US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011

Optimal Pediatric Outpatient Antibiotic Prescribing

Importance

In the US, 50% of all pediatric outpatient antibiotics prescribed are unnecessary or inappropriate. Less is known about the appropriateness of pediatric outpatient antibiotic prescribing.

Objective

To identify the overall percentage of outpatient antibiotic prescriptions that are optimal according to guideline recommendations for first-line antibiotic choice and duration.

Design, Setting, and Participants

This cross-sectional study obtained data on any clinical encounter for a patient younger than 20 years with at least 1 outpatient oral antibiotic, intramuscular ceftriaxone, or penicillin prescription filled in the state of Tennessee from January 1 to December 31, 2022, from IQVIA's Longitudinal Prescription Claims and Medical Claims databases. Each clinical encounter was assigned a single diagnosis corresponding to the lowest applicable tier in a 3-tier antibiotic tier system. Antibiotics prescribed for tier 1 (nearly always required) or tier 2 (sometimes required) diagnoses were compared with published national guidelines. Antibiotics prescribed for tier 3 (rarely ever required) diagnoses were considered to be suboptimal for both choice and duration.

Main Outcomes and Measures

Primary outcome was the percentage of optimal antibiotic prescriptions consistent with guideline recommendations for first-line antibiotic choice and duration. Secondary outcomes were the associations of optimal prescribing by diagnosis, suboptimal antibiotic choice, and patient- and clinician-level factors (ie, age and Social Vulnerability Index) with optimal antibiotic choice, which were measured by odds ratios (ORs) and 95% CIs calculated using a multivariable logistic regression model.

Results

A total of 506 633 antibiotics were prescribed in 488 818 clinical encounters (for 247 843 females [50.7%]; mean [SD] age, 8.36 [5.5] years). Of these antibiotics, 21 055 (4.2%) were for tier 1 diagnoses, 288 044 (56.9%) for tier 2 diagnoses, and 197 660 (39.0%) for tier 3 diagnoses. Additionally, 194 906 antibiotics (38.5%) were optimal for antibiotic choice, 259 786 (51.3%) for duration, and 159 050 (31.4%) for both choice and duration. Acute otitis media (AOM) and pharyngitis were the most common indications, with 85 635 of 127 312 (67.3%) clinical encounters for AOM and 42 969 of 76 865 (55.9%) clinical encounters for pharyngitis being optimal for antibiotic choice. Only 257 of 4472 (5.7%) antibiotics prescribed for community-acquired pneumonia had a 5-day duration. Optimal antibiotic choice was more likely in patients who were younger (OR, 0.98; 95% CI, 0.98-0.98) and were less socially vulnerable (OR, 0.84; 95% CI, 0.82-0.86).

Conclusions and Relevance

This cross-sectional study found that less than one-third of antibiotics prescribed to pediatric outpatients in Tennessee were optimal for choice and duration. Four stewardship interventions may be targeted: (1) reduce the number of prescriptions for tier 3 diagnoses, (2) increase optimal prescribing for AOM and pharyngitis, (3) provide clinician education on shorter antibiotic treatment courses for community-acquired pneumonia, and (4) promote optimal antibiotic prescribing in resource-limited settings.

MAPRS: An intelligent approach for post-prescription review based on multi-label learning

Antimicrobial resistance (AMR) is a major threat to public health worldwide. It is a promising way to improve appropriate prescription by the review and stewardship of antimicrobials, and Post-Prescription Review (PPR) is currently the main tool used in hospitals. Existing methods of PPR typically focus on the dichotomy of antimicrobial prescription based on binary classification which, however, is usually a multi-label classification problem. Moreover, previous research did not explain the causes beneath the inappropriate antimicrobial used in the clinical setting, which could be practically important for problem location and decision improvement. In this paper, we collected antimicrobial prescriptions and related data from clean surgery in a hospital in northeastern China, and proposed a Multi-label Antimicrobial Post-Prescription Review System (MAPRS). MAPRS first uses NLP techniques to process unstructured data in prescriptions and explores the value of clinical record text for solving medical problems. Then, Classifier Chains are used to deal with multi-label problems and fused with machine learning algorithms to construct a classifier. At last, a SHAP explanation module is introduced to explain the inappropriate prescriptions. The experimental results show that MAPRS could achieve great performance in a challenging six-category multi-label task, with a subset accuracy of 90.7 % and an average AUROC of 94.3 %. Our results can help hospitals to perform intelligent prescription review and improve the antimicrobial stewardship.

Communicating diagnostic uncertainty reduces expectations of receiving antibiotics: Two online experiments with hypothetical patients

The overprescription of antibiotics due to diagnostic uncertainty and inappropriate patient expectations influence antimicrobial resistance. This research assesses (i) whether communicating diagnostic uncertainty reduces expectations of receiving antibiotics and (ii) which communication strategies minimise unintended consequences of such communication. In two experimental online studies conducted in January and April 2023, participants read a vignette describing a doctor consultation for an ear infection and expressed their expectations of receiving antibiotics, trust in their doctor, rated the doctor's reputation and provided their intention to get a second doctor's opinion. Study 1 (N = 2213) investigated whether communicating diagnostic uncertainty and social externalities of antibiotic use (the negative social impacts of developing antibiotic resistance) decreases expectations for antibiotics and explores potential unintended consequences on the doctor-patient relationship. In Study 2 (N = 527), we aimed to replicate and extend the findings by adding specific treatment recommendations. Disclosing diagnostic uncertainty (vs. certainty) and communicating (vs. not communicating) the social externalities of antibiotic overuse reduced patients' expectations of receiving antibiotics. Yet, communicating uncertainty impaired trust in the doctor and the doctor's reputation. Combining the communication of uncertainty with specific treatment recommendations-particularly delayed antibiotic prescriptions-showed important to prevent these unintended consequences.

Increased risk of pigmentary degeneration of the iris and pigmentary glaucoma with fluoroquinolone antibiotics

PURPOSE

Fluoroquinolones are popular antibiotics used for a myriad of conditions including ocular procedures. Despite numerous case reports of acute pigmentary degeneration of the iris with fluoroquinolone use, a pharmacoepidemiological study has not been performed to examine and quantify this risk.

DESIGN

Retrospective cohort study with a case-control analysis.

PARTICIPANTS

A cohort of 1,231,881 new users of oral or topical moxifloxacin, levofloxacin, and azithromycin were followed to first diagnosis of pigmentary degeneration of the iris or pigmentary glaucoma. Four controls were selected for each case using density sampling, matching on age and calendar time.

METHODS

Users of oral or topical moxifloxacin were compared to levofloxacin and azithromycin, a negative control drug from a separate class.

MAIN OUTCOMES AND MEASURES

First incidence of pigmentary degeneration of the iris or pigmentary glaucoma.

RESULTS

The cohort was comprised of 1,231,881 new users of topical or oral levofloxacin, moxifloxacin, or azithromycin. 542 cases of pigmentary degeneration of the iris and 460 cases of pigmentary glaucoma were identified. The incidence of iris pigmentary degeneration or pigmentary glaucoma for topical moxifloxacin was 10.2/1000 person years compared to 2.6/1000 person years for topical azithromycin. Current topical moxifloxacin users had the highest adjusted IRR for pigmentary degeneration of the iris (IRR = 6.81, [95%CI:2.00-23.18]) and pigmentary glaucoma (IRR = 4.07 [95%CI:1.42-11.62]) respectively.

CONCLUSIONS

The study findings suggest that patients using topical moxifloxacin may have increased risk of developing pigmentary degeneration of the iris and pigmentary glaucoma although the absolute increase was low. Future studies are needed to confirm this association.

Prevalence of Inappropriate Antibiotic Prescribing with or without a Plausible Antibiotic Indication among Safety-Net and Non-Safety Net Populations

BACKGROUND

Clinicians can prescribe antibiotics inappropriately without coding the indication for antibiotics. Whether the prevalence of inappropriate antibiotic prescribing with or without a plausible indication differs between safety-net and non-safety-net populations is unknown.

OBJECTIVE

To assess differences in inappropriate antibiotic prescribing with or without a plausible indication between safety-net and non-safety net populations.

DESIGN

Cross-sectional.

PARTICIPANTS

Office visits in the 2016, 2018, 2019 National Ambulatory Medical Care Survey with ≥ 1 antibiotic prescription among children (0-17 years) and adults (18-64 years).

MAIN MEASURES

Inappropriate antibiotic prescribing with a plausible indication (visits with infection-related diagnosis codes that do not warrant antibiotics, e.g., acute bronchitis); inappropriate prescribing without a plausible indication (visits with codes that are not antibiotic indications, e.g., hypertension). By age group, we used linear regression to assess differences between safety-net (public/no insurance) and non-safety net populations (privately insured), controlling for patient and visit characteristics.

KEY RESULTS

Analyses included 67,065,108 and 122,731,809 weighted visits for children and adults, respectively. Among visits for children in the safety-net and non-safety populations, the prevalence of inappropriate antibiotic prescribing with a plausible indication was 11.7% and 22.0% (adjusted difference: -8.0%, 95% CI: -17.1%, 1.0%); the prevalence of inappropriate prescribing without a plausible indication was 11.8% and 8.6% (adjusted difference: -2.0%, 95% CI: -4.6%, 0.6%). Among visits for adults in the safety-net and non-safety populations, the prevalence of inappropriate antibiotic prescribing with a plausible indication was 12.1% and 14.3% (adjusted difference: -0.1%, 95% CI -9.4%, 9.1%); the prevalence of inappropriate prescribing without a plausible indication was 48.2% and 32.3% (adjusted difference: 12.5%, 95% CI: 3.6%, 21.4%).

CONCLUSIONS

Inappropriate antibiotic prescribing with or without a plausible antibiotic indication is common in all populations, highlighting the importance of broad-based antibiotic stewardship initiatives. However, targeted initiatives focused on improving coding quality in adult safety-net settings may be warranted.

Association of outpatient fluoroquinolone prescribing with the National Medical Products Administration announcements of label changes in China

BACKGROUND

In 2017 and 2021, the National Medical Products Administration (NMPA) announced to revise the drug label of fluoroquinolones. We aimed to evaluate the association of fluoroquinolone prescribing with the NMPA announcements of label changes.

RESEARCH DESIGN AND METHODS

Monthly prevalence of fluoroquinolone prescriptions for uncomplicated urinary tract infections (uUTI), acute exacerbation of chronic bronchitis (AECB), and acute sinusitis (AS) between 2016 and 2022 was calculated, and interrupted time series analysis was applied to assess the impacts of NMPA label changes on fluoroquinolone use.

RESULTS

Prevalence of fluoroquinolone prescriptions decreased by 2.39% (95% CI, -4.72% to -0.07%) for uUTI but increased by 3.02% (95% CI, 1.71% to 4.34%) for AS immediately after the 2017 label change. Moreover, after the 2021 label change, fluoroquinolone use decreased shortly in all the three indications. However, a significant increasing trend was observed in fluoroquinolone use for AECB episodes, and fluoroquinolons were used for 61.4% of treated uUTI, 31.6% of treated AECB, and 5.42% of treated AS at the end of 2022, respectively.

CONCLUSIONS

The label changes issued by the NMPA had no substantial impacts on fluoroquinolone prescribing in the study region in China. Fluoroquinolone prescribing was still highly prevalent for uUTI and AECB and thus requiring further antimicrobial stewardship.

Antibiotic appropriateness at outpatient settings in Ethiopia: the need for an antibiotic stewardship programme

Background

Antibiotics are drugs of natural or synthetic origin used to treat various infections. The practice of excessive and inappropriate antibiotics use is the main global cause of bacterial resistance, which is one of the most serious global public health threats. It is estimated that about 50% of global antibiotic prescriptions are inappropriate. This study assesses the prevalence and pattern of inappropriate prescriptions of antibiotics amongst ambulatory care visits in Ethiopia.

Methods

A facility-based, cross-sectional study with a quantitative approach was conducted amongst randomly selected prescriptions issued for outpatients from May to June 2022 at Debre Markos Specialized Comprehensive Hospital, Northwest Ethiopia. Descriptive statistics, such as frequencies and percentages, were computed. For group comparisons, χ2 and independent sample t-tests were computed. The statistical significance of the association was considered at p<0.05.

Results

A total of 2640 antibiotics were prescribed for patients in the outpatient setting with various bacterial infections via 911 prescriptions, of which 49.5% were non-compliant with the national treatment guideline. Guideline non-compliant prescriptions increased remarkably amongst patients in the outpatient setting diagnosed with community-acquired pneumonia (38.8% versus 30.1%; p=0.006) and peptic ulcer disease (14.9% versus 9%; p=0.006). Moreover, inappropriate prescription was significantly higher amongst patients taking amoxicillin/clavulanic acid (33.2% versus 48.2%; p<0.001) and cephalexin (17.8% versus 24.3%; p=0.016).

Conclusion

Large proportions of antibiotic prescriptions for outpatients were non-compliant with the national treatment guideline, suggesting that prescribers need to give special attention to outpatients whilst ordering antibiotics such as amoxicillin/clavulanic acid and cephalexin. Antibiotic stewardship efforts to optimize outpatient antibiotic prescriptions and reduce the use of potentially inappropriate antibiotics are needed in Ethiopia.

Claiming or abdicating medical authority: Treatment recommendation actions, doctor-patient relationship, and antibiotic overprescription in Chinese paediatrics

Antibiotic overprescription in China has long been considered a problem on the supply side, linked to the financial incentives of physicians. Based on the conversation analysis of 187 video-recorded naturally occurring medical consultations in Chinese paediatric primary care settings, this study finds that the driving force behind the problem of antibiotic overprescription in China has changed. Physicians use a low-authority communication style to recommend treatment, displaying a low level of medical authority and a willingness to accommodate caregivers' preferences in antibiotic prescribing decisions. The problem is now attributed to physician-caregiver interaction, doctor-patient relationship and the antibiotic-saturated prescribing culture. Practice implications involve deepening the understanding of the evolving nature of the antibiotic overprescription problem in China, building trust between physicians and patients/caregivers in order to facilitate the physicians' role as the gatekeeper of antibiotics and providing training programmes to help physicians develop effective communication skills.

Clinical Outcomes of Rapid Respiratory Virus Testing in Emergency Departments: A Systematic Review and Meta-Analysis

Importance

Rapid tests for respiratory viruses, including multiplex panels, are increasingly available in emergency departments (EDs). Their association with patient outcomes remains unclear.

Objective

To determine if ED rapid respiratory virus testing in patients with suspected acute respiratory infection (ARI) was associated with decreased antibiotic use, ancillary tests, ED length of stay, and ED return visits and hospitalization and increased influenza antiviral treatment.

Data Sources

Ovid MEDLINE, Embase (Ovid), Scopus, and Web of Science from 1985 to November 14, 2022.

Study Selection

Randomized clinical trials of patients of any age with ARI in an ED. The primary intervention was rapid viral testing.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Two independent reviewers (T.S. and K.W.) extracted data and assessed risk of bias using the Cochrane Risk of Bias, version 2.0. Estimates were pooled using random-effects models. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations framework.

Main Outcomes and Measures

Antibiotic use and secondary outcomes were pooled separately as risk ratios (RRs) and risk difference estimates with 95% CIs.

Results

Of 7157 studies identified, 11 (0.2%; n = 6068 patients) were included in pooled analyses. Routine rapid viral testing was not associated with antibiotic use (RR, 0.99; 95% CI, 0.93-1.05; high certainty) but was associated with higher use of influenza antivirals (RR, 1.33; 95% CI, 1.02-1.75; moderate certainty) and lower use of chest radiography (RR, 0.88; 95% CI, 0.79-0.98; moderate certainty) and blood tests (RR, 0.81; 95% CI, 0.69-0.97; moderate certainty). There was no association with urine testing (RR, 0.95; 95% CI, 0.77-1.17; low certainty), ED length of stay (0 hours; 95% CI, -0.17 to 0.16; moderate certainty), return visits (RR, 0.93; 95%, CI 0.79-1.08; moderate certainty) or hospitalization (RR, 1.01; 95% CI, 0.95-1.08; high certainty). Adults represented 963 participants (16%). There was no association of viral testing with antibiotic use in any prespecified subgroup by age, test method, publication date, number of viral targets, risk of bias, or industry funding.

Conclusions and Relevance

The results of this systematic review and meta-analysis suggest that there are limited benefits of routine viral testing in EDs for patients with ARI. Further studies in adults, especially those with high-risk conditions, are warranted.

Delayed and Non-Antibiotic Therapy for Urinary Tract Infections: A Literature Review

Urinary tract infections are among the most common infections encountered in the clinic and remain a top indication for women to receive antibiotics. Delayed antibiotic prescribing and non-antibiotic symptomatic therapies are treatment paradigms common to other uncomplicated infectious diseases, such as upper respiratory infections. We aimed to review the literature on delayed antibiotics and non-antibiotic treatments as alternatives to immediate antibiotic prescriptions for uncomplicated cystitis. A literature search was performed in PubMed, Google Scholar, and Web of Science to identify relevant clinical trials and reference lists of included articles were examined to find additional studies. All published trials where same day treatment with antibiotics was compared to scenarios where antibiotics were intentionally delayed or withheld or where antibiotics were compared to non-antimicrobial agents or placebo were analyzed. A total of 13 articles were included. Trials were grouped into categories based on their comparator groups: placebo (n = 5), delayed antibiotic therapy (n = 3), and symptomatic treatment (n = 5). Antibiotic delay and ibuprofen, while less effective than antibiotics in early microbiologic and clinical cure, may still be considered plausible alternatives to immediate antibiotic treatment in non-pregnant women with cystitis. Day 7 and later symptomatic resolution ranges from 26-75% with delayed or placebo therapy and 70-83% with nonsteroidal anti-inflammatory drugs. Symptom improvement, however, may be delayed compared to immediate antibiotics. These approaches have shown to decrease antibiotic use in primary care settings with low rates of pyelonephritis. Methodology included in these studies may be considered in stewardship interventions for outpatient clinics.

Fluoroquinolones do not provide added risk of out-of-hospital cardiac arrest: a nationwide study

AIM

Conflicting results have been reported regarding the association between fluoroquinolones (FQs) and the risk of out-of-hospital cardiac arrest (OHCA). In particular, it has not become clear whether OHCA in FQ users is related to the inherent comorbidities or whether there is a direct pro-arrhythmic effect of FQs. Therefore, we studied the relation between FQs and OHCA in the general population.

METHODS

Through Danish nationwide registries, we conducted a nested case-control study with OHCA cases of presumed cardiac causes and age/sex/OHCA date-matched non-OHCA controls from the general population. Conditional logistic regression models with adjustments for well-known risk factors of OHCA were employed to estimate the OR with 95% CI of OHCA comparing FQs with amoxicillin.

RESULTS

The study population consisted of 46 578 OHCA cases (mean: 71 years (SD: 14.40), 68.8% men) and 232 890 matched controls. FQ was used by 276 cases and 328 controls and conferred no increase in the odds of OHCA compared with amoxicillin use after controlling for the relevant confounders (OR: 0.91 (95% CI: 0.71 to 1.16)). The OR of OHCA associated with FQ use did not vary significantly by age (OR≤65: 0.96 (95% CI: 0.53 to 1.74), OR>65: 0.88 (95% CI: 0.67 to 1.16), p value interaction=0.7818), sex (ORmen: 0.96 (95% CI: 0.70 to 1.31), ORwomen: 0.80 (95% CI: 0.53 to 1.20), p value interaction=0.9698) and pre-existing cardiovascular disease (ORabsent: 1.02 (95% CI: 0.57 to 1.82), ORpresent: 0.98 (95% CI: 0.75 to 1.28), p value interaction=0.3884), including heart failure (ORabsent: 0.93 (95% CI: 0.72 to 1.22), ORpresent: 1.11 (95% CI: 0.61 to 2.02), p value interaction=0.7083) and ischaemic heart disease (ORabsent: 0.85 (95% CI: 0.64 to 1.12), ORpresent: 1.38 (95% CI: 0.86 to 2.21), p value interaction=0.6230).

CONCLUSION

Our findings do not support an association between FQ exposure and OHCA in the general population. This lack of association was consistent in men and women, in all age categories, and in the presence or absence of cardiovascular disease.

Ambulatory Antibiotic Use Patterns in Bolivia: Identifying Targets for Future Antibiotic Stewardship Efforts in Latin America

We evaluated antibiotic use in a private health insurance network in Bolivia with two different healthcare plans. The Health Maintenance Organization plan had 29% lower antibiotic consumption and fewer broad-spectrum antibiotics prescribed than the Preferred Provider Organization. Furthermore, we identified potential targets for future antibiotic stewardship efforts.

Omadacycline in the treatment of community-acquired bacterial pneumonia in patients with comorbidities: a post-hoc analysis of the phase 3 OPTIC trial

Introduction

The 2019 American Thoracic Society/Infectious Disease Society of America guidelines recommend respiratory fluoroquinolones to treat community-acquired bacterial pneumonia (CABP) in adults with comorbidities. Fluoroquinolones are effective against both typical and atypical pathogens. However, fluoroquinolone treatment has a risk of adverse effects, and the Food and Drug Administration has issued black box safety warnings for their use. Inpatient use of fluoroquinolones has reduced as a result; however, most antibiotic courses are completed as outpatients and discharge prescriptions account for the majority of fluoroquinolone use. As such, a new treatment option is needed to replace fluoroquinolones. Omadacycline is an aminomethylcycline antibiotic with a broad spectrum of activity and is available as a once-daily intravenous or bioequivalent oral formulation.

Methods

This study assessed the safety and clinical efficacy of omadacycline compared with moxifloxacin for the treatment of adult CABP patients with Pneumonia Severity Index (PSI) risk class II/III and ≥1 comorbidity through a post-hoc analysis of the phase 3 OPTIC study (NCT02531438).

Results

In total, 239 omadacycline- and 222 moxifloxacin-treated patients were assessed. The median age was similar between groups (omadacycline: 57 years; moxifloxacin: 58 years), with 26.0% and 26.6%, respectively, ≥65 years of age. Early clinical response was 91.6% for patients with ≥1 comorbidity treated with omadacycline and 91.4% for those treated with moxifloxacin. Post-treatment evaluation results for overall response were 89.1% in the omadacycline group and 87.4% in the moxifloxacin group.

Conclusion

Safety warnings have reduced inpatient use of fluoroquinolones; however, outpatient and discharge prescriptions account for the majority of fluoroquinolone use. Outpatients with comorbidities need an efficacious alternative to fluoroquinolones. Omadacycline maintains the similar efficacy and benefits of fluoroquinolones as a once-daily, monotherapy, bioequivalent oral option with potent in vitro activity against the most common CABP pathogens, including S. pneumoniae and atypical pathogens, but offers a materially different safety profile consistent with its tetracycline heritage. In conclusion, both omadacycline and moxifloxacin exhibited similar efficacy in patients with PSI risk class II/III and comorbidities. Omadacycline fulfills an unmet need as an oral monotherapy treatment option for adult patients with CABP, which will further reduce the use of fluoroquinolones.

Clinical trial registration

https://www.clinicaltrials.gov/study/NCT02531438, identifer: NCT02531438; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2013-004071-13, identifier: EudraCT #2013-004071-13.

Gut microbiota diversity of hospitalized older adult patients with and without antibiotic-associated diarrhea

BACKGROUND

The incidence of antibiotic-related diarrhea (AAD) is high in older adults.

AIM

To examine the gut microbiota changes in older adults who received antibiotics to identify the microbial signatures associated with antibiotic use and AAD.

METHODS

A nested prospective observational cohort study was conducted between December 2019 and June 2021 in patients ≥ 65 years old at Huashan Hospital affiliated with Fudan University. The patients were grouped as antibiotic-treated (HA group) and no antibiotics (HC group); the HA group was subdivided as with vs. without AAD. Fecal samples were collected at admission (i.e., before eventual antibiotics) and after 7 days.

RESULT

Thirty-eight and 19 participants were included in the HA and HC groups. There were significant differences in gut microbiota between the HA after antibiotics vs. HC groups, with a higher Firmicutes/Bacteroidetes ratio. Before antibiotics in the HA group, the relative abundances of Akkermansia and Alistipes were lower in the AAD subgroup than the no-AAD subgroup, while the relative abundance of Actinomyces was higher. After antibiotics in the HA group, specific bacterial species were decreased in the AAD subgroup compared with the no-AAD subgroup. Among HA participants without probiotics, the abundance of Akkermansia in the patients without AAD was higher than in the patients with AAD at baseline (P = 0.007).

CONCLUSION

Patients with or without AAD have different gut microbiota compositions before antibiotics. Antibiotics can lead to dysbiosis, with a decrease in beneficial bacteria and an increase in Enterococcus.

Impact of COVID-19-related regulatory changes on nationwide access to buprenorphine: An interrupted time series design

Background

The impact of COVID-19-related healthcare changes on access to buprenorphine (BUP) nationwide in the US is unknown.

Methods

We conducted an interrupted time series with the IQVIA LRx database. The study timeline included BUP prescriptions from 52 weeks before (2/23/19-2/21/20) to 52 weeks after (4/4/20-4/2/21) the initial pandemic period (2/22/20-4/3/20). Segmented regression estimated relative changes in total milligrams (MG) of BUP available per week nationwide at 1, 26, and 52 weeks post-initial-pandemic. We evaluated treatment disruptions in previously stable patients, defined as ≥6 months of BUP prescriptions.

Results

A total of 31 617 849 prescriptions were included. Total MG BUP dispensed increased at 1 and 26 weeks and then returned to baseline trends at 52 weeks post-initial pandemic period (4.1% [95% CI: 3.7,4.5], 2.1% [1.5,2.6], 0.1% [-0.6,0.9]). Stably-treated patients saw a decrease in 7-, 14-, and 28-day treatment disruptions at 52 weeks post-initial-pandemic period (-21.6% [-25.6,-17.7]; -10.8% [-16.3,-5.3]; -27.3% [-33.0,-21.6]). Men retained an increase in MG BUP compared to women at 52 weeks (0.7% [0.01,1.4] versus -0.6% [-1.5,0.2]). Younger age groups (18-29 years and 30-39 years) had a decrease in MG BUP at 52 weeks compared to expected baseline trend (-16.6 [-24.2, -9.0]; -1.6 [-3.0, -0.1). Patients with Medicaid demonstrated an increase in MG BUP at 52 weeks (8.3% [6.3,10.3]). MG BUP prescribed by APP prescribing increased by over 140 000 mg per week prior to the pandemic and continued to increase.

Conclusions

Regulatory changes around buprenorphine prescribing facilitated patient access to buprenorphine during the pandemic.

Impact of antibiotics on off-target infant gut microbiota and resistance genes in cohort studies

BACKGROUND

Young children are frequently exposed to antibiotics, with the potential for collateral consequences to the gut microbiome. The impact of antibiotic exposures to off-target microbes (i.e., bacteria not targeted by treatment) and antibiotic resistance genes (ARGs) is poorly understood.

METHODS

We used metagenomic sequencing data from paired stool samples collected prior to antibiotic exposure and at 1 year from over 200 infants and a difference-in-differences approach to assess the relationship between subsequent exposures and the abundance or compositional diversity of microbes and ARGs while adjusting for covariates.

RESULTS

By 1 year, the abundance of multiple species and ARGs differed by antibiotic exposure. Compared to infants never exposed to antibiotics, Bacteroides vulgatus relative abundance increased by 1.72% (95% CI: 0.19, 3.24) while Bacteroides fragilis decreased by 1.56% (95% CI: -4.32, 1.21). Bifidobacterium species also exhibited opposing trends. ARGs associated with exposure included class A beta-lactamase gene CfxA6. Among infants attending day care, Escherichia coli and ARG abundance were both positively associated with antibiotic use.

CONCLUSION

Novel findings, including the importance of day care attendance, were identified through considering microbiome data at baseline and post-intervention. Thus, our study design and approach have important implications for future studies evaluating the unintended impacts of antibiotics.

IMPACT

The impact of antibiotic exposure to off-target microbes and antibiotic resistance genes in the gut is poorly defined. We quantified these impacts in two cohort studies using a difference-in-differences approach. Novel to microbiome studies, we used pre/post-antibiotic data to emulate a randomized controlled trial. Compared to infants unexposed to antibiotics between baseline and 1 year, the relative abundance of multiple off-target species and antibiotic resistance genes was altered. Infants who attended day care and were exposed to antibiotics within the first year had a higher abundance of Escherichia coli and antibiotic resistance genes; a novel finding warranting further investigation.

Evaluation of the Clinical Outcome and Cost Analysis of Antibiotics in the Treatment of Acute Respiratory Tract Infections in the Emergency Department in Saudi Arabia

This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.

Association between initiation of fluoroquinolones and hospital admission or emergency department visit for suicidality: population based cohort study

OBJECTIVE

To evaluate the association between initiation of fluoroquinolones and hospital admission or emergency department visit for suicidality.

DESIGN

Population based cohort study.

SETTING

IBM MarketScan database, USA.

PARTICIPANTS

2 756 268 adults (≥18 years) who initiated an oral fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, ofloxacin, gatifloxacin, norfloxacin, lomefloxacin, besifloxacin) or comparator antibiotic (January 2003 to September 2015) and had at least six months of continuous health plan enrollment and a diagnosis of pneumonia or urinary tract infection (UTI) three days or less before the drug initiation date. Comparator antibiotics were azithromycin in the pneumonia cohort and trimethoprim-sulfamethoxazole in the UTI cohort. Participants were matched 1:1 within each cohort on a propensity score, calculated from a multivariable logistic regression model that included 57 baseline covariates.

MAIN OUTCOMES MEASURE

Primary outcome was hospital admission or emergency department visit for suicidal ideation or self-harm within 60 days after treatment initiation. Cox proportional hazard models were used to estimate hazard ratios and 95% confidence intervals.

RESULTS

The pneumonia cohort included 551 042 individuals, and the UTI cohort included 2 205 526 individuals. During the 60 day follow-up, 181 events were observed in the pneumonia cohort and 966 in the UTI cohort. The adjusted hazard ratios for fluoroquinolones were 1.01 (95% confidence interval 0.76 to 1.36) versus azithromycin in the pneumonia cohort and 1.03 (0.91 to 1.17) versus trimethoprim-sulfamethoxazole in the UTI cohort. Results were consistent across sensitivity analyses and subgroups of sex, age, or history of mental illnesses.

CONCLUSION

Initiation of fluoroquinolones was not associated with a substantially increased risk of admission to hospital or emergency department visits for suicidality compared with azithromycin or trimethoprim-sulfamethoxazole.

Whole-genome sequencing for surveillance of fluoroquinolone resistance in rifampicin-susceptible tuberculosis in a rural district of Shanghai: A 10-year retrospective study

Background

Fluoroquinolones (FQs) are the most important second-line anti-tuberculosis (anti-TB) drugs, primarily used for the treatment of multidrug- or rifampicin-resistant TB (MDR/RR-TB). However, FQs are also commonly used to treat other bacterial infections. There are few published data on the rates of FQ resistance among rifampicin-susceptible TB.

Methods

We used whole-genome sequencing (WGS) to determine the prevalence of FQ resistance among rifampicin-susceptible TB in a rural district of Shanghai. This was a population-based retrospective study of all culture-positive pulmonary TB patients diagnosed in the Chongming district of Shanghai, China during 2009-2018.

Results

The rate of FQ resistance was 8.4% (29/345) among TB, 6.2% (20/324) among rifampicin-susceptible TB, and 42.9% (9/21) among MDR/RR-TB. Transmission of FQ-resistant strains was defined as strains differing within 12 single-nucleotide polymorphisms (SNPs) based on WGS. Among the rifampicin-susceptible TB, 20% (4/20) of FQ resistance was caused by the transmission of FQ-resistant strains and 45% (9/20) of FQ resistance was identified as hetero-resistance.

Conclusions

The prevalence of FQ resistance in rifampicin-susceptible TB was higher than expected in Shanghai. Both the transmission and the selection of drug-resistant strains drive the emergence of FQ resistance in rifampicin-susceptible TB isolates. Therefore, the WGS-based surveillance system for TB should be urgently established and the clinical awareness of the rational use of FQs for respiratory infections should be enhanced to prevent the premature occurrence of FQ resistance.

Photodynamic Antimicrobial Therapy Based on Conjugated Polymers

Pathogenic microorganisms have been a serious threat to human life and have become a public health problem of global concern. However, in the actual treatment there is a lack of efficient antimicrobial strategies which do not easily develop drug resistance; this can lead to inaccurate drug treatment that worsens the infection and even threatens life. With the emergence of a variety of drug-resistant bacteria and fungi, photodynamic therapy has gradually become one of the most promising treatment methods for drug-resistant bacteria infection; this is because it is controllable, non-invasive, and not prone to cause the development of drug resistance. Organic conjugated polymers that possess high fluorescence intensity, a large molar extinction coefficient, excellent light stability, an adjustable energy band, easy modification, good biocompatibility, and the ability to photosensitize oxygen to produce reactive oxygen species have been widely used in the fields of solar cells, highly sensitive detection systems, biological imaging, and anti-cancer and anti-microbial treatment. Photodynamic therapy is non-invasive and has high temporal and spatial resolution and is a highly effective antimicrobial treatment that does not easily induce drug resistance; it has also stimulated the scientific research enthusiasm of researchers and has become a research hotspot in the antimicrobial field. In this review, the photodynamic antibacterial applications of conjugated polymers with different structure types are summarized, and their development directions are considered.

Association of Outpatient Oral Macrolide Use With Sensorineural Hearing Loss in Children, Adolescents, and Young Adults

Importance

Prior publications have reported the sporadic development of sensorineural hearing loss (SNHL) after intravenous or high-dose macrolide therapy for adults with comorbid conditions, but investigations of the auditory effect of oral outpatient dosing for children, adolescents, and young adults have been limited.

Objective

To determine whether broad-based outpatient use of oral macrolide therapy is associated with increased risk of pediatric SNHL through nationally representative analyses.

Design, Setting, and Participants

A retrospective case-control study of 875 matched pairs of children, adolescents, and young adults was performed, matching on age, sex, and the time elapsed since prescription date. All eligible pediatric patients were included, with matched control participants from the TRICARE US military health insurance system who were evaluated between October 1, 2009, and September 30, 2014.

Exposures

Oral outpatient macrolide treatment compared with penicillin use among pediatric patients.

Main Outcomes and Measures

The clinical outcome of interest was SNHL in children, adolescents, and young adults. Multivariable conditional logistic regression was used to compare the risk of prior macrolide exposure with penicillin exposure, adjusted for other risk factors and potential confounders. Four time frames between exposure and diagnosis were additionally assessed.

Results

There were 875 eligible matched pairs of children, adolescents, and young adults included. The mean (SD) age of the participants was 5.7 (4.9) years; 1082 participants were male (62%), 58 were Asian (3%), 254 were Black (15%), 1152 were White (66%), and 286 were of Native American and other (no further breakdown was available in the TRICARE database) race and ethnicity (16%). In multivariable analysis, participants who had SNHL had increased odds of having received a macrolide prescription compared with a penicillin prescription when all time frames from exposure were included (adjusted odds ratio, 1.31; 95% CI, 1.05-1.64). There were significantly higher odds of macrolide exposure than penicillin exposure when diagnosis and testing occurred more than 180 days after antibiotic exposure (adjusted odds ratio, 1.79; 95% CI, 1.23-2.60).

Conclusions and Relevance

In this case-control study of a nationally representative patient population, findings suggest that children, adolescents, and young adults with SNHL had increased odds of outpatient oral macrolide use compared with penicillin use, particularly when having received a diagnosis more than 180 days after exposure. Further study of the association of macrolides with SNHL in children, adolescents, and young adults is warranted.

Association Between Rotavirus Vaccination and Antibiotic Prescribing Among Commercially Insured US Children, 2007-2018

Background

Vaccines may play a role in controlling the spread of antibiotic resistance. However, it is unknown if rotavirus vaccination affects antibiotic use in the United States (US).

Methods

Using data from the IBM MarketScan Commercial Database, we conducted a retrospective cohort of US children born between 2007 and 2018 who were continuously enrolled for the first 8 months of life (N = 2 136 136). We followed children through 5 years of age and compared children who completed a full rotavirus vaccination series by 8 months of age to children who had not received any doses of rotavirus vaccination. We evaluated antibiotic prescriptions associated with an acute gastroenteritis (AGE) diagnosis and defined the switching of antibiotics as the prescription of a second, different antibiotic within 28 days. Using a stratified Kaplan-Meier approach, we estimated the cumulative incidence for each study group, adjusted for receipt of pneumococcal conjugate vaccine, provider type, and urban/rural status.

Results

Overall, 0.8% (n = 17 318) of participants received an antibiotic prescription following an AGE diagnosis. The 5-year adjusted relative cumulative incidence of antibiotic prescription following an AGE diagnosis was 0.793 (95% confidence interval [CI], .761–.827) among children with complete rotavirus vaccination compared to children without rotavirus vaccination. Additionally, children with complete vaccination were less likely to switch antibiotics (0.808 [95% CI, .743–.887]). Rotavirus vaccination has averted an estimated 67 045 (95% CI, 53 729–80 664) antibiotic prescriptions nationally among children born between 2007 and 2018.

Conclusions

These results demonstrate that rotavirus vaccines reduce antibiotic prescribing for AGE, which could help reduce the growth of antibiotic resistance.

Uses of mathematical modeling to estimate the impact of mass drug administration of antibiotics on antimicrobial resistance within and between communities

BACKGROUND

Antibiotics are a key part of modern healthcare, but their use has downsides, including selecting for antibiotic resistance, both in the individuals treated with antibiotics and in the community at large. When evaluating the benefits and costs of mass administration of azithromycin to reduce childhood mortality, effects of antibiotic use on antibiotic resistance are important but difficult to measure, especially when evaluating resistance that "spills over" from antibiotic-treated individuals to other members of their community. The aim of this scoping review was to identify how the existing literature on antibiotic resistance modeling could be better leveraged to understand the effect of mass drug administration (MDA) on antibiotic resistance.

MAIN TEXT

Mathematical models of antibiotic use and resistance may be useful for estimating the expected effects of different MDA implementations on different populations, as well as aiding interpretation of existing data and guiding future experimental design. Here, strengths and limitations of models of antibiotic resistance are reviewed, and possible applications of those models in the context of mass drug administration with azithromycin are discussed.

CONCLUSIONS

Statistical models of antibiotic use and resistance may provide robust and relevant estimates of the possible effects of MDA on resistance. Mechanistic models of resistance, while able to more precisely estimate the effects of different implementations of MDA on resistance, may require more data from MDA trials to be accurately parameterized.

Stress-Induced Mutagenesis, Gambler Cells, and Stealth Targeting Antibiotic-Induced Evolution

Mechanisms of evolution and evolution of antibiotic resistance are both fundamental and world health problems. Stress-induced mutagenesis defines mechanisms of mutagenesis upregulated by stress responses, which drive adaptation when cells are maladapted to their environments—when stressed. Work in mutagenesis induced by antibiotics had produced tantalizing clues but not coherent mechanisms. We review recent advances in antibiotic-induced mutagenesis that integrate how reactive oxygen species (ROS), the SOS and general stress responses, and multichromosome cells orchestrate a stress response-induced switch from high-fidelity to mutagenic repair of DNA breaks. Moreover, while sibling cells stay stable, a mutable “gambler” cell subpopulation is induced by differentially generated ROS, which signal the general stress response. We discuss other evolvable subpopulations and consider diverse evolution-promoting molecules as potential targets for drugs to slow evolution of antibiotic resistance, cross-resistance, and immune evasion. An FDA-approved drug exemplifies “stealth” evolution-slowing drugs that avoid selecting resistance to themselves or antibiotics.

Treatment with Distinct Antibiotic Classes Causes Different Pulmonary Outcomes on Allergic Airway Inflammation Associated with Modulation of Symbiotic Microbiota

Background

Asthma is a chronic pulmonary disease that affects about 300 million people worldwide. Previous studies have associated antimicrobial use with allergies, but the real impact of antibiotics on asthma is still elusive. We investigated the potential impact of amoxicillin (Amox), trimethoprim/sulfamethoxazole (TMP/SMX), and metronidazole (Metro) in a murine model of OVA-induced allergic airway inflammation.

Methods

BALB/c mice received three cycles of 7 days of antibiotics in drinking water followed by 7 days washout and were sensitized i.p. with OVA/Alum at days 0 and 14. After the end of the last antibiotic washout, the mice were challenged with aerosolized OVA. Pulmonary parameters were evaluated, and serum, BAL, and feces were collected for analysis.

Results

Amox- and TMP/SMX-treated animals displayed more severe allergic airway inflammation parameters with increased airway hyperresponsiveness, reduced lung alveolar volume, and increased levels in BAL of IL-4 and IL-6. In contrast, Metro-treated mice showed preserved FEV-50, decreased lung inflammation, and higher levels of butyrate and propionate in their feces. Metro treatment was associated with increased OVA-specific IgA in serum. BAL microbiota was abundant in allergic groups but not in nonallergic controls with the Amox-treated group displaying the increased frequency of Proteobacteria, while Metro and TMP/SMX showed increased levels of Firmicutes. In the gut, we observed the enrichment of Akkermansia muciniphila associated with reduced airway inflammation phenotype in the Metro group, even after the recovery period.

Conclusion

Our data suggest that different antibiotic treatments may impact the course of experimental allergic airway inflammation in diverse ways by several mechanisms, including modulation of short-chain fat acids production by intestinal microbiota.

Search for Indexes to Evaluate Trends in Antibiotic Use in the Sub-Prefectural Regions Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan

The evaluation indexes of antimicrobial use (AMU) in sub-prefectural regions have not been established because these regional units are susceptible to the effects of population inflows and outflows. We defined the difference in AMU calculated each year as a new evaluation index and compared the AMU of secondary medical areas with those already reported for Japan and each prefecture. Patients/1000 inhabitants/day (PID) for oral antibiotics in 2013 and 2016 were calculated using the National Database of Health Insurance Claims and Specific Health Checkups. ΔPID was defined as the difference between the PIDs in 2013 and 2016. Differences in AMUs for Japan and prefectures that have already been published were also calculated, and the concordance rate with ΔPID in each secondary medical area was evaluated. Antibiotics and age groups with less than 50% concordance between secondary medical area and previously reported AMU changes were observed. This revealed that even at the secondary medical area level, which is more detailed than the prefectural level, the AMU changes were not consistent. Therefore, in order to appropriately promote measures against antimicrobial resistance, we suggest the necessity of not only surveying AMU at the national or prefectural levels but also examining sub-prefectural trends in AMU.

Study of the indications for macrolide prescriptions in a Colombian population

Introduction

The inappropriate use of antibiotics is associated with a greater risk for antimicrobial resistance, high health care costs, adverse events, and worse clinical outcomes.

Objective

To determine the prescription patterns and approved and nonapproved indications for macrolides in a group of patients from Colombia.

Materials and methods

This was a cross-sectional study on the indications for the use of macrolides in outpatients registered in a drug-dispensing database of approximately 8.5 million people affiliated with the Colombian health system. Sociodemographic, pharmacological, and clinical variables were considered.

Results

A total of 9.344 patients had received a macrolide prescription; their median age was 40.1 years (interquartile range: 27.1-53.3 years) and 58.3% were women. The most commonly prescribed macrolide was azithromycin (38.8%) most frequently for Helicobacter pylori infection (15.9%) and pneumonia treatment (15.8%). A total of 31.3% of the prescriptions were used for unapproved indications: common cold (7.8%), COVID-19 (4.0%), and acute bronchitis (3.5%). Residence in the Caribbean region (OR=1.17; 95%CI 1.05-1.31), dental prescriptions (OR=2.75; 95%CI 1.91-3.96), presence of chronic respiratory comorbidities (OR=1.30; 95%CI 1.08-1.56), and prescription of erythromycin (OR=3.66; 95%CI 3.24-4.14) or azithromycin (OR=2.15; 95%CI 1,92-2.41) were associated with a higher probability of macrolide use for unapproved indications while being 18-64 years old (OR=0.81; 95%CI 0.71-0.93) or 65 years or older (OR=0.77; 95%CI 0.63-0.94) and residing in Bogotá-Cundinamarca (OR=0.74; 95%CI 0.65-0.85) were associated with reduced risk.

Conclusions

Most patients received macrolides for respiratory tract infections; erythromycin and azithromycin were used for unapproved indications in people under 18 years of age and those with chronic respiratory diseases.

Epidemiology of Antibiotic Use and Drivers of Cross-Border Procurement in a Mexican American Border Community

Background

The U.S.-Mexico Border is an area of opportunity for improved health care access; however, gaps remain as to how and where U.S. border residents, particularly those who are underinsured, obtain care. Antibiotics are one of the most common reported drivers of cross-border healthcare access and a medication of particular concern since indiscriminate or inappropriate use is associated with antimicrobial resistance. In addition, many studies assessing preferences for Mexican pharmaceuticals and healthcare in U.S. border residents were done prior to 2010 when many prescription medications, including antibiotics, were available over the counter in Mexico.

Methods

Data used in this study were collected during the baseline examination of an ongoing longitudinal cohort study in Starr Country, Texas, one of 14 counties on the Texas-Mexico border. Participants self-reported the name, date of use, and the source country of each antibiotic used in the past 12 months. Logistic regression was used to determine social, cultural, and clinical features associated with cross-border procurement of antibiotics.

Results

Over 10% of the study cohort reported using antibiotics in the past 30 days with over 60% of all rounds used in the past 12 months sourced from Mexico. A lack of health insurance and generation score, a measure of acculturation, were the strongest predictors of cross-border procurement of antibiotics.

Conclusions

Factors previously associated with cross-border acquisition of antibiotics are still present despite changes in 2010 to prescription drug regulations in Mexico. These results may be used to inform future public health initiatives to provide culturally sensitive education about responsible antibiotic stewardship and to address barriers to U.S. healthcare and pharmaceutical access in medically underserved, impoverished U.S.-Mexico border communities.

Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data - United States, 2019

Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.

Perinatal Penicillin Exposure Affects Cortical Development and Sensory Processing

The prevalent use of antibiotics in pregnant women and neonates raises concerns about long-term risks for children’s health, but their effects on the central nervous system is not well understood. We studied the effects of perinatal penicillin exposure (PPE) on brain structure and function in mice with a therapeutically relevant regimen. We used a battery of behavioral tests to evaluate anxiety, working memory, and sensory processing, and immunohistochemistry to quantify changes in parvalbumin-expressing inhibitory interneurons (PV+ INs), perineuronal nets (PNNs), as well as microglia density and morphology. In addition, we performed mesoscale calcium imaging to study neural activity and functional connectivity across cortical regions, and two-photon imaging to monitor dendritic spine and microglial dynamics. We found that adolescent PPE mice have abnormal sensory processing, including impaired texture discrimination and altered prepulse inhibition. Such behavioral changes are associated with increased spontaneous neural activities in various cortical regions, and delayed maturation of PV+ INs in the somatosensory cortex. Furthermore, adolescent PPE mice have elevated elimination of dendritic spines on the apical dendrites of layer 5 pyramidal neurons, as well as increased ramifications and spatial coverage of cortical microglia. Finally, while synaptic defects are transient during adolescence, behavioral abnormalities persist into adulthood. Our study demonstrates that early-life exposure to antibiotics affects cortical development, leaving a lasting effect on brain functions.

Association between antibiotics and gut microbiome dysbiosis in children: systematic review and meta-analysis

Antibiotics in childhood have been linked with diseases including asthma, juvenile arthritis, type 1 diabetes, Crohn's disease and mental illness. The underlying mechanisms are thought related to dysbiosis of the gut microbiome. We conducted a systematic review of the association between antibiotics and disruption of the pediatric gut microbiome. Searches used MEDLINE, EMBASE and Web of Science. Eligible studies: association between antibiotics and gut microbiome dysbiosis; children 0-18 years; molecular techniques of assessment; outcomes of microbiome richness, diversity or composition. Quality assessed by Newcastle-Ottawa Scale or Cochrane Risk of Bias Tool. Meta-analysis where possible. A total of 4,668 publications identified: 12 in final analysis (5 randomized controlled trials (RCTs), 5 cohort studies, 2 cross-sectional studies). Microbiome richness was measured in 3 studies, species diversity in 6, and species composition in 10. Quality of evidence was good or fair. 5 studies found a significant reduction in diversity and 3 a significant reduction in richness. Macrolide exposure was associated with reduced richness for twice as long as penicillin. Significant reductions were seen in Bifidobacteria (5 studies) and Lactobacillus (2 studies), and significant increases in Proteobacteria such as E. coli (4 studies). A meta-analysis of RCTs of the effect of macrolide (azithromycin) exposure on the gut microbiome found a significant reduction in alpha-diversity (Shannon index: mean difference -0.86 (95% CI -1.59, -0.13). Antibiotic exposure was associated with reduced microbiome diversity and richness, and with changes in bacterial abundance. The potential for dysbiosis in the microbiome should be taken into account when prescribing antibiotics for children.Systematic review registration number: CRD42018094188.

Ginger Extract Decreases Susceptibility to Dextran Sulfate Sodium-Induced Colitis in Mice Following Early Antibiotic Exposure

Background: Intestinal microbial colonization in early life plays a crucial role in immune development and mucosal homeostasis in later years. Antibiotic exposure in early life increases the risk of inflammatory bowel disease (IBD). Ginger acts like a prebiotic and has been used in traditional Chinese medicine for colitis. We investigated the protective effect of ginger against dextran sulfate sodium (DSS)-induced colitis in mice exposed to antibiotic in their early years. Methods: A weaned mouse model exposed to azithromycin (AZT) for 2 weeks was used to mimic antibiotic exposure in childhood among humans. A diet containing ginger extract was administered to mice for 4 weeks after antibiotic exposure. The susceptibility to DSS-induced colitis was evaluated in terms of weight loss, disease activity index (DAI) score, colon length, colitis biomarkers, and intestinal barrier function. The gut microbiota was analyzed in terms of 16S rRNA levels. Results: Ginger extract prevented weight loss, colon shortening, inflammation, and intestinal barrier dysfunction in mice exposed to antibiotics in early life. Ginger increased the bacterial diversity and changed the abundance of bacterial belonging to family Peptococcaceae and Helicobacter species to modulate microbiota structure and composition adversely affected by early antibiotic exposure. Conclusion: Ginger has a protective effect in potentially decreasing the susceptibility to colitis in mice exposed to antibiotics early in life.

Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care

BACKGROUND

The desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians' diagnostic uncertainty combined with parents' concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care.

METHODS

Pharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R.

RESULTS

The past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials.

CONCLUSIONS

Paediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.

Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

BACKGROUND

Geographic trends in antibiotic prescribing show regional variation in antibiotic overuse and antimicrobial resistance, posing a threat to global health care systems. This study's objective was to examine interprovincial variation in outpatient antibiotic dispensing in Canada in 2019.

METHODS

We conducted a cross-sectional study of antibiotic prescriptions dispensed in Canadian provinces in 2019, leveraging the IQVIA Geographic Prescription Monitor database. We report annual rates of overall antibiotic dispensing, broad-spectrum antibiotic dispensing and age-specific antibiotic dispensing as prescriptions per 1000 population in each province and nationally.

RESULTS

A total of 23 406 640 antibiotic prescriptions were dispensed nationally in 2019, at a rate of 627.3 prescriptions per 1000 population. Overall antibiotic dispensing rates in Newfoundland and Labrador (920.5 prescriptions per 1000 population) and Saskatchewan (713.7 prescriptions per 1000 population) significantly exceeded the national rate, whereas the rate in British Columbia (543.3 prescriptions per 1000 population) was significantly below the national rate. We observed additional variation when provincial rates of antibiotic dispensing were stratified by drug class and age group.

INTERPRETATION

We identified interprovincial variation in antibiotic use in Canadian provinces in 2019. These findings highlight the need for provincial targets for antibiotic use to reduce overuse and antimicrobial resistance.

Reduction in broad-spectrum antimicrobial prescriptions by primary care pediatricians following a multifaceted antimicrobial stewardship program

BACKGROUND

Since 2016, following the Italian "National Plan to Contrast Antimicrobial Resistance", Campania Region has implemented an antimicrobial stewardship program, including the obligation to associate an appropriate International Classification of Diseases-9 code to each antibiotic prescription, the publication of schemes for empirical antibiotic therapy and educational interventions.

METHODS

To evaluate the impact of these interventions on the prescribing habits of family pediatricians, we conducted a retrospective cohort study (January 2016-December 2020), including all patients registered in an associate practice of Primary Care Pediatricians. We collected data on antibiotic prescriptions through a specific study management software; our primary outcomes were the annual prescription rates, calculated for both the number of patients in follow-up and the number of medical consultations, and the annual prescription rates for selected antibiotic classes and molecules. To investigate the hypothesis that chronic conditions would be associated with an increased rate of prescription, we also tested the association between underlying conditions and the number of antibiotics received.

RESULTS

During the study period, 2,599 children received 11,364 antibiotic prescriptions (mean 4.37, SD 4.28). From 2016 to 2020 we observed a substantial reduction in both the annual prescription rate per 100 patients (9.33 to 3.39; R ²= 0.927, p = 0.009), and the annual prescription rate per 100 medical consultations (25.49 to 15.98; R ²= 0.996, p < 0.01). The prescription rates of Amoxicillin-Clavulanate (50.25 to 14.21; R ²= 0.983, p = 0.001) and third generation Cephalosporins (28.43 to 5.43; R ²= 0.995, p < 0.01) significantly decreased; we didn't find significant modifications in the prescription rates of Amoxicillin and Quinolones; finally, we observed a trend toward reduction in the prescription of Macrolides. No statistical association was found between antibiotics prescribing frequency and history of chronic diseases.

DISCUSSION

Following the implementation of the regional interventions on antimicrobial stewardship, we observed a substantial reduction in the overall antibiotic prescription per patients and per medical consultations, with a statistically significant reduction in the use of broad-spectrum molecules. Considering the results of our analysis, new guidance and training interventions addressed to specialists in the primary care sector should be implemented to further limit antibiotic resistance.

Lack of regulation over antibiotic prescription and dispensation: A prospective cohort in a community setting

Background

The emergence of bacterial resistance caused health authorities to attempt to implement strict regulations for rational antibiotic prescription. However, supervision is often neglected in low- and middle-income countries, leading to inappropriate administration of antibiotics. The objective of our study is to highlight the lack of monitoring in the community setting of a middle-income country.

Material and methods

We asked 68 patients presenting to an infectious diseases consultation office to report the antibiotic courses they had taken in the three months preceding their visit. We assessed for treatment indication, molecule choice, dosing and duration, as well as microbial cultures, demographics and specialty of the prescriber.

Results

Among the 68 patients included in our study, we counted a total of 95 outpatient antibiotic courses, mostly composed of quinolones (36%), followed by amoxicillin-clavulanate (21%). The prescriber was most commonly a primary care physician, but we reported several cases of auto-medication and dispensation of antibiotics by pharmacists. Only 30% of cases had true indications for antibiotics.

Conclusion

In sum, our results indicate an evident lack of regulation over the administration of antibiotics. This easy accessibility needs to be promptly addressed as we run the risk of inevitable bacterial resistance.

Evaluation of Molecular Point-of-Care Testing for Respiratory Pathogens in Children With Respiratory Infections: A Retrospective Case-Control Study

Objectives

Overuse of antibiotics and antibiotic resistance are global healthcare problems. In pediatric patients with respiratory infections, viral and bacterial etiologies are challenging to distinguish, leading to irrational antibiotic use. Rapid and accurate molecular diagnostic testing methods for respiratory pathogens has been shown to facilitate effective clinical decision-making and guide antibiotic stewardship interventions in the developed regions, but its impacts on pediatric patient care in the developing countries remain unclear.

Methods

In this single-center, retrospective case-control study, we compared demographics, clinical characteristics, especially microbiological findings, and antibiotic usage between pediatric patients with respiratory infection receiving FilmArray Respiratory Panel (FilmArray RP) testing and a matched routine testing control group. Our primary outcome was the duration of intravenous antibiotics treatment (DOT) during hospitalization.

Results

Each group consisted of 346 children with a respiratory infection. In the FilmArray RP testing group, the DOT was shorter than that in the routine testing group (6.41 ± 3.67 days versus 7.23 ± 4.27 days; p = 0.006). More patients in the FilmArray RP testing group de-escalated antibiotic treatments within 72 hours of hospitalization (7.80%, 27/346 versus 2.60%, 9/346; p = 0.002). By contrast, fewer patients in the FilmArray RP testing group had escalated antibiotic treatments between 72 hours and seven days (7.80% versus 14.16%; p = 0.007). The cost of hospitalization was significantly lower in the FilmArray RP testing group ($ 1413.51 ± 1438.01 versus $ 1759.37 ± 1929.22; p = 0.008). Notably, the subgroup analyses revealed that the FilmArray RP test could shorten the DOT, improve early de-escalation of intravenous antibiotics within 72 hours of hospitalization, decline the escalation of intravenous antibiotics between 72 hours and seven days, and reduce the cost of hospitalization for both patient populations with or without underlying diseases.

Conclusions

Molecular point-of-care testing for respiratory pathogens could help to reduce intravenous antibiotic use and health care costs of pediatric patients with respiratory infections in developing countries.

Association of Fluoroquinolone Prescribing Rates With Black Box Warnings from the US Food and Drug Administration

IMPORTANCE

In 2013 and 2016, the US Food and Drug Administration (FDA) issued warnings and recommended limited use of fluoroquinolones for patients with certain acute conditions. It is not clear how prescribers have responded to these warnings.

OBJECTIVE

To analyze changes in prescribing of fluoroquinolones after the 2013 and 2016 FDA warnings and to examine the physician characteristics associated with these changes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used Medicare administrative claims data on Medicare fee-for-service beneficiaries and OneKey data on physicians and their organizations from January 1, 2011, to December 31, 2017. The sample was restricted to outpatient visits for sinusitis, bronchitis, and uncomplicated urinary tract infections. An interrupted time series approach was used to analyze the changes in the prescription rate after each FDA warning. Data analysis was performed between January 1, 2011, and December 31, 2017.

INTERVENTIONS

Two FDA black box warnings released in August 2013 and July 2016.

MAIN OUTCOMES AND MEASURES

The main outcome was an indicator for fluoroquinolone prescriptions in 3 periods: before the 2013 warning (baseline period), after the 2013 warning but before the 2016 warning (postwarning period 1), and after the 2016 warning (postwarning period 2).

RESULTS

The sample comprised 1 238 397 unique patients with a total of 2 720 071 outpatient acute care visits. Of this sample, 848 360 were women (68.5%), and the mean (SD) age was 69.7 (12.6) years. The immediate prescribing levels of fluoroquinolones in postwarning period 1 increased by 3.42 percentage points (95% CI, 3.23-3.62; P < .001) and declined by -0.77 percentage points (95% CI, -1.00 to -0.54; P < .001) in postwarning period 2. The prescribing trend increased by 0.08 percentage points per month (95% CI, 0.08-0.10; P < .001) in postwarning period 1 and 0.06 percentage points per month (95% CI, 0.04-0.08; P < .001) in postwarning period 2. In postwarning period 1, the prescribing levels for physicians who were affiliated with hospitals with a top 10th percentile case mix index vs those without such affiliation decreased by -1.13 percentage points (95% CI, -1.92 to -0.34; P = .005), whereas the levels for primary care physicians declined by -1.34 percentage points (95% CI, -1.78 to -0.88; P < .001) compared with non-primary care physicians in postwarning period 2. Physicians at teaching hospitals were the only ones who showed a decline in prescribing trend in postwarning period 1.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found an overall decline in prescribing of fluoroquinolones after the release of FDA warnings. Understanding the association of physician and organizational characteristics with fluoroquinolone prescribing behavior may ultimately help to identify mechanisms to improve de-adoption.

Antibiotic use and associated factors in adult outpatients from 2000 to 2019

The aims of the study were to assess the changes in 19-years use of antibiotics (overall, by age, sex and geographical area) and of those classes deemed to be quality indicators for their consumption and to evaluate factors associated to antibiotic use. We analyzed drug prescription data collected in the administrative database of the Lombardy Region (Northern Italy) for outpatients aged 40+ years from 2000 to 2019. Logistic regression analyses were performed to evaluate the association between receiving at least one antibiotic prescription and year of observation, gender, age groups, area of residence, polypharmacy and hospitalizations in the index year. The prevalence of patients prescribed with antibiotics remained high from 2000 (33.8%) to 2019 (32.6%). Prevalence of use of second-line choice antibiotics (penicillin combinations with beta-lactamase inhibitors, third and fourth generation cephalosporins, macrolides) continued to increase, only fluoroquinolones decreased in 2019 (19%) comparing to 2018 (26%), at the time when the Italian Medicines Agency promulgated safety warnings. Females (OR 1.28, 95%CI 1.27-1.28), people living in Brescia (OR 1.24, 95%CI 1.24-1.25), those exposed to polypharmacy (OR 2.57, 95%CI 2.56-2.57) and those hospitalized 1 to 3 (OR 1.86, 95%CI 1.85-1.86) or more than 3 (OR 2.02, 95%CI 2.01-2.03) times a year had a statistically significant higher risk of receiving antibiotics. The high use of antibiotics over the study period further reinforces the need of impactful interventions, in order to improve the rational use of antibiotics and to reduce the risks of antimicrobial resistance. The differences outlined should be considered when monitoring and planning these interventions.

The Impact of COVID-19 on Outpatient Antibiotic Prescriptions in Ontario, Canada; An Interrupted Time Series Analysis

Background

The coronavirus disease 2019 (COVID-19) pandemic has potentially impacted outpatient antibiotic prescribing. Investigating this impact may identify stewardship opportunities in the ongoing COVID-19 period and beyond.

Methods

We conducted an interrupted time series analysis on outpatient antibiotic prescriptions and antibiotic prescriptions/patient visits in Ontario, Canada, between January 2017 and December 2020 to evaluate the impact of the COVID-19 pandemic on population-level antibiotic prescribing by prescriber specialty, patient demographics, and conditions.

Results

In the evaluated COVID-19 period (March–December 2020), there was a 31.2% (95% CI, 27.0% to 35.1%) relative reduction in total antibiotic prescriptions. Total outpatient antibiotic prescriptions decreased during the COVID-19 period by 37.1% (95% CI, 32.5% to 41.3%) among family physicians, 30.7% (95% CI, 25.8% to 35.2%) among subspecialist physicians, 12.1% (95% CI, 4.4% to 19.2%) among dentists, and 25.7% (95% CI, 21.4% to 29.8%) among other prescribers. Antibiotics indicated for respiratory infections decreased by 43.7% (95% CI, 38.4% to 48.6%). Total patient visits and visits for respiratory infections decreased by 10.7% (95% CI, 5.4% to 15.6%) and 49.9% (95% CI, 43.1% to 55.9%). Total antibiotic prescriptions/1000 visits decreased by 27.5% (95% CI, 21.5% to 33.0%), while antibiotics indicated for respiratory infections/1000 visits with respiratory infections only decreased by 6.8% (95% CI, 2.7% to 10.8%).

Conclusions

The reduction in outpatient antibiotic prescribing during the COVID-19 pandemic was driven by less antibiotic prescribing for respiratory indications and largely explained by decreased visits for respiratory infections.

Use of Antibiotics among Residents Living Close to Poultry or Goat Farms: A Nationwide Analysis in The Netherlands

Prior regional studies found a high risk of pneumonia for people living close to poultry and goat farms. This epidemiological study in the Netherlands used nationwide antibiotic prescription data as a proxy for pneumonia incidence to investigate whether residents of areas with poultry and goat farms use relatively more antibiotics compared to areas without such farms. We used prescription data on antibiotics most commonly prescribed to treat pneumonia in adults and livestock farming data, both with nationwide coverage. Antibiotic use was expressed as defined daily doses per (4-digit Postal Code (PC4) area)-(age group)-(gender)-(month) combination for the year 2015. We assessed the associations between antibiotic use and farm exposure using negative binomial regression. The amoxicillin, doxycycline, and co-amoxiclav use was significantly higher (5-10% difference in use) in PC4 areas with poultry farms present compared to areas without, even after adjusting for age, gender, smoking, socio-economic status, and goat farm presence. The adjusted models showed no associations between antibiotic use and goat farm presence. The variables included in this study could only partly explain the observed regional differences in antibiotic use. This was an ecological study that precludes inference about causal relations. Further research using individual-level data is recommended.

Assessment of the Knowledge and Approach of General Dentists Who Treat Children and Pediatric Dentists Regarding the Proper Use of Antibiotics for Children

Background: Antibiotics are widely used in dentistry. Dentists often provide antibiotics unnecessarily. Excessive use can induce resistant bacterial strains. There are certain indications for the proper use of antibiotics for pediatric dentistry according to the European and American Pediatric Dentistry (EAPD and AAPD). Very often dentists do not follow these guidelines. Objectives: This study aims to examine the level of knowledge among general dentists (who also treat children) and pediatric dentists on proper use of antibiotics. In addition, we examined whether there is unjustified use of antibiotics, if dentists are aware of the new and conservative approach of administering antibiotics to patients, and whether there is a relationship between years of professional seniority and dentist's knowledge level of proper use of antibiotics. Methods: One hundred general dentists (GD) who treat children in addition to 100 pediatric dentists (PD) completed the study questionnaires which measured knowledge, practice and attitudes regrading using antibiotics during dental treatment among children. Results: The general average of level of knowledge on proper use of antibiotics among general dentists was relatively low for both GD (60.7%) and PDs (65%). PDs demonstrated a relatively greater knowledge of correct use of antibiotics, especially in cases of endodontics and trauma. PDs also showed higher awareness to latest guidelines for the admission of "prophylactic antibiotics" according to the American Association (AAPD) and/or the European Union (EAPD) compared with GDs (86.2% vs. 66.3%). Conclusion: The level of knowledge of both general dentists and pediatric dentists is poor, with a large percentage of dentists from both groups not knowing whether antibiotics are needed in a specific dental case or not. Compliance with the EAPD/AAPD guidelines is also low and inadequate. The method of prescribing antibiotics given by dentists can be improved by increasing awareness, educational initiatives, and postgraduate courses among dentists regarding the recommended indications.

Trend in antibiotic prescription to children aged 0-6 years old in the capital region of Denmark between 2009 and 2018: Differences between municipalities and association with socioeconomic composition

BACKGROUND

To curb future antibiotic resistance it is important to monitor and investigate current prescription patterns of antibiotics.

OBJECTIVES

To examine trends in antibiotic prescription to children aged 0-6 years old and the association with socioeconomic status of municipalities in the Capital region of Denmark between 2009 and 2018.

METHODS

This is a register-based study combining data on antibiotic treatments from 2009 to 2018, inhabitant-data and socioeconomic municipality scores. Subjects were children aged 0-6 years, residing in the Capital Region of Denmark. The study quantifies the use of antibiotics as number of antibiotic treatments/1000 inhabitants/year (TIY), inhabitants defined as children aged 0-6. Socioeconomic status of the municipalities is evaluated by a score from 3 to 12.

RESULTS

The average TIY of the municipalities decreased from 741.2 [95%CI 689.3-793.2] in 2009 to 348.9 [329.4-368.4] in 2018. The difference between the highest and lowest prescribing municipalities was reduced from 648.3 TIY in 2009-212.5 TIY in 2018. The average increase in TIY per unit increase in socioeconomic municipality score changed from 20.05 [7.69-31.06] in 2009 to -4.58 [-16.02-5.60] in 2018, representing a decreasing association between socioeconomic municipality score and use of antibiotic in the respective municipalities.

CONCLUSION

The trend in antibiotic prescription to children aged 0-6 years old decreased substantially in all the investigated municipalities in the 10-year study period. Local differences in prescription rates declined towards a more uniform prescription pattern across municipalities and association with socioeconomic status of the municipalities was reduced.

Surveillance of Wisconsin Organisms for Trends in Antimicrobial Resistance and Epidemiology (SWOTARE): 2018-2019 Report on Enterobacter cloacae and Klebsiella pneumoniae Clinical Isolates

Objectives: Both Enterobacter cloacae and Klebsiella pneumoniae have been regarded as important opportunistic pathogens for humans. Recent data have described the spread of multi-resistant strains of these organisms. Development of novel resistance phenotypes may result in a reduction in anti-infective efficacy, therefore making patient treatment decisions challenging. The Surveillance of Wisconsin Organisms for Trends in Antimicrobial Resistance and Epidemiology (SWOTARE) program aims to combat this issue and improve antibiotic stewardship by monitoring antimicrobial resistance at a local level.Design: Multi-center laboratory surveillance, with testing at a single location utilizing standardized media and susceptibility testing protocolsMethods: In the years 2018 and 2019, a total of 591 clinically-significant E. cloacae and 668 clinically-significant K. pneumoniae isolates were collected through this initiative; limited demographic data were also supplied. Isolates were tested by broth microdilution procedures advocated by Clinical and Laboratory Standards Institute.Results: On a statewide level, both E. cloacae and K. pneumoniae demonstrated in vitro potency to carbapenem and aminoglycoside agents at rates exceeding 96%. K. pneumoniae isolates were generally more susceptible to cephem and monobactam agents than E. cloacae isolates; the converse was true for fluoroquinolone agents. Patterns of local antimicrobial resistance were revealed that were not apparent at the state level. E. cloacae isolates submitted from the Northcentral and Southeast regions demonstrated decreased susceptibility to five antimicrobial agents (notably third- and fourth-generation cephems) when compared to the state average. Isolates derived from males, older individuals, and urogenital sources exhibited decreased susceptibility to third- and fourth-generation cephem agents (P ≤ 0.047). With respect to K. pneumoniae, antimicrobial resistance phenotype was not a function of geography or gender. However, isolates emanating from older patients and the respiratory tract showed decreased susceptibility to ampicillin/sulbactam and cefazolin, respectively (P ≤ 0.019).Conclusions: Antimicrobial resistance surveillance at a local level provides utility to community/rural hospital clinicians, pharmacists, and infection control practitioners. With respect to E. cloacae, further surveillance efforts may be necessary in the Northcentral and Southeast regions of Wisconsin. Subanalysis of demographic data indicated cephem-resistance correlates that are not apparent at the statewide level.

Non-Visit-Based and Non-Infection-Related Antibiotic Use in the US: A Cohort Study of Privately Insured Patients During 2016-2018

BACKGROUND

Ambulatory antibiotic prescriptions without a clinic visit or without documentation of infection could represent overuse and contribute to adverse outcomes. We aim to describe US ambulatory antibiotic prescribing, including those without an associated visit or infection diagnosis.

METHODS

We conducted an observational cohort study using data of all patients receiving antibacterial, antibiotic prescriptions from 04/01/2016 to 06/30/2018 in a large US private health insurance plan. We identified outpatient antibiotic prescriptions as (1) associated with a clinician visit and an infection-related diagnosis; (2) associated with a clinician visit but no infection-related diagnosis; or (3) not associated with an in-person clinician visit in the 7 days before the prescription (non-visit-based). We then assessed whether non-visit-based antibiotic prescriptions (NVBAPs) differed from visit-based antibiotics by patient, clinician, or antibiotic characteristics using multivariable models.

RESULTS

The cohort included 8.6M enrollees who filled 22.3M antibiotic prescriptions. NVBAP accounted for 31% (6.9M) of fills, and non-infection-related prescribing accounted for 22% (4.9M). NVBAP rates were lower for children than for adults (0-17 years old, 16%; 18-64 years old, 33%; >65 years old, 34%). Among most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). Specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine (20%), and pediatricians (10%). In multivariable models, NVBAP was associated with increasing age, and NVBAP was less likely for patients in the South, those with more baseline clinical visits, or those with chronic lung disease.

CONCLUSIONS

Over half of ambulatory antibiotic use was either non-visit-based or non-infection-related. Particularly given health care changes due to the coronavirus disease 2019 pandemic, efforts to improve antibiotic prescribing must account for non-visit-based and non-infection-related prescribing.

Consumption of macrolides, lincosamides and streptogramins in the community, European Union/European Economic Area, 1997-2017

OBJECTIVES

Data on the consumption of macrolides, lincosamides and streptogramins (MLS) in the community were collected from 30 EU/European Economic Area (EEA) countries over two decades. This article reviews temporal trends, seasonal variation, presence of change-points and changes in composition of the main subgroups of MLS.

METHODS

For the period 1997-2017, data on consumption of MLS, i.e. ATC group J01F, in the community and aggregated at the level of the active substance, were collected using the WHO ATC/DDD methodology (ATC/DDD index 2019). Consumption was expressed in DDD per 1000 inhabitants per day and in packages per 1000 inhabitants per day. Consumption of MLS was analysed and presented as trends, seasonal variation, presence of change-points and compositional changes, using a classification based on mean plasma elimination half-life for macrolides.

RESULTS

In 2017, consumption of MLS in the community expressed in DDD per 1000 inhabitants per day varied by a factor of 13 between countries with the highest (Greece) and the lowest (Sweden) consumption. Consumption of MLS did not change significantly up to 2003, after which it significantly increased up to 2007. No significant change was observed after 2007. Consumption of MLS showed high seasonal variation. The proportional consumption of long-acting macrolides significantly increased over time compared with that of intermediate-acting macrolides, and proportional consumption of the latter increased compared with that of short-acting macrolides.

CONCLUSIONS

Consumption of MLS did not change significantly over time during 2007-2017, while the proportional consumption of long-acting macrolides increased. Seasonal variation remained high, which suggests that MLS are still prescribed inappropriately in many countries.

Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions

BACKGROUND

Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices.

METHODS

We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019.

RESULTS

We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period.

CONCLUSION

Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.

Prescription Drug Dispensing to US Children During the COVID-19 Pandemic

BACKGROUND

After the US coronavirus disease 2019 outbreak, overall prescription dispensing declined but then rebounded. Whether these same trends occurred for children is unknown.

METHODS

Using the IQVIA National Prescription Audit, which contains monthly dispensing counts from 92% of US retail pharmacies, we assessed changes in the monthly number of prescriptions dispensed to US children aged 0 to 19 years during 2018-2020. We compared dispensing totals in April to December 2020 and April to December 2019 overall, by drug class, and among drug classes that typically treat acute infections (eg, antibiotics) or chronic diseases (eg, antidepressants).

RESULTS

Between January 2018 and February 2020, the median monthly number of prescriptions dispensed to children was 25 744 758. Dispensing totals declined from 25 684 219 to 16 742 568 between March and April 2020, increased to 19 657 289 during October 2020, and decreased to 15 821 914 during December 2020. Dispensing totals during April to December 2020 (160 630 406) were 27.1% lower compared with April to December 2019 (220 284 613). Among the 3 drug classes accounting for the most prescriptions in 2019, the corresponding percentage changes were -55.6% for antibiotics, -11.8% for attention-deficit/hyperactivity disorder medications, and 0.1% for antidepressants. Among drug classes that typically treat acute infections and chronic diseases, percentage changes were -51.3% and -17.4%, respectively.

CONCLUSIONS

Prescription dispensing to children declined by one-quarter in April to December 2020 compared with April to December 2019. Declines were greater for infection-related drugs than for chronic disease drugs. Decreased dispensing of the latter is potentially concerning and warrants further investigation. Whether reductions in dispensing of infection-related drugs are temporary or sustained will be important to monitor going forward.

Predicting Oral Beta-lactam susceptibilities against Streptococcus pneumoniae

BACKGROUND

Oral beta-lactam antimicrobials are not routinely tested against Streptococcus pneumoniae due to presumed susceptibility based upon penicillin minimum inhibitory concentration (MIC) testing. Currently, Clinical and Laboratory Standards Institute provides comments to use penicillin MIC ≤0.06 to predict oral cephalosporin susceptibility. However, no guidance is provided when cefotaxime MIC is known, leading to uncertainty with interpretation. The purpose of this study was to evaluate cefotaxime and penicillin MICs and their respective correlation to oral beta-lactam categorical susceptibility patterns.

METHODS

249 S. pneumoniae isolates were identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-ToF) and then tested by broth microdilution method to penicillin, cefotaxime, amoxicillin, cefdinir, cefpodoxime, and cefuroxime.

RESULTS

Using Clinical and Laboratory Standards Institute (CLSI) non-meningitis breakpoints for cefotaxime, 240/249 isolates were classified as susceptible. Of the cefotaxime susceptible isolates, 23% of the isolates are misrepresented as cefdinir susceptible. Amoxicillin correlated well with penicillin MIC breakpoints with only 1 discordant isolate out of 249.

CONCLUSION

The correlation between amoxicillin and penicillin creates a very reliable predictor to determine categorical susceptibility. However oral cephalosporins were not well predicted by either penicillin or cefotaxime leading to the possible risk of treatment failures. Caution should be used when transitioning to oral cephalosporins in cefotaxime susceptible isolates, especially with higher cefotaxime MICs.

The infant gut resistome is associated with E. coli and early-life exposures

BACKGROUND

The human gut microbiome harbors a collection of bacterial antimicrobial resistance genes (ARGs) known as the resistome. The factors associated with establishment of the resistome in early life are not well understood. We investigated the early-life exposures and taxonomic signatures associated with resistome development over the first year of life in a large, prospective cohort in the United States. Shotgun metagenomic sequencing was used to profile both microbial composition and ARGs in stool samples collected at 6 weeks and 1 year of age from infants enrolled in the New Hampshire Birth Cohort Study. Negative binomial regression and statistical modeling were used to examine infant factors such as sex, delivery mode, feeding method, gestational age, antibiotic exposure, and infant gut microbiome composition in relation to the diversity and relative abundance of ARGs.

RESULTS

Metagenomic sequencing was performed on paired samples from 195 full term (at least 37 weeks' gestation) and 15 late preterm (33-36 weeks' gestation) infants. 6-week samples compared to 1-year samples had 4.37 times (95% CI: 3.54-5.39) the rate of harboring ARGs. The majority of ARGs that were at a greater relative abundance at 6 weeks (chi-squared p < 0.01) worked through the mechanism of antibiotic efflux. The overall relative abundance of the resistome was strongly correlated with Proteobacteria (Spearman correlation = 78.9%) and specifically Escherichia coli (62.2%) relative abundance in the gut microbiome. Among infant characteristics, delivery mode was most strongly associated with the diversity and relative abundance of ARGs. Infants born via cesarean delivery had a trend towards a higher risk of harboring unique ARGs [relative risk = 1.12 (95% CI: 0.97-1.29)] as well as having an increased risk for overall ARG relative abundance [relative risk = 1.43 (95% CI: 1.12-1.84)] at 1 year compared to infants born vaginally.

CONCLUSIONS

Our findings suggest that the developing infant gut resistome may be alterable by early-life exposures. Establishing the extent to which infant characteristics and early-life exposures impact the resistome can ultimately lead to interventions that decrease the transmission of ARGs and thus the risk of antibiotic resistant infections.