infection caused by the pathogens investigated, for patients in primary care.

Empirical treatment of neonatal sepsis: are the current guidelines adequate?

OBJECTIVES

To use national laboratory surveillance data to determine whether pathogens responsible for neonatal bacteraemia were sensitive to nationally recommended antibiotic regimens.

DESIGN

All reports of neonatal bacteraemia received by the Health Protection Agency's voluntary surveillance scheme in England and Wales from January 2006 until March 2008, were extracted from the database. Organisms were ranked by frequency, and proportions susceptible to antimicrobials recommended for empirical treatment of neonatal sepsis were determined.

RESULTS

There were 1516 reports of bacteraemia for neonates <48 h old (early-onset) and 3482 reports for neonates 2-28 days old (late-onset). For early-onset bacteraemia, group B streptococcus (GBS) was the most frequent pathogen (31%) followed by coagulase-negative staphylococci (CoNS; 22%), non-pyogenic streptococci (9%) and Escherichia coli (9%). For late-onset bacteraemia, CoNS were isolated most frequently (45%), followed by Staphylococcus aureus (13%), Enterobacteriaceae (9%), E coli (7%) and GBS (7%). More than 94% of organisms (early-onset) were susceptible to regimens involving combinations of penicillin with either gentamicin or amoxicillin, amoxicillin combined with cefotaxime or cefotaxime monotherapy. More than 95% of organisms (late-onset) were susceptible to gentamicin with either flucloxacillin or amoxicillin and amoxicillin with cefotaxime, but only 79% were susceptible to cefotaxime monotherapy.

CONCLUSIONS

Current guidelines for empirical therapy in neonates with sepsis are appropriate. However, gentamicin-based regimens should be used in preference to cefotaxime-based treatments, because of lower levels of susceptibility to cefotaxime and the need to avoid exerting selective pressure for resistance. Surveillance data linked to clinical data should further inform rational antibiotic prescribing in neonatal units.

Changes in the classification and management of skin and soft tissue infections

Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used 'Eron classification' is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) 'Guidelines on the Management of Cellulitis in Adults' have not been validated in clinical trials. In the current issue of JAC, investigators at Ninewells Hospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.

Enhanced surveillance of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in children in the UK and Ireland

OBJECTIVE

To determine the incidence and demographic features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in children in the UK and Ireland and to characterise MRSA isolated from cases.

DESIGN

Prospective surveillance study.

SETTING

Children aged <16 years hospitalised with bacteraemia due to MRSA.

METHODS

Cases were ascertained by active surveillance involving paediatricians reporting to the British Paediatric Surveillance Unit and by routine laboratory surveillance. Patient characteristics were obtained using questionnaires sent to reporting paediatricians. MRSA isolates were characterised using molecular and phenotypic techniques including antimicrobial susceptibility testing.

RESULTS

265 episodes of MRSA bacteraemia were ascertained, involving 252 children. The overall incidence rate was 1.1 per 100 000 child population per year (95% CI 0.9 to 1.2): 61% of the children were aged <1 year (a rate of 9.7 cases per 100 000 population per year (95% CI 8.2 to 11.4)) and 35% were <1 month. Clinical data were obtained from 115 cases. The clinical presentation varied, with fever present in only 16% of neonates compared with 72% of older children. A history of invasive procedure was common, with 32% having had intravascular lines and 13% having undergone surgery. 62% of patients for whom data were available were receiving high-dependency care (46% in SCBU/NICU and 16% in PICU). Of 93 MRSA isolates studied, 73% belonged to epidemic strains widely associated with nosocomial infection in the UK and Ireland.

CONCLUSIONS

MRSA bacteraemia in children was relatively uncommon and was predominantly seen in very young children, often those receiving neonatal or paediatric intensive care. Bacteraemia predominantly involved well-documented epidemic strains of MRSA associated with nosocomial infection.

Increasing skin infections and Staphylococcus aureus complications in children, England, 1997-2006

During 1997-2006, general practitioner consultations for skin conditions for children <18 years of age in England increased 19%, from 128.5 to 152.9/1,000 child-years, and antistaphylococcal drug prescription rates increased 64%, from 17.8 to 29.1/1,000 child-years. During the same time period, hospital admissions for Staphylococcus aureus infections rose 49% from 53.4 to 79.3/100,000 child-years.

A potential role for daptomycin in enterococcal infections: what is the evidence?

Nosocomial infections caused by enterococci present a challenge for clinicians because treatment options are often limited due to the widespread occurrence of strains resistant to multiple antibiotics, including vancomycin. Daptomycin is a first-in-class cyclic lipopeptide that has proven efficacy for the treatment of Gram-positive infections. Although methicillin-resistant Staphylococcus aureus has been the most prominent target in the clinical development of daptomycin, this agent has demonstrated potent bactericidal activity in enterococcal infection models and has been used for the treatment of enterococcal infections in humans. In recent years, large-scale susceptibility studies have shown that daptomycin is active against >98% of enterococci tested, irrespective of their susceptibility to other antibacterial agents. This lack of cross-resistance reflects the fact that daptomycin has a mode of action distinct from those of other antibiotics, including glycopeptides. While there are limited data available from randomized controlled trials, extensive clinical experience with daptomycin in enterococcal infections (including bacteraemia, endocarditis, skin and soft tissue infections, bone and joint infections and urinary tract infections) has been reported. This growing body of evidence provides useful insights regarding the efficacy of daptomycin against enterococci in clinical settings.

The changing aetiology of paediatric bacteraemia in England and Wales, 1998–2007

Bacteraemia in children is a potentially life-threatening condition. The objective of this study was to determine trends in the aetiology of bacteraemia in children aged 1 month–15 years in England and Wales by collecting data voluntarily reported by National Health Service hospital microbiology laboratories. Over the 10-year period 1998–2007, a total of 51 788 bacteraemia cases involving 105 genera/species of bacteria were reported. Total annual reports of bacteraemia increased from 4125 to 6916, with a mean increase of 6.5 % per year (95 % CI: 1.3–12.1 %). In 2007, just over half the cases were accounted for by four groups of organisms: coagulase-negative staphylococci (28 %), Staphylococcus aureus (10 %), non-pyogenic streptococci (9 %) and Streptococcus pneumoniae (7 %). These organisms along with a further 13 species/genera accounted for 90 % of the cases. The commonest Gram-negative organisms were Neisseria meningitidis and Escherichia coli, which each accounted for 5 % of total bacteraemia reports in 2007. There was a significant decrease in reports of bacteraemia due to the three vaccine-preventable pathogens Haemophilus influenzae, N. meningitidis and Strep. pneumoniae, following the introduction of each vaccine programme or catch-up campaign. This study identified the commonest causes of bacteraemia in children in England and Wales, and highlighted the shifts in trends observed over time.

Decline of EMRSA-16 amongst methicillin-resistant Staphylococcus aureus causing bacteraemias in the UK between 2001 and 2007

OBJECTIVES

Between 1998 and 2000, 95.6% of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemias in the UK were due to two epidemic strains, namely EMRSA-15 or EMRSA-16 (60.2% and 35.4%, respectively). We sought to determine the proportions of these strains before and after the general decline in MRSA bacteraemia that began around 2004.

METHODS

Consecutive MRSA isolates collected in 2001, 2003, 2005 and 2007 by the BSAC Bacteraemia Surveillance Programme were categorized to multilocus sequence typing (MLST) clonal complex and to SCCmec type by PCR. MICs were determined by the BSAC method. Data trends were tested for significance using a generalized linear regression model.

RESULTS

Collectively, EMRSA-15 and EMRSA-16 consistently accounted for approximately 95% of MRSA studied between 2001 and 2007, but the proportions of EMRSA-16 declined from 21.4% in 2001 to 9% in 2007 (P < 0.05), whilst the proportion of EMRSA-15 rose commensurately, accounting for 85% of MRSA in 2007. Ciprofloxacin and erythromycin resistance were common amongst both EMRSA-15 and EMRSA-16.

CONCLUSIONS

EMRSA-15 and EMRSA-16 remain the main MRSA strains in bacteraemia in the UK, but the proportion of EMRSA-16 declined from the late 1990 s, thus preceding the general decline in MRSA bacteraemias that began in the middle of the present decade.

Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model

This paper presents a detailed description of health care resource utilisation and costs of a pilot interdisciplinary health care model of palliative home care in Ontario, Canada. The descriptive evaluation entailed examining the use of services and costs of the pilot program: patient demographics, length of stay broken down by disposition (discharged, alive, death), access to services/resources, use of family physician and specialist services, and drug use. There were 434 patients included in the pilot program. Total costs were approximately CAN$2.4 million, and the cost per person amounted to approximately CAN$5586.33 with average length of stay equal to over 2 months (64.22 days). One may assume that length of stay would be influenced by the amount of service and support available. Future research might investigate whether in-home palliative home care is the most cost effective and suitable care setting for those patients requiring home care services for expected periods of time.

Changes in clinical indications for community antibiotic prescribing for children in the UK from 1996 to 2006: will the new NICE prescribing guidance on upper respiratory tract infections just be ignored?

OBJECTIVE

To analyse changes in clinical indications for community antibiotic prescribing for children in the UK between 1996 and 2006 and relate these findings to the new NICE guidelines for the treatment of upper respiratory tract infections in children.

STUDY DESIGN

Retrospective cohort study.

METHOD

The IMS Health Mediplus database was used to obtain annual antibiotic prescribing rates and associated clinical indications in 0-18-year-old patients between 1 January 1996 and 31 December 2006 in the UK.

RESULTS

Antibiotic prescribing declined by 24% between 1996 and 2000 but increased again by 10% during 2003-2006. Respiratory tract infection was the most common indication for which an antibiotic was prescribed, followed by "abnormal signs and symptoms", ear and skin infections. Antibiotic prescriptions for respiratory tract infections have decreased by 31% (p<0.01) mainly because of reduced prescribing for lower respiratory tract infections (56% decline, p<0.001) and specific upper respiratory tract infections including tonsillitis/pharyngitis (48% decline, p<0.001) and otitis (46% decline, p<0.001). Prescribing for non-specific upper respiratory tract infection increased fourfold (p<0.001). Prescribing for "abnormal signs and symptoms" increased significantly since 2001 (40% increase, p<0.001).

CONCLUSION

There has been a marked decrease in community antibiotic prescribing linked to lower respiratory tract infection, tonsillitis, pharyngitis and otitis. Overall prescribing is now increasing again but is associated with non-specific upper respiratory tract infection diagnoses. General practitioners may be avoiding using diagnoses where formal guidance suggests antibiotic prescribing is not indicated. The new NICE guidance on upper respiratory tract infections is at risk of being ignored.

Derivatives of pyrimidine, phthalimide and anthranilic acid as inhibitors of human hydroxysteroid dehydrogenase AKR1C1

Human hydroxysteroid dehydrogenase (HSD) AKR1C1 is a member of the aldo-keto reductase superfamily, and it functions mainly as a 20alpha-HSD. It catalyzes the reduction of the potent progesterone to the weak 20alpha-hydroxyprogesterone, and of 3alpha,5alpha-tetrahydroprogesterone (5alpha-THP; allopregnanolone) to 5alpha-pregnane-3alpha,20alpha-diol. AKR1C1 thus decreases the levels of progesterone and 5alpha-THP in peripheral tissue. Progesterone inhibits cell proliferation, stimulates differentiation of endometrial cells, and is also important for maintenance of pregnancy, while 5alpha-THP allosterically modulates the activity of the gamma-aminobutyric acid receptor. Inhibitors of AKR1C1 are thus potential agents for treatment of endometrial cancer and endometriosis, as well as other diseases like premenstrual syndrome, catamenial epilepsy and depressive disorders.We have synthesized a series of pyrimidine, phthalimido and athranilic acid derivatives, and have here examined their inhibitory properties towards AKR1C1. A common aldo-keto reductase substrate, 1-acenaphthenol, was used to monitor the NAD(+)-dependent oxidation catalyzed by AKR1C1. The most potent inhibitors of AKR1C1 were the pyrimidine derivative N-benzyl-2-(2-(4-methoxybenzyl)-6-oxo-1,6-dihydropyrimidin-4-yl)acetamide (K(i)=17 microM) and the anthranilic acid derivative 2-(((2',3-dichlorobiphenyl-4-yl)carbonyl)(methyl)amino)benzoic acid (K(i)=33 microM), both of which are non-competitive inhibitors.

The European Antibiotic Awareness Day

The European Antibiotic Awareness Day, which will have as its theme the need to stop unnecessary use of antibiotics, will take place on 18 November 2008. It is hoped that healthcare workers and other professionals, particularly those involved with child care, as well the general public and members of the media, will participate in the various activities and discussions that will take place across Europe as part of this initiative. The European Antibiotic Awareness Day will be an annually recurring event that will raise awareness about the risks associated with inappropriate use of antibiotics and how to use antibiotics responsibly.

The emergence of Stenotrophomonas maltophilia

Superbug or opportunist?

Empty sella syndrome associated with a hyperfunctioning microadenoma invading the clivus

The empty sella syndrome is usually associated with normal pituitary function. If dysfunction is present, this is commonly hypofunction. Hyperfunctioning microadenomas have been described in the presence of the empty sella syndrome. We present the first reported cases of a microadenoma invading the clivus associated with an empty sella.

Morbidity and mortality of pneumococcal meningitis and serotypes of causative strains prior to introduction of the 7-valent conjugant pneumococcal vaccine in England

OBJECTIVES

To assess the incidence of pneumococcal meningitis, associated deaths and serotypes of causative pneumococci in England prior to the inclusion of the 7-valent conjugated pneumococcal vaccine in the routine childhood immunisation programme in 2006.

METHODS

Cases were identified using hospital episode statistics (HES) and voluntary reports or submission of isolates to the Health Protection Agency. Mortality data and population estimates were from the Office for National Statistics.

RESULTS

Based on HES, the annual incidence of pneumococcal meningitis was about 1 case per 100,000 population between 1998 and 2005 (an average of approximately 480 cases per year) with case fatality rates increasing from 5% in <15 year olds to 30% in >64 year olds. Enhanced surveillance comprising a combination of voluntary reporting of cases and referral of isolates gave case ascertainment rates of 50-70% compared to those derived from HES, and similar case fatality rates. The age distribution of pneumococcal meningitis was similar with both datasets, infection being reported mostly commonly in children aged less than 5 years, with the highest incidence in children aged 2-11 months. Based on the serotype distribution of isolates obtained in 2005, the serotype coverage afforded by the 7-valent conjugate vaccine is 72% for patients aged less than 2 years.

CONCLUSIONS

These data provide baseline information on the incidence of pneumococcal meningitis and associated mortality, together with the serotypes of infecting strains of pneumococci, which will be critical for evaluation of the public health impact of the 7-valent conjugated pneumococcal vaccine in England.

A haemangiopericytoma of the ethmoid sinus causing oncogenic osteomalacia: a case report and review of the literature

Oncogenic osteomalacia is a rare cause of osteomalacia. It is caused by a tumour which is generally benign. These tumours, when identified, are often found in the head and neck region. The case is reported here of a haemangiopericytoma isolated in the ethmoid sinus, and the literature regarding tumours at this site is reviewed. Including the present case there are five reported in the world literature of an ethmoid sinus tumour causing oncogenic osteomalacia. The treatment for this disease is excision of the mass, which is where the head and neck specialist's expertise is required.

Interventions in healthcare-associated infection: researchers urged to CONSORT with ORION

The ORION (Outbreak Reports and Intervention studies Of Nosocomial infection) statement has been prepared by a group of investigators with the expressed purpose of increasing the quality of research and reporting in the area of nosocomial infection. It is hoped that publication of the ORION statement will aid investigators in the design, performance and reporting of studies in this area, and will encourage journals and research councils to incorporate it into their submission and reviewing processes.

Drug evaluation: OPT-80, a narrow-spectrum macrocyclic antibiotic

Optimer Pharmaceuticals Inc, in collaboration with Par Pharmaceutical Companies Inc, is developing OPT-80, a narrow-spectrum macrocyclic antibiotic secreted by the actinomycete Dactylosporangium aurantiacum, for the potential treatment of Clostridium difficile-associated diarrhea (CDAD) and vancomycin-resistant Enterococcus infection. A phase IIb/III clinical trial of OPT-80 in patients with CDAD is underway.

Trends in penicillin and macrolide resistance among pneumococci in the UK and the Republic of Ireland in relation to antibiotic sales to pharmacies and dispensing doctors

It is widely believed that reducing antimicrobial usage should reduce resistance, although observational evidence is mixed. Pneumococci make ideal subjects to test this belief as they are widely surveyed and lack an animal reservoir. Accordingly, susceptibility data for pneumococci in the UK and Ireland were retrieved from the Health Protection Agency's LabBase/CoSurv system and from the European Antimicrobial Resistance Surveillance System (EARSS) and British Society for Antimicrobial Chemotherapy (BSAC) databases. The BSAC surveillance examines respiratory pneumococci; the other systems focus upon invasive organisms only, with the LabBase/CoSurv system being the most comprehensive, capturing data on most bacteraemias in England and Wales. National pharmacy sales data were obtained from the IMS Health MIDAS database and were modelled to the resistance data by logistic and linear regression analysis. All systems except for the BSAC respiratory surveillance data indicated that penicillin resistance has fallen significantly since 1999 in the UK, whereas macrolide resistance has been essentially stable, or has risen slightly. The data for Ireland were based on smaller sample sizes but suggested a fall in penicillin non-susceptibility from 1999 to 2004, with conflicting evidence for macrolide resistance. The recent decreasing trend in penicillin resistance is in contrast to a rising trend in England and Wales until (at least) 1997 and strongly rising macrolide resistance from 1989 to 1993. UK pharmacy sales of macrolides and oral beta-lactams fell by ca. 30% in the late 1990s following increased concern about resistance, before stabilising or rising weakly; sales in Ireland were stable or rose slightly in the study period. We conclude that falling penicillin resistance in pneumococci followed reduced sales of oral beta-lactams to pharmacies in the UK, but a similar fall in macrolide sales was not associated with any fall in resistance. Stabilisation or decline in penicillin resistance has occurred in Ireland despite stable or increasing oral beta-lactam sales.

Back to the basics: epidemiology in the Journal of Antimicrobial Chemotherapy

Good epidemiological methods and appropriate statistical analysis are cornerstones of any valid, reliable and publishable epidemiological study. This editorial summarizes epidemiological studies published in the Journal of Antimicrobial Chemotherapy (12 issues, May 2005--April 2006) with respect to study objective, type and design. A significant proportion of these studies started off with a single study group. Drawing on this finding, various methodological aspects of choosing a sampling frame and of sampling methods are reviewed.

Prevalence and mechanisms of cephalosporin resistance in Enterobacteriaceae in London and South-East England

OBJECTIVES

To investigate the molecular epidemiology of Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs) in London and South-East England.

METHODS

A prospective study involving 16 hospital microbiology laboratories in London and South-East England was undertaken over a 12 week period. Each laboratory submitted up to 100 consecutive cephalosporin-resistant Enterobacteriaceae isolates judged clinically significant by microbiology staff. Centralized testing was undertaken to confirm organism identification and cephalosporin resistance and to analyse resistance mechanisms.

RESULTS

The predominant mechanism of cephalosporin resistance in isolates from both hospital and community settings was the production of CTX-M-type ESBLs, with CTX-M-producing Escherichia coli as the most numerous resistant organism overall. Other major mechanisms of cephalosporin resistance included production of non-CTX-M ESBLs and AmpC beta-lactamases. Most ESBL (both CTX-M and non-CTX-M) producers were multiply resistant to non-beta-lactam antibiotics, including trimethoprim, ciprofloxacin and gentamicin.

CONCLUSIONS

CTX-M enzymes, which were unrecorded in the UK prior to 2000, have become the major mechanism of cephalosporin resistance in Enterobacteriaceae in South-East England. E. coli has overtaken Klebsiella and Enterobacter spp. to become the major host for ESBLs. Due to the multiple antibiotic resistance exhibited by many ESBL-producers, these changes have major implications for antimicrobial therapy.

Study on spontaneous cerebrospinal fluid rhinorrhoea: its aetiology and management

The aim of this study was to identify the common features in a study group of patients with spontaneous cerebrospinal fluid (CSF) rhinorrhoea, to develop a hypothesis to explain the cause of this condition and to investigate the outcome of surgical techniques adopted to repair the leak. In this retrospective study the authors have reviewed all the cases of spontaneous CSF leaks attending and receiving treatment from the otolaryngology department of Queen Elizabeth Hospital, Birmingham, from 1992 to 2002.

Of 34 patients with CSF leaks, 15 were spontaneous in nature and formed the study group. Of these 15 patients, 14 were female; with ages ranging from 37 to 70 years and a median age of 50 years. All the female patients were overweight with a body mass index (BMI) >24.9 and, of these, nine were considered obese with a BMI >30. It was attempted to identify common factors in the study group and it was evident that female sex, obesity and age played a key role in this condition.

The follow-up period ranged from two to 98 months. Thirteen patients were asymptomatic but two patients remained symptomatic, one of these despite repeated surgical intervention.

Surveillance and epidemiology of MRSA bacteraemia in the UK

Surveillance of bacteraemia caused by methicillin-resistant Staphylococcus aureus (MRSA) in the UK has involved collection of data from hospital microbiology laboratories via several mechanisms, including a voluntary reporting scheme that has been operational in England and Wales since 1989 and mandatory reporting schemes that have been running independently in England, Wales, Scotland and Northern Ireland since 2001. In addition, surveillance schemes involving panels of participating sentinel laboratories that submit isolates for centralized susceptibility testing, such as the Bacteraemia Resistance Surveillance Programme run by the BSAC, have also been established. Each of these data sources have particular advantages, but they also have their individual limitations, with the result that they each give an incomplete picture if considered in isolation. However, by pooling the findings from these different but complementary surveillance programmes, a much more comprehensive and credible picture of the problem posed by MRSA is produced. These schemes have shown both a dramatic rise in the total numbers of cases of S. aureus bacteraemia reported annually and an increase in the proportion of such cases that involve MRSA (from 2% in 1990 to >40% in the early 2000s), although the most recent data indicate a slight reversal of these trends. Characterization of isolates of MRSA shows a marked temporal relationship between the rise in MRSA bacteraemias and the emergence and spread of two strains of epidemic MRSA, EMRSA-15 and EMRSA-16. Surveillance and control of MRSA infection continue to be high profile and further developments to the mandatory surveillance system in England are likely in the near future.

Susceptibility to moxifloxacin of pneumococci isolated in English hospitals participating in the European Antimicrobial Resistance Surveillance System (EARSS) in 2003

Susceptibility to moxifloxacin, penicillin and erythromycin was determined for 592 invasive Streptococcus pneumoniae collected from 20 English hospitals participating in the European Antimicrobial Resistance Surveillance System (EARSS) during 2003. Resistance to moxifloxacin, penicillin and erythromycin was observed in 0.8%, 5.4% and 13% of the isolates, respectively. These results show that the large majority of pneumococci were susceptible to moxifloxacin in 2003, the year when it was licensed for clinical use in the UK.

Antimicrobial resistance of invasive Streptococcus pneumoniae isolates in a British district general hospital: the international connection

Between January 2000 and March 2001,Streptococcus pneumoniaewere isolated from the blood of 56 patients admitted to a single district general hospital in the South-East of England. The serotype and antibiotic susceptibility were determined for all isolates and, for those resistant to erythromycin, the presence or absence of themef(A) anderm(B) genes was determined by PCR. Multi-locus sequence typing, along with PFGE, was undertaken on all isolates resistant to penicillin or erythromycin and a group of antibiotic-susceptible isolates, to identify whether globally distributed pneumococcal clones, as described by the Pneumococcal Molecular Epidemiology Network (PMEN), were present in the study population. Three serotype 9V penicillin-resistant isolates were identified as belonging to the Spain9V-3 clone, while 14 erythromycin-resistant isolates of serotype 14 belonged to the England14-9 clone. A single multi-resistant isolate of serotype 6B, was found to be a single-locus variant of the Spain6B-2 clone. All 14 erythromycin-resistant serotype 14 isolates possessed themef(A) gene, while the single multi-resistant isolate possessed theerm(B) gene. These findings confirm the wide distribution and clinical impact of PMEN clones, which accounted for all of the penicillin and erythromycin resistance observed amongst invasive isolates in a district general hospital over a 15-month period.