Risk Factors Associated with Carbapenemase Producing Carbapenem-Resistant Enterobacteriaceae (CP-CRE) Positive Cultures in a Cohort of U.S. Veterans

INTRODUCTION

Carbapenem-resistant Enterobacterales (CRE) cause approximately 13,100 infections with 8% mortality in the United States annually. The subset of carbapenemase-producing CRE (CP-CRE) infections have much higher mortality rates (40% -50%). There has been little research on characteristics unique to CP-CRE. The goal of this study was to assess differences between those with nonCP-CRE and CP-CRE cultures in U.S. Veterans.

METHODS

A retrospective cohort of Veterans with CRE cultures from 2013-2018 and their demographic, medical, and facility level covariates were collected. Clustered multiple logistic regression models were used to assess independent factors associated with CP-CRE.

RESULTS

3,096 unique patients with cultures positive for either nonCP-CRE or CP-CRE were included. Being African American (Odds Ratio (OR)=1.44 (95% Confidence Interval (CI) 1.15,1.80), diagnosis in 2017 (OR=3.11 (95% CI 2.13,4.54)) or 2018 (OR=3.93 (95%CI 2.64,5.84)), congestive heart failure (OR=1.35 (95%CI 1.11,1.64)), and gastroesophageal reflux disease (OR=1.39 (95%CI 1.03,1.87)) were associated with CP-CRE cultures. 752 (24.3%) patients had no known antibiotic exposure in the year before culture; these individuals had a comparatively increased frequency of prolonged PPI use (17.3% vs 5.6%).

DISCUSSION

Among a cohort of patients with CRE, African Americans, individuals with congestive heart failure, and patients with gastroesophageal reflux disease had greater odds of having a CP-CRE culture. Roughly one in four patients with CP-CRE had no known antibiotic exposure in the year before their positive culture.

Hospitalized patients with diarrhea: Rate of Clostridioides difficile infection underdiagnosis and drivers of clinical suspicion

OBJECTIVES

Clostridioides difficile infection (CDI) represents a challenging issue, with an evolving epidemiology. Main objectives of our study were: to assess the frequency of diarrhea of overall etiology, including CDI, as a cause of hospital admission or occurring during hospital stay;- to determine the rate of underdiagnosis of community-acquired (CA-), health care associated (HCA)- and hospital onset (HO-) CDI, and explore factors associated with its clinical suspicion by physicians.

METHODS

A prospective cohort study included all hospitalized patients with diarrhea at two acute-care hospitals. C. difficile (CD) tests were performed on every stool samples, irrespective of the treating physician request. Factors associated with the likelihood of CD test request by physicians were assessed.

RESULTS

We enrolled 871 (6%) patients with diarrhea. CD test performed on all diarrheic stool samples was positive in 228 cases (26%); 37, 106, 85 cases of CA- (14%), HCA- (42%) and HO- diarrhea (24%), respectively. Treating physicians did not request CD test in 207 (24%) diarrhea cases. The rate of CDI underdiagnosis was 11% (24/228); it was higher in CA-CDI (27%, 10/37). Logistic regression analysis identified age >65 years (RR 1.1; 95 CI 1.06-1.2) and hospitalizations in the previous 3 months (RR 1.2; 95% CI 1.1-1.3) as independent factors associated with the likelihood of requesting the CD test by the physician. These risk factors differed by epidemiological classification of diarrhea and by hospital.

CONCLUSIONS

Our study confirmed the relevance of CDI underdiagnosis and provided new insights in the factors underlying the lack of CDI clinical suspicion.

Prescription of antibiotics in the medical care of newly arrived refugees and migrants

PURPOSE

Unnecessary and inappropriate use of antibiotics is a widespread problem in primary care. However, current data on the care of refugees and migrants in initial reception centers is pending. This article provides data on prescription frequencies of various antibiotics and associated diagnoses.

METHODS

In this retrospective observational study, patient data of 3255 patients with 6376 medical contacts in two initial reception centers in Germany were analyzed. Patient data, collected by chart review, included sociodemographic characteristics, diagnoses, and prescriptions. Antibiotic prescription behavior and corresponding physician-coded diagnoses were analyzed.

RESULTS

Nineteen percent of all patients in our study received systemic antibiotics during the observation period, with children below the age of 10 years receiving antibiotics most frequently (24%). The most commonly prescribed antibiotics were penicillins (65%), macrolides (12%), and cephalosporins (7%). The most frequent diagnoses associated with antibiotic prescription were acute tonsillitis (26%), bronchitis (21%), infections of the upper respiratory tract (14%), and urinary tract infections (10%). In case of acute bronchitis 74% of the antibiotic prescriptions were probably not indicated. In addition, we found a significant number of inappropriate prescriptions such as amoxicillin for tonsillitis (67%), and ciprofloxacin and cotrimoxazol for urinary tract infections (49%).

CONCLUSION

Regarding inappropriate prescription of antibiotics in refugee healthcare, this study shows a rate ranging from 8% for upper respiratory tract infections to 75% for acute bronchitis. Unnecessary use of antibiotics is a global problem contributing to gratuitous costs, side effects, and antimicrobial resistance. This research contributes to the development of stringent antibiotic stewardship regiments in the particularly vulnerable population of migrants and refugees.

Bugs That Can Resist Antibiotics but Not Men: Gender-Specific Differences in Notified Infections and Colonisations in Germany, 2010-2019

Data from surveillance networks show that men have a higher incidence rate of infections with anti-microbial-resistant (AMR) pathogens than women. We systematically analysed data of infections and colonisations with AMR pathogens under mandatory surveillance in Germany to quantify gender-specific differences. We calculated incidence-rates (IR) per 100,000 person-years for invasive infections with Methicillin-resistant Staphylococcus aureus (MRSA), and for infections or colonisations with carbapenem-non-susceptible Acinetobacter spp. (CRA), and Enterobacterales (CRE), using the entire German population as a denominator. We limited the study periods to years with complete notification data (MRSA: 2010-2019, CRA/CRE: 2017-2019). We used Poisson regression to adjust for gender, age group, federal state, and year of notification. In the study periods, IR for all notifications were 4.2 for MRSA, 0.90 for CRA, and 4.8 for CRE per 100,000 person--years. The adjusted IR ratio for infections of men compared to women was 2.3 (95% confidence interval [CI]: 2.2-2.3) for MRSA, 2.2 (95%CI: 1.9-2.7) for CRA, and 1.7 (95%CI: 1.6-1.8) for CRE. Men in Germany show about double the risk for infection with AMR pathogens than women. This was also true for colonisations, where data were available. Screening procedures and associated hygiene measures may profit from a gender-stratified approach.

Primary and secondary clarithromycin resistance in Helicobacter pylori and mathematical modeling of the role of macrolides

Clarithromycin is a macrolide antibiotic widely used for eradication of Helicobacter pylori infection, and thus resistance to this antibiotic is a major cause of treatment failure. Here, we present the results of a retrospective observational study of clarithromycin resistance (Cla-res) in 4744 H. pylori-infected patients from Central Hungary. We use immunohistochemistry and fluorescence in situ hybridization on fixed gastric tissue samples to determine H. pylori infection and to infer Cla-res status, respectively. We correlate this information with macrolide dispensing data for the same patients (available through a prescription database) and develop a mathematical model of the population dynamics of Cla-res H. pylori infections. Cla-res is found in 5.5% of macrolide-naive patients (primary Cla-res), with no significant sex difference. The model predicts that this primary Cla-res originates from transmission of resistant bacteria in 98.7% of cases, and derives from spontaneous mutations in the other 1.3%. We find an age-dependent preponderance of female patients among secondary (macrolide-exposed) clarithromycin-resistant infections, predominantly associated with prior use of macrolides for non-eradication purposes. Our results shed light into the sources of primary resistant cases, and indicate that the growth rate of Cla-res prevalence would likely decrease if macrolides were no longer used for purposes other than H. pylori eradication.

Clarithromycin is a macrolide antibiotic widely used for eradication of Helicobacter pylori infection. Here, Kocsmár et al. study clarithromycin resistance and previous macrolide consumption in 4,744 H. pylori-infected patients, shedding light into the sources of primary resistant cases and the role played by prior consumption of macrolides for non-eradication purposes.

Antimicrobial resistance and COVID-19: Intersections and implications

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.

Communication training and the prescribing pattern of antibiotic prescription in primary health care

BACKGROUND

The treatment of upper respiratory tract infections (URTIs) accounts for the majority of antibiotic prescriptions in primary care, although an antibiotic therapy is rarely indicated. Non-clinical factors, such as time pressure and the perceived patient expectations are considered to be reasons for prescribing antibiotics in cases where they are not indicated. The improper use of antibiotics, however, can promote resistance and cause serious side effects. The aim of the study was to clarify whether the antibiotic prescription rate for infections of the upper respiratory tract can be lowered by means of a short (2 x 2.25h) communication training based on the MAAS-Global-D for primary care physicians.

METHODS

In total, 1554 primary care physicians were invited to participate in the study. The control group was formed from observational data. To estimate intervention effects we applied a combination of difference-in-difference (DiD) and statistical matching based on entropy balancing. We estimated a corresponding multi-level logistic regression model for the antibiotic prescribing decision of German primary care physicians for URTIs.

RESULTS

Univariate estimates detected an 11-percentage-point reduction of prescriptions for the intervention group after the training. For the control group, a reduction of 4.7% was detected. The difference between both groups in the difference between the periods was -6.5% and statistically significant. The estimated effects were nearly identical to the effects estimated for the multi-level logistic regression model with applied matching. Furthermore, for the treatment of young women, the impact of the training on the reduction of antibiotic prescription was significantly stronger.

CONCLUSIONS

Our results suggest that communication skills, implemented through a short communication training with the MAAS-Global-D-training, lead to a more prudent prescribing behavior of antibiotics for URTIs. Thereby, the MAAS-Global-D-training could not only avoid unnecessary side effects but could also help reducing the emergence of drug resistant bacteria. As a consequence of our study we suggest that communication training based on the MAAS-Global-D should be applied in the postgraduate training scheme of primary care physicians.

Prevalence and Determinants of Antibiotic Consumption in the Elderly during 2006-2017

Elderly people are a particularly important population with regard to antibiotic overuse, using around 50% more antibiotics per capita than younger adults. The aim of this study was to analyze the prevalence, associated factors and evolution over time of antibiotic consumption among the Spanish population aged ≥ 65 years from 2006 to 2017. A descriptive cross-sectional study was conducted using data from the Spanish National Health Survey in 2006, 2011/2012 and 2017, and from the European Health Survey in Spain in 2009 and 2014. The sample consisted of 26,891 non-institutionalized individuals ≥ 65 years. Antibiotic consumption was the dependent variable, and sociodemographic variables, lifestyle habits and health status were analyzed using a logistic regression model. The prevalence of antibiotic consumption was 4.94%, with a marked increase from 2006 (4.64%) to 2017 (5.81%) (p < 0.0001). Higher antibiotic consumption was associated with poor or very poor self-perceived health status, no polypharmacy and not having been in hospital during the previous twelve months, while a lower consumption was linked to being limited but not severely due to a health problem and not being at all limited.

Treatment of Helicobacter pylori Is Not Associated With Future Clostridium difficile Infection

INTRODUCTION

Helicobacter pylori (HP) infection is associated with many gastrointestinal disorders, including gastric cancer, and consensus guidelines recommend eradication after detection. There is a theoretical, yet uninvestigated, concern that HP treatment could increase the risk of Clostridium difficile infection (CDI). Using the data from a large cohort of patients with HP, we investigated whether HP eradication is associated with CDI.

METHODS

A retrospective cohort study within the Veterans Health Administration on 38,535 patients (median age 61.8 years; 91.8% men) with detected HP between January 1, 1994, and December 31, 2018 was conducted. Primary outcome was a positive laboratory test for CDI within 3 months of HP detection. Multivariable logistic regression evaluated the following: patient demographics, previous CDI, recent hospitalization, and whether the patient received HP eradication therapy (by antibiotic and regimen, and including proton pump therapy). Secondary analysis of those treated evaluated whether eradication of HP was associated with CDI.

RESULTS

Among 38,535 patients, 28,818 (74.8%) were treated for HP and 284 (0.74%) developed CDI. In multivariable analysis, prominent factors included hospital discharge within 12 weeks (odds ratio [OR] 2.15; 95% confidence interval [CI]: 1.22-3.77) and 4 weeks (OR 3.46; 95% CI: 2.18-5.48), P < 0.001, and previous CDI (OR 12.5; 95% CI: 9.21-17.0, P < 0.001). Treatment of HP was not associated with future CDI. In secondary analysis of those treated, confirmation of eradication was not associated with future CDI (OR 1.49; 95% CI: 0.67-3.29).

DISCUSSION

In a large study of US patients with HP, we demonstrate that neither treatment nor eradication of HP is associated with CDI. Previous C. difficile infection and recent hospital discharge, established risk factors for CDI, are strongly associated. These findings suggest that treatment should be continued to be prescribed when HP is detected (http://links.lww.com/AJG/B507).

Antibiotic Use Associated with Confirmed Influenza, Pertussis, and Nontyphoidal Salmonella Infections

Purpose: Antibiotics are not the recommended treatment for uncomplicated influenza or nontyphoidal salmonella infections, whereas they are for current pertussis infection. We investigated adherence to these recommendations in a population of older community-dwelling adults. Methods: Population-based prospective cohort study of Australian adults 45 years of age and older followed by record-linkage to laboratory-confirmed influenza, pertussis, and nontyphoidal salmonella notifications, hospitalization records, and antibiotic dispensing data from January 1, 2009 to December 31, 2015. Proportions of those with infections who were prescribed antibiotics were estimated, and characteristics associated with antibiotic prescribing were examined. Results: There were 1,056 influenza, 151 pertussis, and 334 nontyphoidal salmonella cases in the cohort eligible for analysis. Antibiotics were dispensed in 56.2% (594/1,056) of influenza, 78.8% (119/151) of pertussis, and 39.5% (132/334) of nontyphoidal salmonella cases within the ±10-day window around the infection onset date. The likelihood of antibiotic dispensing did not differ according to most participant characteristics examined, including whether cases had an associated hospitalization, their age, and recorded comorbidities. Macrolides were the predominant class of antibiotics dispensed for pertussis (79%), whereas both beta-lactams (36.3%) and macrolides (35.4%) were used for cases of influenza. There was no dominant antibiotic class dispensed among those with nontyphoidal salmonella. Conclusions: Given concerns regarding increasing antibiotic resistance, the high proportion of adults with influenza and nontyphoidal salmonella cases dispensed antibiotics indicate the need for further strengthening of antimicrobial stewardship by raising education and awareness of guidelines for managing these infections.

Gender differences in community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is the most common type of lower respiratory tract infection and a major cause of morbidity and mortality in adults worldwide. Sex and gender play an active role in the incidence and outcomes of major infectious diseases, including CAP.

EVIDENCE ACQUISITION

We searched the following electronic databases from January 2001 to December 2018: MEDLINE, EMBASE, CINHAIL, CENTRAL (Cochrane Central register of Controlled Trials), DARE (Database of Abstracts of Reviews of Effectiveness), Cochrane Database of Systematic Reviews and ACP Journal Club database.

EVIDENCE SYNTHESIS

Several studies have reported higher male susceptibility to pulmonary infections and higher risk of death due to sepsis. Biological differences (e.g. hormonal cycles and cellular immune-mediated responses) together with cultural, behavioral and socio-economic differences are important determinants of the course and outcome of CAP. However, gender-related bias in the provision of care and use of hospital resources has been reported among women, resulting in delayed hospital admission and consequently necessary care.

CONCLUSIONS

CAP is more severe in males than in females, leading to higher mortality in males, especially in older age. To identify gender differences in CAP can guide patient's prognostication and management.

Helicobacter pylori heteroresistance to clarithromycin in adults-New data by in situ detection and improved concept

BACKGROUND

Clarithromycin (Cla) heteroresistance of Helicobacter pylori (H pylori) infections is commonly assessed by comparing the resistance status of antrum and corpus biopsy samples and by demonstrating the discrepancy between them (interniche heteroresistance). However, fluorescence in situ hybridization (FISH) technique is capable of showing the synchronous presence of susceptible and resistant bacteria (intraniche heteroresistance), enabling the detection of heteroresistant H pylori populations within one biopsy sample.

MATERIALS AND METHODS

Antrum and corpus biopsy specimens of 305 H pylori-infected patients were investigated with an rRNA-targeted Cla-resistance FISH test. Anamnestic data were collected from the institutional electronic register. Prevalence rates of susceptible, homo- and heteroresistant cases were correlated with the anamnestic and clinicopathological data.

RESULTS

Overall Cla-resistance rate was 23.9% (73 cases), consisting of 35 (11.5%) homoresistant and 38 (12.5%) heteroresistant cases. Thirty-five patients had at least one biopsy site where susceptible and resistant bacteria were present simultaneously. From this subset, 20 cases demonstrated intraniche heteroresistance on both sites. Prior Cla-based eradication attempts were more frequent in homoresistant than in susceptible and heteroresistant cases (P < .001, P < .001, respectively). Cla-containing therapy eradicated heteroresistant infections at a significantly lower rate in comparison with susceptible cases (P = .0112), but more effectively than homoresistants (P = .0393).

CONCLUSIONS

The most frequent type of Cla-heteroresistance is the coexistence of susceptible and resistant H pylori bacteria in the same location (intraniche heteroresistance). A previous Cla-based eradication attempt predisposes patients to homoresistant infection. Heteroresistance is characterized by a non-eradication-related background and intermediate characteristics in many respects when compared to susceptible and homoresistant cases.

Drug Utilization Pattern of Antibiotics: The Role of Age, Sex and Municipalities in Determining Variation

Purpose

The purpose was to analyze drug prescription and antibiotic use by age and sex in Italy’s Campania Region, and to estimate the distribution of prescription rates in children (≤14 years old), adults (between 15 and 65 years old), and older adults (≥65 years old) at a municipality level.

Methods

This was a retrospective analysis of pharmacy records in Campania (Southern Italy), in 2016. Difference in antibiotic prescriptions in different age groups was assessed by prevalence rates. Age-adjusted prevalence rates were categorized into quintiles and mapped by the patient’s municipality of residence. Relationship between prevalence rates for the different age groups was estimated using the non-parametric Spearman rank correlation test.

Results

There were 2,738,118 were patients with at least one antibiotic prescription. Antibiotics prescription was higher in children aged <5 years and in the older adults aged >70 years. Prevalence rate distribution was different among municipalities in all age groups. A positive correlation between the rank distribution of prevalence rates at municipality level was identified for children and adults (rs=0.56; P<0.01), adults and the older adults (rs=0.79; P<0.01), and children and the older adults (rs=0.46; P<0.01). Among the studied age groups, the most prescribed antibiotic class was penicillin (except the older adults aged ≥85 years) ranging from 45% in children to 27.2% in the older adults. Fluoroquinolones were the least prescribed antibiotic class, ranging from 0.2% in children to 30.2% in the older adults.

Conclusion

A considerably high use of antibiotic drugs has been detected in Campania Region, with values exceeding the regional and national average. Prescriptions at municipal level differ from one age group to another. Antibiotic use is often unjustified, and to decrease the number of prescriptions and improve their appropriateness, several measures at territorial level are recommended.

Indications and classes of outpatient antibiotic prescriptions in Japan: A descriptive study using the national database of electronic health insurance claims, 2012-2015

OBJECTIVES

To evaluate condition-specific antibiotic prescription rates and the appropriateness of antibiotic use in outpatient settings in Japan.

METHODS

Using Japan's national administrative claims database, all outpatient visits with infectious disease diagnoses were linked to reimbursed oral antibiotic prescriptions. Prescription rates stratified by age, sex, prefecture, and antibiotic category were determined for each infectious disease diagnosis. The proportions of any antibiotic prescription to all infectious disease visits and the proportions of first-line antibiotic prescriptions to all antibiotic prescriptions were calculated for each infectious disease diagnosis.

RESULTS

Of the 659 million infectious disease visits between April 2012 and March 2015, antibiotics were prescribed in 266 million visits (704 prescriptions per 1000 population per year). Third-generation cephalosporins, macrolides, and quinolones accounted for 85.9% of all antibiotic prescriptions. Fifty-six percent of antibiotic prescriptions were directed toward infections for which antibiotics are generally not indicated. The diagnoses with frequent antibiotic prescription were bronchitis (184 prescriptions per 1000 population per year), viral upper respiratory infections (166), pharyngitis (104), sinusitis (52), and gastrointestinal infection (41), for which 58.3%, 40.6%, 58.9%, 53.9%, and 26.1% of visits antibiotics were prescribed, respectively. First-line antibiotics were rarely prescribed for pharyngitis (8.8%) and sinusitis (9.8%). More antibiotics were prescribed for children aged 0-9 years, adult women, and patients living in western Japan.

CONCLUSIONS

Antibiotic prescription rates are high in Japan. Acute respiratory or gastrointestinal infections, which received the majority of the antibiotics generally not indicated, should be the main targets of antimicrobial stewardship intervention.

Who is willing to stay sick for the collective? - Individual characteristics, experience, and trust

•

We study attitudes towards antibiotics and antibiotic resistance.

•

We analyze results from a novel web-survey of Swedish citizens (n = 1906).

•

Acceptability of doctor's decision not to prescribe antibiotics was found to be large.

•

Trust in the healthcare sector is linked to acceptability of doctor's decision.

•

Concern about antibiotic resistance is linked to willingness to limit antibiotic use.

Correlation of antimicrobial prescription rate and county income in medicare part D

The objective of this study was to examine whether patient income has an impact on likelihood of being prescribed an antimicrobial agent at the county level. A better understanding of factors that influence antimicrobial prescription is needed to efficiently mitigate rates of antimicrobial agents prescribed.This cross-sectional study used data from two publicly available datasets. The 2015 Medicare Part D PUF data quantifies the antimicrobial prescription rate at the county level and data from US Census Bureau provides information on socioeconomic status at the county level.At the county level, we explained 48% of the variation in antimicrobial prescriptions by socioeconomic status, age, gender, and race. More specifically, socioeconomic status accounted for 26% of the variation in antimicrobial rate and as income increased, correlation with antimicrobial prescription rate trended down.We determined patient income and other sociodemographics to influence the prescription of antimicrobial agents. Interventions should consider these factors to effectively evaluate antimicrobial prescription methods. Findings from this study can help guide intervention efforts which aim to minimize the number of inappropriate antimicrobials prescribed, such as antimicrobial stewardship programs. Effective interventions have the capability of decreasing levels of inappropriate antimicrobials prescribed and prevent future cases of resistance.

Sex differences in the prevalence of Helicobacter pylori infection: an individual participant data pooled analysis (StoP Project)

BACKGROUND

Helicobacter pylori (H. pylori) infection is more frequent among men, though the magnitude of the association might be inaccurate due to potential misclassification of lifetime infection and publication bias. Moreover, infection is common, and most studies are cross-sectional. Thus, prevalence ratios (PRs) may be easier to interpret than odds ratios (ORs).

AIM

The aim of this study was to quantify the association between sex and H. pylori infection using controls from 14 studies from the Stomach Cancer Pooling (StoP) Project.

PARTICIPANTS AND METHODS

H. pylori infection was defined based on IgG serum antibody titers or multiplex serology. Participants were also classified as infected if gastric atrophy was present, based on histological examination or serum pepsinogen (PG) levels (PG I≤70 and PG I/II ratio≤3). Summary ORs and PRs, adjusted for age, social class and smoking, and corresponding 95% confidence intervals (CIs), were estimated through random-effects meta-analysis.

RESULTS

Men had significantly higher OR (OR: 1.33, 95% CI: 1.04-1.70) and PR (PR: 1.05, 95% CI: 1.00-1.10) of infection, with stronger associations among hospital-based or older controls. Results were similar when considering the presence of gastric atrophy to define infection status, particularly among participants older than 65 years.

CONCLUSION

This collaborative pooled-analysis supports an independent effect of sex on the prevalence of H. pylori infection, while minimizing misclassification of lifetime infection status and publication bias.

Evidence of a care home effect on antibiotic prescribing for those that transition into a care home: a national data linkage study

We compared antibiotic prescribing to older people in different settings to inform antibiotic stewardship interventions. We used data linkage to stratify individuals aged 65 years and over in Northern Ireland, 1st January 2012–31st December 2013, by residence: community dwelling, care home dwelling or ‘transitioned’ if admitted to a care home. The odds of being prescribed an antibiotic by residence were analysed using logistic regression, adjusting for patient demographics and selected medication use (proxy for co-morbidities). Trends in monthly antibiotic prescribing were examined in the 6 months pre- and post-admission to the care home. The odds of being prescribed at least one antibiotic were twofold higher in care homes compared with community dwellers (adjusted odds ratio 2.05, 95% CI 1.93–2.17). There was a proportionate increase of 51.5% in the percentage prescribed an antibiotic on admission, with a monthly average of 23% receiving an antibiotic in the 6 months post admission. While clinical need likely accounts for some of the observed antibiotic prescribing in care homes we cannot rule out more liberal prescribing, given the twofold difference between care home residents and their community dwelling peers having accounted for co-morbidities. The appropriateness of antibiotic prescribing in the care home setting should be examined.

Antibiotic Prescribing Practices and Errors among Hospitalized Pediatric Patients Suffering from Acute Respiratory Tract Infections: A Multicenter, Cross-Sectional Study in Pakistan

Background and objective: The noncompliance of treatment guidelines by healthcare professionals, along with physiological variations, makes the pediatric population more prone to antibiotic prescribing errors. The present study aims to evaluate the prescribing practices and errors of the most frequently prescribed antibiotics among pediatric patients suffering from acute respiratory tract infections who had different lengths of stay (LOS) in public hospitals. Methods: A retrospective, cross-sectional study was conducted in five tertiary-care public hospitals of Lahore, Pakistan, between 1 January 2017 and 30 June 2017. The study population consisted of pediatric inpatients aged 0 to 9 years. Results: Among the 11,892 pediatric inpatients, 82.8% were suffering from lower acute respiratory tract infections and had long LOS (53.1%) in hospital. Penicillins (52.4%), cephalosporins (16.8%), and macrolides (8.9%) were the most frequently prescribed antibiotics. Overall, 40.8% of the cases had antibiotic prescribing errors related to wrong dose (19.9%), wrong frequency (18.9%), and duplicate therapy (18.1%). Most of these errors were found in the records of patients who had long LOS in hospital (53.1%). Logistic regression analysis revealed that the odds of prescribing errors were lower in female patients (OR = 0.6, 95% CI = 0.1⁻0.9, p-value = 0.012). Patients who were prescribed with ≥3 antibiotics per prescription (OR = 1.724, 95% CI = 1.1⁻2.1, p-value = 0.020), had long LOS (OR = 12.5, 95% CI = 10.1⁻17.6, p-value < 0.001), and were suffering from upper respiratory tract infections (URTI) (OR = 2.8, 95% CI = 1.7⁻3.9, p-value < 0.001) were more likely to experience prescribing errors. Conclusion: Antibiotics were commonly prescribed to patients who had long LOS. Prescribing errors (wrong dose, wrong frequency, and duplicate therapy) were commonly found in cases of lower respiratory tract infections (LRTIs), especially among those who had prolonged stay in hospital.

Comparison of patient characteristics, clinical management, infectious specialist consultation, and outcome in men and women with methicillin-sensitive Staphylococcus aureus bacteremia: a propensity-score adjusted retrospective study

BACKGROUND

Sex-related treatment inequalities are suggested to explain outcome differences between men and women in Staphylococcus aureus bacteremia (SAB). We compared patient characteristics, clinical management, infectious specialist consultation (ISC) and outcome in men and women with SAB.

METHODS

Multicenter retrospective study of methicillin-sensitive (MS-) SAB patients categorized according to sex and ISC consultation provided within 7 days of diagnosis.

RESULTS

Altogether 617 SAB patients were included in the analysis: 62% males and 38% females. Male sex was associated less often to nosocomial bacteremia (OR 0.69, 95% CI 0.50-0.96, p = 0.029) and more often to alcoholism (OR 2.25, 95% CI 1.31-3.87, p = 0.003). No sex-related differences were seen in basic or immunologic laboratory tests, illness severity, intensive care unit treatment or thromboembolic events. ISC was provided to most patients (94%) irrespective of sex. No differences were seen in clinical management of men or women: Transthoracic or -esophageal echocardiography (61% vs. 65%), deep infection (77% vs. 72%), infection removal (30% vs. 27%) and anti-staphylococcal antibiotics as first-line treatment (54% vs. 51%). However, male sex was connected to more frequent adjunctive rifampicin treatment (52% vs. 41%, p = 0.025). No difference in 28- or 90-day mortality (13% vs. 13% and 18% vs. 20%) or SAB relapse (0% vs. 1%) was observed between men and women. Propensity-score adjusted Cox proportional analysis gave no connection of sex to mortality within 90 days.

CONCLUSION

Patient characteristics, clinical management, ISC guidance, bacteremia relapse, and outcome did not differ in men and women with MS-SAB.

Social disparities in patient safety in primary care: a systematic review

BACKGROUND

Patient safety is a quality indicator for primary care and it should be based on individual needs, and not differ among different social groups. Nevertheless, the attention on social disparities in patient safety has been mainly directed towards the hospital care, often overlooking the primary care setting. Therefore, this paper aims to synthesise social disparities in patient safety in the primary care setting.

METHODS

The Databases PubMed and Web of Science were searched for relevant studies published between January 1st 2006 and January 31st 2017. Papers investigating racial, gender and socioeconomic disparities in regards to administrative errors, diagnostic errors, medication errors and transition of care errors in primary care were included. No distinction in terms of participants' age was made.

RESULTS

Women and black patients are more likely to experience patient safety events in primary care, although it depends on the type of disease, treatment, and healthcare service. The available literature largely describes gender and ethnic disparities in the different patient safety domains whilst income and educational level are studied to a lesser extent.

CONCLUSIONS

The results of this systematic review suggest that vulnerable social groups are likely to experience adverse patient safety events in primary care. Enhancing family doctors' awareness of these inequities is a necessary first step to tackle them and improve patient safety for all patients. Future research should focus on social disparities in patient safety using socioeconomic indicators, such as income and education.

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015

BACKGROUND

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention.

OBJECTIVE

Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs.

DESIGN

Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015.

PATIENTS

Antibiotic-treated adults (≥ 20 years) seeking ED care.

MAIN MEASURES

Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics.

KEY RESULTS

Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group.

CONCLUSIONS

Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

Prescribing antibiotics when the stakes are higher — do GPs prescribe less when patients are pregnant? A retrospective observational study

Background

Most oral antibiotics are prescribed by GPs, and they are therefore the most important influencers with regard to improving antibiotic prescription patterns. Although GPs’ prescription patterns in general are well-studied, little is known about antibiotic prescription patterns in pregnancy.

Aim

To study GPs’ antibiotic prescriptions in respiratory tract infections (RTIs) during pregnancy, and assess differences, if any, between pregnant and non-pregnant patients.

Design & setting

Retrospective observational study combining prescription data from the Norwegian Peer Academic Detailing (Rx-PAD) study database, pregnancy data from the Norwegian birth registry, and pharmacy dispension data from the Norwegian Prescription Database (NorPD).

Method

Records of patient contacts with 458 GPs, between December 2004 and February 2007, were screened for RTI episodes. Similar diagnoses were grouped together, as were similar antibiotics. Episodes were categorised according to whether the patient was pregnant or not, and included women aged 16–46 years. Logistic regression models were used to assess odds ratios (ORs), and calculated relative risks (cRRs) were produced. The authors also adjusted for clustering at various levels.

Results

Overall prescription rate for RTI episodes was 30.8% (n = 96 830). The cohort was reduced to include only episodes with women pregnant in the study period (n = 18 890). The antibiotic prescription rate in pregnancy was 25.9% versus 34.2% in the time before and after pregnancy (cRR = 0.66 [95% confidence intervals {CI} = 0.68 to 0.81]).

During pregnancy, 83.0% of the antibiotic prescriptions were picked up at a pharmacy, compared to an 86.6% filling rate in non-pregnant patients. The difference was not significant when adjusting for clustering at the patient level.

Conclusion

Norwegian GPs prescribe fewer antibiotics overall when patients are pregnant and, when they do prescribe, choose more narrow spectrum antibiotics for RTIs. This indicates a possible lower target rate for GP prescriptions to females. A low antibiotic dispension rate during pregnancy may represent a discussion topic in the consultation setting, to address possible reasons and avoid under-treatment.

Understanding the gender gap in antibiotic prescribing: a cross-sectional analysis of English primary care

OBJECTIVES

To explore the causes of the gender gap in antibiotic prescribing, and to determine whether women are more likely than men to receive an antibiotic prescription per consultation.

DESIGN

Cross-sectional analysis of routinely collected electronic medical records from The Health Improvement Network (THIN).

SETTING

English primary care.

PARTICIPANTS

Patients who consulted general practices registered with THIN between 2013 and 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total antibiotic prescribing was measured in children (<19 years), adults (19-64 years) and the elderly (65+ years). For 12 common conditions, the number of adult consultations was measured, and the relative risk (RR) of being prescribed antibiotics when consulting as female or with comorbidity was estimated.

RESULTS

Among 4.57 million antibiotic prescriptions observed in the data, female patients received 67% more prescriptions than male patients, and 43% more when excluding antibiotics used to treat urinary tract infection (UTI). These gaps were more pronounced in adult women (99% more prescriptions than men; 69% more when excluding UTI) than in children (9%; 0%) or the elderly (67%; 38%). Among adults, women accounted for 64% of consultations (62% among patients with comorbidity), but were not substantially more likely than men to receive an antibiotic prescription when consulting with common conditions such as cough (RR 1.01; 95% CI 1.00 to 1.02), sore throat (RR 1.01, 95% CI 1.00 to 1.01) and lower respiratory tract infection (RR 1.00, 95% CI 1.00 to 1.01). Exceptions were skin conditions: women were less likely to be prescribed antibiotics when consulting with acne (RR 0.67, 95% CI 0.66 to 0.69) or impetigo (RR 0.85, 95% CI 0.81 to 0.88).

CONCLUSIONS

The gender gap in antibiotic prescribing can largely be explained by consultation behaviour. Although in most cases adult men and women are equally likely to be prescribed an antibiotic when consulting primary care, it is unclear whether or not they are equally indicated for antibiotic therapy.

Gender differences in the use of anti-infective medications before and after widowhood: a register-based study

BACKGROUND

Recent findings suggest that bereavement due to spousal loss is associated with a decline in general immune functions, and thus to increased susceptibility to infections among widowed individuals. The present study aims to investigate whether spousal loss weakens immune defences more among men than among women using a 5% random sample of the total Danish population, and anti-infective medication use as a proxy for immune response.

METHODS

We followed 6076 Danish individuals (67% women) aged ≥50 from 5 years before and up to 5 years after widowhood to examine changes in prescriptions of anti-infectives for systemic use.

RESULTS

Women used more anti-infective drugs both before and after spousal loss (women: OR= 1.31; 95% CI 1.21 to 1.42). The age-related changes in the use of anti-infective medications in the period before widowhood were similar to that in the period after widowhood among both men and women. Also, age-related changes in the use of anti-infective medications were similar in both genders.

CONCLUSIONS

The present study shows that individuals are more likely to use anti-infective medication after being widowed than before being widowed, but this change is likely to be related to increasing age and it is similar in both genders.

Identifying practice-related factors for high-volume prescribers of antibiotics in Danish general practice

Objectives

In Denmark, general practice is responsible for 75% of antibiotic prescribing in the primary care sector. We aimed to identify practice-related factors associated with high prescribers, including prescribers of critically important antibiotics as defined by WHO, after accounting for case mix by practice.

Methods

We performed a nationwide register-based survey of antibiotic prescribing in Danish general practice from 2012 to 2013. The unit of analysis was the individual practice. We used multivariable regression analyses and an assessment of relative importance to identify practice-related factors driving high antibiotic prescribing rates.

Results

We included 98% of general practices in Denmark ( n  =   1962) and identified a 10% group of high prescribers who accounted for 15% of total antibiotic prescriptions and 18% of critically important antibiotic prescriptions. Once case mix had been accounted for, the following practice-related factors were associated with being a high prescriber: lack of access to diagnostic tests in practice (C-reactive protein and urine culture); high use of diagnostic tests (urine culture and strep A throat test); a low percentage of antibiotic prescriptions issued over the phone compared with all antibiotic prescriptions; and a high number of consultations per 1000 patients. We also found that a low number of consultations per 1000 patients was associated with a reduced likelihood of being a high prescriber of antibiotics.

Conclusions

An apparent underuse or overuse of diagnostic tests in general practice as well as organizational factors were associated with high-prescribing practices. Furthermore, the choice of antibiotic type seemed less rational among high prescribers.

The Antibiotic Guardian campaign: a qualitative evaluation of an online pledge-based system focused on making better use of antibiotics

BACKGROUND

The Antibiotic Guardian Campaign was developed to increase commitment to reducing Antimicrobial Resistance (AMR), change behaviour and increase knowledge through an online pledge system for healthcare professionals and members of the public to become Antibiotic Guardians (AG). This qualitative evaluation aimed to understand AG experiences of the campaign and perceived impact on behaviour.

METHODS

Ninety-four AGs (48 via a survey and 46 who had agreed to future contact) were invited to participate in a telephone semi-structured interview. The sample was based on self-identification as a healthcare professional or a member of the public, pledge group (e.g. adults, primary care prescribers etc.), pledge and gender. Interviews explored how participants became aware of the campaign, reasons for joining, pledge choices, responses to joining and views about the campaign's implementation. Interviews were analysed using the Framework Method.

RESULTS

Twenty-two AGs (10 healthcare professionals and 12 members of the public) were interviewed. AGs became aware of the campaign through professional networks and social media, and were motivated to join by personal and professional concern for AMR. Choice of pledge group and pledge were attributed to relevance and potential impact on AMR and the behaviour of others through pledge enactment and promotion of the campaign. Most AGs could not recall their pledge unprompted. Most felt they fulfilled their pledge, although this reflected either behaviour change or the pledge reinforcing pre-existing behaviour. The campaign triggered AGs to reflect on AMR related behaviour and reinforced pre-existing beliefs. Several AGs promoted the campaign to others. Responding collectively as part of the campaign was thought to have a greater impact than individual action. However, limited campaign visibility was observed and the campaign was perceived to have restricted ability to reach those unaware of AMR.

CONCLUSIONS

AGs were motivated to reduce AMR and most felt they fulfilled their pledges although for many this appeared to be through reinforcement of existing behaviours. We recommend that the campaign engages those without pre-existing knowledge of AMR by increasing its visibility, capitalising on the diffusion of its message and including more awareness-raising content for those with limited AMR knowledge.

Smoking increases the likelihood of Helicobacter pylori treatment failure

BACKGROUND AND AIMS

Data regarding the impact of smoking on the success of Helicobacter pylori (H. pylori) eradication are conflicting, partially due to the fact that sociodemographic status is associated with both smoking and H. pylori treatment success. We aimed to assess the effect of smoking on H. pylori eradication rates after controlling for sociodemographic confounders.

METHODS

Included were subjects aged 15 years or older, with a first time positive C¹³-urea breath test (C¹³-UBT) between 2007 to 2014, who underwent a second C¹³-UBT after receiving clarithromycin-based triple therapy. Data regarding age, gender, socioeconomic status (SES), smoking (current smokers or "never smoked"), and drug use were extracted from the Clalit health maintenance organization database.

RESULTS

Out of 120,914 subjects with a positive first time C¹³-UBT, 50,836 (42.0%) underwent a second C¹³-UBT test. After excluding former smokers, 48,130 remained who were eligible for analysis. The mean age was 44.3±18.2years, 69.2% were females, 87.8% were Jewish and 12.2% Arabs, 25.5% were current smokers. The overall eradication failure rates were 33.3%: 34.8% in current smokers and 32.8% in subjects who never smoked. In a multivariate analysis, eradication failure was positively associated with current smoking (Odds Ratio {OR} 1.15, 95% CI 1.10-1.20, p<0.001), female gender (OR 1.20, 95% CI 1.14-1.25, p<0.001) and a low socioeconomic status (OR 1.24, 95% CI 1.17-1.31, p<0.001).

CONCLUSIONS

After controlling for socio-demographic confounders, smoking was found to significantly increase the likelihood of unsuccessful first-line treatment for H. pylori infection.

Antimicrobial stewardship in the Federal Bureau of Prisons: Approaches from the national and local levels

OBJECTIVES

To determine the impact of national and local antimicrobial stewardship measures on overall antibiotic prescribing in the Federal Bureau of Prisons (BOP).

SETTING

Care was delivered to more than 160,000 inmates in 122 BOP facilities in the United States and Puerto Rico.

PRACTICE DESCRIPTION

Medical centers and health services clinics staffed by in-house medical staff, consultants, and specialists. Staffs include a variety of disciplines, including physicians, pharmacists, dentists, nurses, infection control personnel, therapists, health services administrators, and institution executive staff.

PRACTICE INNOVATION

Innovations occurred on 2 levels: local components were used to reinforce national initiatives. Local institutions used a multidisciplinary team approach including education and focused evaluations of all antibiotic prescriptions before dispensing. National initiatives included the development of a closed formulary, clinical practice guidelines, an antimicrobial stewardship group led by pharmacy, development of tools and strategies for institutions, inclusion in the BOP strategic plan, and a drug utilization evaluation.

EVALUATION

This was a study of antimicrobial stewardship within BOP and the resultant impact on antibiotic prescriptions. In addition, one institution's antimicrobial stewardship methods were reviewed to determine the impact on antibiotic prescribing practices.

RESULTS

The total number of antibiotic prescriptions in BOP-managed institutions in fiscal year (FY) 2010 (October 2009 to September 2010) was 142,907 and progressively decreased to 105,832 in FY2015. The number of antibiotic prescriptions per 1000 inmates correspondingly decreased from 829 in FY2010 to 625 in FY2015. The overall number of antibiotic prescriptions as a percentage of total prescriptions decreased from 7.64% in FY2010 to 5.84% in FY2015.

CONCLUSION

A robust multidisciplinary antimicrobial stewardship program has likely contributed to a decrease in both the total number and the rate of antibiotic prescriptions on a per-1000-patient basis in BOP.

EpideMiology and control measures of outBreaks due to Antibiotic-Resistant orGanisms in EurOpe (EMBARGO): a systematic review protocol

INTRODUCTION

Improving our understanding of outbreaks due to antibiotic-resistant bacteria (ARB) and their control is critical in the current public health scenario. The threat of outbreaks due to ARB requires multifaceted efforts. However, a global overview of epidemiological characteristics of outbreaks due to ARB and effective infection control measures is missing. In this paper, we describe the protocol of a systematic review aimed at mapping and characterising the epidemiological aspects of outbreaks due to ARB and infection control measures in European countries.

METHODS AND ANALYSIS

The databases MEDLINE, Web of Knowledge and Cochrane library will be searched using a 3-step search strategy. Selection of articles for inclusion will be performed by 2 reviewers using predefined eligibility criteria. All study designs will be included if they report an outbreak and define the microbiological methods used for microorganism identification. The target bacteria will be methicillin-resistant and vancomycin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, ceftazidime-resistant and carbapenem-resistant Acinetobacter baumannii, ceftazidime-resistant and carbapenem-resistant Pseudomonas aeruginosa, ciprofloxacin-resistant Escherichia coli, extended-spectrum β-lactamase-producing E. coli and Klebsiella pneumoniae, carbapenem-resistant and carbapenamase-producing Enterobacteriaceae. Data will be extracted using a tailored pilot tested form and the quality of reporting will be assessed using the ORION (Outbreak Reports and Intervention Studies Of Nosocomial infections) tool. Data will be synthesised and reported by the type of ARB, setting and country. Infection control measures and bundles of measures will be described. The effectiveness will be reported as defined by the authors. Regression analysis will be used to define independent factors associated with outbreaks' control. Heterogeneity between studies will be assessed by forest plots and I² statistics.

ETHICS AND DISSEMINATION

Ethical approval is not applicable for this study. Findings will be disseminated through journal publication and conference presentations and talks.