Ceftriaxone versus ampicillin for the treatment of community-acquired pneumonia. A propensity matched cohort study

OBJECTIVES

Ceftriaxone is recommended as first-line antibiotic treatment (with the addition of macrolide) for hospitalised adults with community acquired pneumonia (CAP). Narrower-spectrum β-lactam as ampicillin, may be associated with comparable clinical outcomes, with less emergence of resistant pathogens or Clostridioides difficile infection (CDI). We aimed to examine whether ampicillin and ceftriaxone (with the addition of macrolides for both arms) are comparable for the treatment of hospitalized adults due to CAP.

METHODS

This was a single center, observational cohort study. We included adult patients who were hospitalized in internal medicine wards due to CAP and were treated with either ceftriaxone or ampicillin with the addition of macrolide. A propensity-score model was used. The primary outcome was 30-day all-cause mortality. A multivariable logistic regression analysis and Kaplan-Meier survival analysis was performed. We performed subgroup analyses for the main outcome based on CURB-65 score and age.

RESULTS

A total of 1586 patients fulfilled the inclusion criteria. There was no difference in 30-day mortality rate in the total cohort (28/233 vs. 208/1353 in ampicillin and ceftriaxone arm, respectively; p = 0.184). In the propensity matched cohort (197 in ampicillin and 394 in ceftriaxone arm), there was no significant difference in 30-day all-cause mortality between treatment groups in multivariable analysis of the main model (OR 0.67, 95% CI, 0.37-1.2; p = 0.189) and Kaplan-Meier survival analysis (p = 0.108). Thirty-day mortality rate was (19/197 vs. 57/394, in ampicillin and ceftriaxone arms, respectively; p = 0.108) Patients who were treated with ampicillin experienced significantly lower rates of CDI (0/197, 0% vs. 8/394, 2%; p = 0.044).

DISCUSSION

Ampicillin was associated with comparable clinical outcomes in comparison to ceftriaxone for patients who were hospitalized due to CAP. Ampicillin was associated with significantly lower rate of CDI. Results need to be confirmed by more robust study designs.

To Compare Short-term Surgical Outcome among Patients given Continuous Postoperative Antibiotic Prophylaxis and those given no Postoperative Antibiotics after Urethroplasty for Hypospadias: A Pilot Study

Introduction

There is no well-accepted guideline or uniform practice for the usage of prophylactic antibiotics along with urethroplasty for hypospadias. As antibiotic resistance is growing, it is imperative to rationalize the usage of antibiotics when a patient is operated for hypospadias.

Aims and Objectives

The study is aimed at finding if there is any difference in outcome if prophylactic antibiotics are given after urethroplasty for hypospadias.

Study Design

Prospective randomized controlled study.

Material and Methods

Forty patients between 6 months and 12 years of age were included in the pilot study. All patients received a single preoperative antibiotic and surgery as per the discretion of the operating surgeon. The participants were randomly assigned to Group A or B, Group A not receiving any prophylactic antibiotic after surgery, and Group B receiving prophylactic antibiotics till indwelling urethral catheter was in situ as per the present antibiotic policy of the institute. The patients were followed up clinically at catheter removal, 1 week after surgery and 1 month after surgery. Urine was analyzed at the start of surgery and after catheter removal. Data were tabulated and analyzed using nonparametric Fischer's exact test with help of Epi Info™ v5.5.8.

Results

Twenty-four patients were included in Group A and 16 in Group B. The clinical profile is presented in the detailed manuscript. Although pus cells could be demonstrated on urine examination in 82.5% of the study participants, only 10% grew organisms on culture media. No difference could be demonstrated among the two groups statistically. On following up with the patients for 1 month, the groups were comparable with respect to surgical site infections, and surgical complications such as urethrocutaneous fistula/dehiscence and thin stream. [Table: see text].

Discussion

There was a wide variability among practicing pediatric urologists in prescribing antibiotic prophylaxis for patients undergoing urethroplasty for hypospadias. In the Urologic Surgery Antimicrobial Prophylaxis Policy by the American Urology Association, no recommendation has been made with respect to urethroplasty. Our results are in concurrence with the available English literature which has not shown any benefit of prophylactic antibiotics after hypospadias repair.

Conclusions

Antibiotics may not have a definite role in the prevention of surgical complications and it may be imperative to avoid unnecessary antibiotics to reduce antibiotic resistance.

Reduction of antibiotic use and multi-drug resistance bacteria infection in neonates after improvement of antibiotics use strategy in a level 4 neonatal intensive care unit in southern China

The investigation on antibiotic stewardship in neonatal intensive care unit in China is scarce. This study aimed to analyze the effect of a comprehensive 2-year antibiotic stewardship in a level 4 NICU. During this baseline period from October 1st 2017 to October 1st 2019, continuation of empirical antibiotic therapy for ruled-out sepsis courses was beyond 72 h and for pneumonia was more than 7 days. Meropenem or vancomycin was used even if they were not the only bacterial sensitive antibiotics. The intervention period was from October 2nd 2019 to August 23rd 2021. Three areas for quality improvement were targeted in our center: discontinuation of antibiotic use in ruled-out sepsis within 72 h, treatment duration for culture-negative pneumonia less than 7 days, and vancomycin or meropenem was not used unless the cultured bacteria was only susceptible to them. The total antibiotic consumption decreased from 791.1 to 466.3 days of therapy per 1000 patient days from baseline to intervention period. Antibiotics were stopped within 72 h for 47.48% patients with rule-out sepsis and within 7 days for 75.70% patients with pneumonia compared with 11.56% and 37.69% during the baseline period respectively. The prevalence of multi-drug resistance bacteria decreased from 67.20 to 48.90%. The total use rate of meropenem or vancomycin decreased from 7.6 to 1.8%. Our quality improvement approach on antibiotic strategy significantly reduced antibiotic use and prevalence of multi-drug resistance bacteria in our NICU.

Impact of selective reporting of antibiotic susceptibility testing results on meropenem prescriptions for the treatment of Pseudomonas aeruginosa infections after 2020 EUCAST criteria update: an observational study in a university hospital

BACKGROUND

We previously reported an increase in meropenem prescriptions for Pseudomonas aeruginosa infections in our hospital after the implementation of the 10th version of the EUCAST breakpoints table for P. aeruginosa in January 2020. As a consequence, antibiotic susceptibility testing results were adapted by masking meropenem for P. aeruginosa isolates susceptible to either ceftazidime, cefepime or piperacillin-tazobactam. We aimed to assess the changes in meropenem prescriptions after the implementation of the selective reporting.

METHODS

In this retrospective single-centre observational study, we analysed antimicrobial therapies prescribed for P. aeruginosa infections after the susceptibility testing results have been made available over three periods: "before EUCAST update", "after EUCAST update without selective reporting" and "after EUCAST update with selective reporting", at Lausanne University Hospital, Switzerland. We collected epidemiological, microbiological and clinical data. The primary outcome was the prescription of meropenem to treat P. aeruginosa infections after the release of susceptibility testing results. Secondary outcomes were the use of increased dosage of non-meropenem anti-pseudomonal drugs, and IDs' consultations rates after the release of susceptibility testing results.

RESULTS

Among the 457 patients included, 65 (14.2%) received meropenem: 5/148 (3.4%) before EUCAST update, 51/202 (25.3%) after EUCAST update without selective reporting, and 9/107 (8.4%) after EUCAST update with selective reporting. Supervision and counselling from IDs as well as the use of increased dosages of non-carbapenem antibiotics increased in both periods after EUCAST update, compared to the first period, respectively: 40.5% (60/148) versus 61.4% (124/202) versus 51.4% (55/107) (P < 0.001), and 57.9% (84/148) versus 91.1% (183/202) versus 90.7% (97/107) (P < 0.001).

CONCLUSIONS

Selective reporting of antibiotic susceptibility testing results might decrease unnecessary meropenem prescriptions for the treatment of P. aeruginosa infections and could be part of multimodal antibiotic stewardship interventions.

Infectious diseases pharmacy practice, education, and research in Saudi Arabia: A review and future perspectives by the Infectious Diseases Pharmacy Specialty Network at the Saudi Society of Clinical Pharmacy

Background

Infectious diseases (ID) pharmacy is one of the rapidly evolving clinical pharmacy specialties in the Kingdom of Saudi Arabia (KSA). There are gaps in the literature on ID pharmacy status in KSA. This review aimed to provide an update on the current status of several areas related to ID pharmacy in KSA, including practice, education, and research, and make pertinent recommendations for future development to achieve the KSA Vision, 2030, KSA Vision, 2030.

Methods

This review was developed by a group of ID pharmacists working in different sectors under the umbrella of the ID Pharmacy Specialty Network (PSN) of the Saudi Society of Clinical Pharmacy (SSCP). The authors evaluated domains related to ID pharmacy in KSA and searched the literature for relevant articles. Based on the experts' assessment of the current gaps and challenges, recommendations were made for future improvement.

Results

Several aspects of ID pharmacy in KSA were evaluated, including history and development, antimicrobial resistance (AMR), antimicrobial stewardship programs (ASP), roles of ID pharmacists, ID pharmacy education, and research. The biggest challenges include AMR, the varying levels of ASP implementation, and the low number of ID-trained pharmacists, especially in non-major cities. Several recommendations for improvement were discussed.

Conclusion

Infectious diseases pharmacy has sustained remarkable progress in KSA in several areas. However, more efforts are needed to increase ASP implementation, increase the number of ID-trained pharmacists, and encourage ID pharmacists in publishing and participating in practice guidelines, which will eventually help achieve the KSA Vision, 2030, KSA Vision, 2030.

Information about the natural history of acute infections commonly seen in primary care: a systematic review of clinical practice guidelines

BACKGROUND

Many of the acute infections that are seen in primary care and sometimes managed with antibiotics are self-resolving and antibiotics may be unnecessary. Information about the natural history of these infections underpins antibiotic stewardship strategies such as delayed prescribing and shared decision making, yet whether it's reported in guidelines is unknown. We examined, in clinical guidelines, the reporting of natural history information and relevant antibiotic stewardship strategies for acute infections commonly seen in primary care.

METHODS

A systematic review of national and international guidelines (2010 onwards), available electronically, for managing acute infections (respiratory, urinary, or skin and soft tissue). We searched MEDLINE, CINAHL, EMBASE, TRIP, and GIN databases and websites of 22 guideline-publishing organisations.

RESULTS

We identified 82 guidelines, covering 114 eligible infections. Natural history information was reported in 49 (59.8%) of the guidelines and 66 (57.9%) of the reported conditions, most commonly for respiratory tract infections. Quantitative information about the expected infection duration was provided for 63.5% (n = 42) of the infections. Delayed antibiotic prescribing strategy was recommended for 34.2% (n = 39) of them and shared decision making for 21% (n = 24).

CONCLUSIONS

Just over half of the guidelines for acute infections that are commonly managed in primary care and sometimes with antibiotics contained natural history information. As many of these infections spontaneously improve, this is a missed opportunity to disseminate this information to clinicians, promote antibiotic stewardship, and facilitate conversations with patients and informed decision making. Systematic review registration CRD42021247048.

Is parenteral antibiotic prophylaxis associated with fewer infectious complications in stented, distal hypospadias repair?

INTRODUCTION

Judicious use of antibiotics for surgical prophylaxis is important for reducing antimicrobial resistance while preventing infectious surgical complications. In the setting of pediatric distal hypospadias repairs, it is unclear if antibiotic surgical prophylaxis is beneficial.

OBJECTIVE

The purpose of this study was to compare rates of infectious complications in pediatric subjects undergoing distal hypospadias repair who received any peri-operative antibiotics to those who did not.

STUDY DESIGN

This was a review of a retrospective cohort from a database of individuals undergoing hypospadias repairs evaluating whether they received peri-operative or post-operative antibiotic prophylaxis and determining the rate of infectious complications in those who did compared to those who did not receive antibiotic prophylaxis. Infectious complications were defined as surgical site infection (SSI) or urinary tract infection (UTI).

RESULTS

There was no significant difference in infectious complication rates between individuals who received peri-operative parenteral antibiotic prophylaxis and those who did not. All subjects with infectious complications received post-operative oral antibiotic prophylaxis. There was one instance of C. difficile infection in a subject who received peri-operative parenteral antibiotics.

DISCUSSION

Reducing antibiotic utilization without increasing infectious surgical complications is important in safely reducing antimicrobial resistance. In this study of pediatric distal hypospadias repair, peri-operative antibiotics did not demonstrate a clear benefit and post-operative oral antibiotics demonstrated no benefit in preventing infectious complications. Other studies evaluating peri- and post-operative antibiotics for pediatric hypospadias repair have also failed to demonstrate a benefit for antibiotics in preventing infections. Practitioners should reconsider the use of antibiotics in this setting.

CONCLUSION

Routine antibiotic prophylaxis does not appear beneficial for preventing infectious complications following uncomplicated, stented pediatric distal hypospadias repairs.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Antibiotic use by dentists in Germany: a review of prescriptions, pathogens, antimicrobial resistance and antibiotic stewardship strategies

BACKGROUND

In Germany, 85% of all antibiotics are prescribed in the outpatient care sector, and dentists account for 11% of the total outpatient antibiotic prescriptions.

OBJECTIVE AND METHOD

Summarise published literature on antibiotic use, pathogens and antibiotic resistance in odontogenic infections and German clinical guidelines and interventions for antibiotic use in dental care.

RESULTS

In contrast to other outpatient physicians, the volume of antibiotics prescribed by dentists in Germany did not decrease over the last decade. Penicillins and aminopenicillins are the most frequently prescribed antibiotics (70% of all prescriptions), followed by clindamycin (26%). Streptococcus spp. and Staphylococcus spp. are frequent pathogens isolated from odontogenic infections. However, the infections are often polybacterial with a mixed growth of anaerobic and aerobic bacteria. While the widespread use of penicillin class antibiotics is compatible with German recommendations on empiric antibiotic therapy, there is evidence that pathogens from odontogenic infections frequently exhibit resistance against them. Moreover, the high prescription volume of clindamycin (⟩25%) appears to be inadequate, since relatively high resistance rates are observed and clindamycin is not recommended as first-line choice in empiric antibiotic therapy. National and international studies show that continuous education of patients and dentists, individual prescription feedback as well as evidence-based guidelines are important measures to improve antibiotic prescription patterns among dentists.

CONCLUSION

To promote rational antibiotic use in outpatient dental care, antibiotic stewardship measures are necessary that include prescription guidelines based on AMR surveillance data as well as continuous education of dentists.

The efficacy and safety of intravesical chondroitin sulphate solution in recurrent urinary tract infections

BACKGROUND

Urinary tract infections are among the most common indications for antibiotic therapy. The emergence of resistant uropathogens indicates the need for treatment alternatives. Replenishment of the glycosaminoglycan layer of the bladder, achieved by intravesical instillation of e.g. chondroitin sulphate (CS), is described to be a cornerstone in the therapy of cystitis. To retrospectively evaluate the efficacy of a therapy with 0.2% CS in patients suffering recurrent urinary tract infections (rUTI) in comparison to a treatment with low-dose long-term antibiotics (LDLTAB) and a combination of both.

METHODS

A total of 151 patients with recurrent UTI who underwent intravesical therapy at Diaconesse hospital in Leiden, The Netherlands were included. 50 patients had been treated with CS, 51 patients had received LDLTAB, and 50 patients had received a combination therapy (LDLTABCS). Data recorded for baseline, after 6, and 12 months of treatment were evaluated. Descriptive statistics were calculated. Exploratory comparisons between groups and within groups were performed by using one-tailed and paired t-tests. Patients filled in a standardized quality of life questionnaire (EQ-5D).

RESULTS

We found a statistically significant reduction of number of infections from 7.10 ± 0.50 SEM to 0.45 ± 0.07 SEM after 12 months therapy with CS compared to 12 months therapy with LDLTAB (from 7.04 ± 0.47 SEM to 1.8 ± 0.15 SEM). The number of visits to the urologist significantly decreased in the CS group from 7.46 ± 0.80 SEM to 1.28 ± 0.11 SEM and from 4.10 ± 0.29 SEM to 1.35 ± 0.11 SEM in the LDLTABCS group. In addition, a significant increase in Quality of life (QoL) was seen in the CS-group (from 58.2 ± 0.82 SEM to 80.43 ± 0.82 SEM) and in the LDLTABCS group (from 62.4 ± 0.97 SEM to 76.73 ± 1.06 SEM). There was no improvement in QoL with LDLTAB (from 58.24 ± 1.08 SEM to 58.96 ± 1.19 SEM). Evaluation's evidence is limited due to its retrospective character.

CONCLUSIONS

Retrospective analysis of data from patients that underwent therapy for rUTIs confirms the safety and efficacy of CS and indicate a superiority to antibiotic treatment of rUTIs.

How to 'SAVE' antibiotics: effectiveness and sustainability of a new model of antibiotic stewardship intervention in the internal medicine area

BACKGROUND

Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period.

METHODS

The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model.

RESULTS

A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention.

CONCLUSIONS

The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.

[What is the proportion of infectiology in the specialization urology? : A pilot study to underline the significance of Antibiotic Stewardship in urology]

BACKGROUND

Urinary tract infections account for one of the most bacterial infectious diseases worldwide.

OBJECTIVES

The primary aim of this pilot project was to identify the relative percentage of antibiotic use in comparison to all patients in a university medical center for the better establishment of antibiotic stewardship (ABS) programs.

MATERIAL AND METHODS

This is an epidemiological pilot project. In the time period of three months it was evaluated which relative percentage of the patients was treated with antibiotics for bacterial urinary tract infection in comparison to all patients.

RESULTS

In summary, about 40% of all urological patients received an antibiotic treatment against urinary tract infections or as perioperative prophylaxis against bacterial infection in the operating room (OR). The antibiotic use at the urological ward is highest in comparison to ambulance or OR.

CONCLUSION

Infectious diseases, especially bacterial infections, account for a significant part of urology. This knowledge is essential to establish ABS programs and to tackle the progression of antibiotic resistance. Detailed studies are necessary to understand antibiotic prescription practice in urology to develop targeted ABS interventions.

The Need of Antimicrobial Stewardship in Post-Operative Infectious Complications of Abdominal Surgery

Background

Post-operative infection is a common complication following abdominal surgery. The two most common infections are secondary peritonitis and surgical site infections, which lead to increased perioperative morbidity, prolonged hospitalization, higher mortality rates, and increased treatment costs. In addition to surgical procedures, treatment is based on effective antibiotic therapy. Due to increasing antimicrobial resistance, the correct use of antimicrobials is becoming more complex. Many initiatives call for the implementation of an antimicrobial stewardship (AMS) programme to optimize anti-infective therapy. The review article summarizes current recommendations in anti-infective therapy of post-operative peritonitis and surgical site infections and highlights the importance of an AMS programme in abdominal surgery.

Summary

Larger studies evaluating the benefit of AMS in abdominal surgery are lacking. However, national and international guidelines have formulated appropriate recommendations for the rational use of antibiotics in post-operative peritonitis and surgical site infections. The rate of post-operative infections can be significantly reduced by perioperative antibiotic prophylaxis. The increase in multidrug-resistant bacteria complicates anti-infective therapy for post-operative infections. Analysis of local susceptibility patterns helps choose an adequate empiric therapy. A high rate of extended-spectrum beta-lactamase-producing bacteria may necessitate the use of other reserve antibiotics in addition to carbapenems, which are approved for the treatment of complicated intra-abdominal infections. A key role for the AMS team is the subsequent de-escalation of antibiotic therapy which limits the use of unnecessary broad-spectrum antibiotics.

Key Messages

The increase in multidrug-resistant bacteria poses challenges for abdominal surgery. Post-operative infections should be treated by an interdisciplinary team of surgeons and specialists for AMS.

Urine testing is associated with inappropriate antibiotic use and increased length of stay in emergency department patients

Background

Exposing patients with a low probability of disease to diagnostic testing with poor test characteristics leads to false positive results. Providers often act on these false results, which can cause unnecessary evaluation and treatment. The treatment of asymptomatic bacteriuria is discouraged, but it still frequently occurs in the inpatient setting; it is less studied in the Emergency Department (ED). In this study, we examine associations between urine testing, inappropriate antibiotic use, and length of stay in discharged ED patients at risk of urinary tract infection (UTI) misdiagnosis.

Methods

A cohort of discharged ED patients at risk of UTI misdiagnosis was created by pulling visit information for patients presenting with abdominal pain, chest pain, headache, vaginal bleeding in pregnancy, and elderly females with weakness or confusion. Predictors of urine testing, and urinary tract infection treatment were determined with logistic regression analysis. A chart review of a representative sample of this cohort was then completed screening for the presence of urinary tract symptoms and urine culture results. Linear regression analysis was then used to generate an adjusted mean difference in length of stay between patients who had urine testing compared to those who did not.

Results

About a quarter of chest pain and headache patients had urine testing, while approximately 75% of abdominal pain patients, vaginal bleeding in pregnancy, and elderly females with weakness or confusion did. Except for chest pain patients, the UTI treatment rate was more than double the positive culture rate, indicating overtreatment. A diagnosis of UTI is based on a combination of UTI symptoms and positive urine cultures, yet only about 15% of patients treated for UTI met these criteria. Lastly, in all chief complaint groups, the length of stay was significantly longer-30 min or more-for those who had urine testing compared to matched controls.

Conclusions

In this observational study of patients at risk of UTI misdiagnosis, urine testing was associated with inappropriate antibiotic use and delayed discharge. There is pressure on providers to perform diagnostic testing, but in patients without specific UTI symptoms, urine testing might cause more harm than benefit.

Impact of Adding Rapid Polymerase Chain Reaction-based Blood Culture Identification Panel to Antimicrobial Stewardship Program: Initial Experience

How to cite this article: Arjun R, Niyas VKM, John KE, Nair A, Hussain F. Impact of Adding Rapid Polymerase Chain Reaction-based Blood Culture Identification Panel to Antimicrobial Stewardship Program: Initial Experience. Indian J Crit Care Med 2022;26(10):1155-1157.

Antibiotic resistance is common in the cultures of intraabdominal abscess drainage after appendectomy

INTRODUCTION

Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis.

METHODS

We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected.

RESULTS

In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage.

CONCLUSIONS

IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance.

LEVEL OF EVIDENCE

Level III.

Novel and Rapid Diagnostics for Common Infections in the Critically Ill Patient

There are several novel platforms that enhance detection of pathogens that cause common infections in the intensive care unit. These platforms have a sample to answer time of a few hours, are often higher yield than culture, and have the potential to improve antibiotic stewardship.

Exposure to World Health Organization's AWaRe antibiotics and isolation of multidrug resistant bacteria: a systematic review and meta-analysis

BACKGROUND

Antibiotic use drives antibiotic resistance.

OBJECTIVES

To systematically review the literature and estimate associations between prior exposure to antibiotics across World Health Organization's (WHO) AWaRe categories (Access, Watch, Reserve) and isolation of critical and high-priority multidrug resistant organisms (MDROs) on the WHO priority pathogen list.

DATA SOURCES

Embase, Ovid Medline, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (from inception to 20/08/2020).

STUDY ELIGIBILITY CRITERIA

Case-control, cohort, or experimental studies that assessed the risk of infection/colonization with MDROs.

PARTICIPANTS

Inpatients or outpatients of any age and sex.

INTERVENTIONS

Prior exposure to antibiotics that could be categorized into the AWaRe framework.

DATA ANALYSIS

Tailored design-specific checklists applied to each included study. For each antibiotic/class, crude odds ratios (ORs) were pooled through random-effects meta-analyses, both overall and by MDRO. Heterogeneity was examined.

RESULTS

We identified 349 eligible studies. All were observational, prone to bias due to design and lack of adjustment for confounding, and not primarily designed to compare associations across AWaRe categories. We found statistically significant associations between prior exposure to almost all antibiotics/classes across AWaRe categories and colonization/infection with any MDRO. We observed higher ORs for Watch and Reserve antibiotics than with Access antibiotics. First generation cephalosporins (Access) had the least association with any MDRO colonization/infection (58 studies; OR = 1.2 [95% CI: 1.0-1.4]), whereas strongest associations were estimated for linezolid (Reserve) (22 studies; OR = 2.6 [95% CI: 2.1-3.1]), followed by carbapenems (Watch) (237 studies; OR = 2.3 [95% CI: 2.1-2.5]). There was high heterogeneity for all antibiotic/MDRO associations.

CONCLUSIONS

Optimising use of Access antibiotics is likely to reduce the selection of MDROs and global antibiotic resistance. Despite data limitations, our study offers a strong rationale for further adoption of AWaRe as an important tool to improve antibiotic use globally.

Antibiotic Stewardship Practices and Prescribing Patterns Across Indian PICUs

OBJECTIVES

To elicit antibiotic prescribing patterns across Indian Pediatric Intensive Care Units (PICU) and assess attributes of the antibiotic stewardship programs.

METHODS

A link to a web-based questionnaire was sent by email to pediatric intensivists across India.

RESULTS

Responses were received from 62 PICUs. Majority of respondents were from private hospitals [49/62 (79.5%)]. The most commonly reported infection requiring PICU admission was community-acquired pneumonia [by 39 (62.9%) PICUs] followed by gastroenteritis [26 (41.9%)], and meningitis [15 (24.1%)]. The blood culture positivity rates varied among participating PICUs with 37 centers (59.6%) reporting low blood culture positivity yield (< 40%). Majority of the respondents acknowledged using a 7-d course of antibiotics even in culture-negative sepsis. Most common empiric antibiotics prescribed for community-acquired infections were beta-lactam monotherapy. The typical beta-lactam prescribed was ceftriaxone. However, for hospital-acquired infections (HAI), such as suspected catheter-related bloodstream infection (CLABSI) and suspected ventilator-associated pneumonia (VAP), a higher number of respondents-39/62 (61.9%) and 33/62 (53.2%), respectively, prescribed combination antibiotics (β-lactam + vancomycin). Forty-two units (67.7%) reported having an antibiotic stewardship program in their PICUs, while twenty-nine (45.1%) centers stated having formulary restrictions. Ten (16.1%) centers had pre-authorization policy for certain antibiotics.

CONCLUSION

A rather diverse pattern of prescribing and administration practices exists across different Indian PICUs. While antibiotic stewardship programmes are established in most centers, formulary restriction and pre-authorisation of antibiotic prescribing were reported by few units. Regular surveillance studies are needed to bring uniformity in antibiotic policy and select appropriate empiric therapy.

Asymptomatic Bacteriuria: Prevalence, Diagnosis, Management, and Current Antimicrobial Stewardship Implementations

Asymptomatic bacteriuria is a common clinical condition that often leads to unnecessary treatment. It has been shown that incidence of asymptomatic bacteriuria increases with age and are more prominent in women than men. In older women, the incidence of asymptomatic bacteriuria is recorded to be more than 15%. This number increased up to 50% for those who reside in long-term care facilities. In most scenarios, asymptomatic bacteriuria does not lead to urinary tract infections, and therefore, antibiotic treatment of asymptomatic bacteriuria has not been shown to improve patient outcomes. In 2019, the Infectious Disease Society of America (IDSA) updated its asymptomatic bacteriuria management guidelines, which emphasized on the risks and benefits of treating the condition. Women who are pregnant should be screened for asymptomatic bacteriuria in the first trimester and treated, if positive. Individuals who are undergoing endoscopic urologic procedures should be screened and treated appropriately for asymptomatic bacteriuria as well. Treating asymptomatic bacteriuria in individuals with diabetes, neutropenia, spinal cord injuries, indwelling urinary catheters, and so on has not been found to improve clinical outcomes. Furthermore, unnecessary treatment is often associated with unwanted consequences including but not limited to increased antimicrobial resistance, Clostridioides difficile infection, and increased health care cost. As a result, multiple antibiotic stewardship programs around the US have implemented protocols to appropriately reduce unnecessary treatment of asymptomatic bacteriuria. It is important to appropriately screen and treat asymptomatic bacteriuria only when there is evidence of potential benefit.

Pancreatic stone protein point-of-care testing can reduce healthcare expenditure in sepsis

BACKGROUND

Sepsis is a life-threatening organ dysfunction in response to infection. Early recognition and rapid treatment are critical to patient outcomes and cost savings, but sepsis is difficult to diagnose because of its non-specific symptoms. Biomarkers such as pancreatic stone protein (PSP) offer rapid results with greater sensitivity and specificity than standard laboratory tests.

METHODS

This study developed a decision tree model to compare a rapid PSP test to standard of care in the emergency department (ED) and intensive care unit (ICU) to diagnose patients with suspected sepsis. Key model parameters included length of hospital and ICU stay, readmission due to infection, cost of sepsis testing, length of antibiotic treatment, antibiotic resistance, and clostridium difficile infections. Model inputs were determined by review of sepsis literature.

RESULTS

The rapid PSP test was found to reduce costs by $1688 per patient in the ED and $3315 per patient in the ICU compared to standard of care. Cost reductions were primarily driven by the specificity of PSP in the ED and the sensitivity of PSP in the ICU.

CONCLUSIONS

The results of the model indicate that PSP testing is cost saving compared to standard of care in diagnosis of sepsis. The abundance of sepsis cases in the ED and ICU make these findings important in the clinical field and further support the potential of sensitive and specific markers of sepsis to not only improve patient outcomes but also reduce healthcare expenditures.

Restrictive prescription of antibiotics in preterm infants with premature rupture of membranes

BACKGROUND

In preterm infants with premature rupture of membranes, antibiotic treatment is frequently started but rates of early onset sepsis are lower. In line with national guidelines, a stratified approach in the decision to start antibiotic treatment using maternal history, clinical impression and biomarkers has been implemented in our level III neonatal center and its results are evaluated.

METHODS

Retrospective cohort study of all preterm newborns with rupture of membranes at least 1 h prior to delivery admitted to our tertiary neonatal intensive care unit. Data on antibiotic exposure, mortality and major neonatal complications were extracted from the electronic patient charts to evaluate the effects and safety of our stratified approach.

RESULTS

Four hundred fifty-six infants met the inclusion criteria. 120 (26%) received primary antibiotics whereas 336 (74%) did not. Of those receiving primary antibiotics, 13 (11%) had a blood culture positive sepsis, 46 (38%) met the criteria of clinical sepsis and in 61 (51%) sepsis was ruled out and antibiotics were stopped after 48-96 h. All infants with blood culture positive sepsis were identified and treated within the first 24 h of life using this approach. None of the 336 infants who were not started on antibiotics primarily needed antibiotic therapy within the first 5 days of life. There were no deaths or major neonatal complications in the group that did not receive empiric antibiotics.

CONCLUSIONS

Our stratified approach for preterm infants with premature rupture of membranes allows a safe reduction of antibiotic exposure even in this high risk population. As a result, only 25% of high risk preterm newborns are treated with antibiotics of which more than half receive less than 5 days of treatment. To treat one infant with blood culture positive sepsis, only 9 infants receive empiric antibiotics.

A semi-supervised decision support system to facilitate antibiotic stewardship for urinary tract infections

Urinary Tract Infections (UTIs) are among the most frequently occurring infections in the hospital. Urinalysis and urine culture are the main tools used for diagnosis. Whereas urinalysis is sufficiently sensitive for detecting UTI, it has a relatively low specificity, leading to unnecessary treatment with antibiotics and the risk of increasing antibiotic resistance. We performed an evaluation of the current diagnostic process with an expert-based label for UTI as outcome, retrospectively established using data from the Electronic Health Records. We found that the combination of urinalysis results with the Gram stain and other readily available parameters can be used effectively for predicting UTI. Based on the obtained information, we engineered a clinical decision support system (CDSS) using the reliable semi-supervised ensemble learning (RESSEL) method, and found it to be more accurate than urinalysis or the urine culture for prediction of UTI. The CDSS provides clinicians with this prediction within hours of ordering a culture and thereby enables them to hold off on prematurely prescribing antibiotics for UTI while awaiting the culture results.

'Perceptions' and 'practices' to antibiotic usage among diabetic patients receiving care from a rural tertiary care center: A mixed-methods study

BACKGROUND

Contribution to antibiotic resistance can happen at two interfaces - doctor prescribing antibiotics inadvertently or patient's usage of antibiotics inadvertently. This study was conducted among diabetic inpatients in a rural tertiary health center in Kolar, South India, to assess the various practices related to antibiotic use and to explore the possible reasons for these practices with regard to antibiotic use.

MATERIALS AND METHODS

An exploratory sequential mixed-methods study was conducted with an initial cross-sectional quantitative study followed by qualitative in-depth interviews during August-September 2019. A pretested semi-structured questionnaire was used to capture the sociodemographic, disease-, and treatment-related characteristics and practices related to antibiotic use. An open-ended interview guide was used to conduct in-depth interviews. The practices to antibiotic use were reported using frequency (percentage). Manual descriptive content analyses were done by two investigators separately to identify codes under the broad topic "reasons for adopted practices with regard to antibiotic use."

RESULTS

Of the 152 diabetic inpatients interviewed, 20 (13.2%) felt that antibiotics are safe drugs and can be used commonly. Among these inpatients, seven (4.6%) knew that antibiotics can kill bacteria and four (2.6%) perceived 'antibiotic resistance' as a big problem in India. The practice of checking the expiry date before using antibiotics was seen in 21 (13.8%) and 44 (29%) of them finished the full course of antibiotics. A total of six codes were identified under the broad theme of "reasons for adopted practices with regard to antibiotic use" among diabetic inpatients.

CONCLUSIONS

Less than one-third of them completed the antibiotic course given by the doctor, and almost everyone was ready for over-the-counter purchase of antibiotics offered by the pharmacist. The reasons for such practices were mostly attributed to the "partial drug purchases" and "incomplete advice by the doctor." There is an urgent need to plan and deliver an interventional package to enhance the knowledge and inculcate good antibiotic usage practices among these high-risk populations.