Antibiotic resistance in the institutionalized elderly

Comparison of the management of Helicobacter pylori infection between the older and younger European populations

The prevalence of Helicobacter pylori remains high in the older population. Specific age-related peculiarities may impact the outcomes of H. pylori treatment. The aim of the study was to evaluate the diagnostics and effectiveness of H. pylori eradication between the younger and older European populations. "European Registry on H. pylori Management (Hp-EuReg)" data from 2013 to 2022 were analyzed. Patients were divided into older (≥ 60 years) and younger (18-59 years) groups. Modified intention-to-treat (mITT) and per-protocol (PP) analysis was performed. 49,461 patients included of which 14,467 (29%) were older-aged. Concomitant medications and penicillin allergy were more frequent among the older patients. Differences between younger and older populations were observed in treatment duration in first-line treatment and in proton pump inhibitors (PPIs) doses in second-line treatment. The overall incidence of adverse events was lower in the older adults group. The overall first-line treatment mITT effectiveness was 88% in younger and 90% in the older patients (p < 0.05). The overall second-line mITT treatment effectiveness was 84% in both groups. The effectiveness of the most frequent first- and second-line triple therapies was suboptimal (< 90%) in both groups. Optimal efficacy (≥ 90%) was achieved by using bismuth and non-bismuth-based quadruple therapies. In conclusion, the approach to the diagnostics and treatment of H. pylori infection did not generally differ between younger and older patients. Main differences were reported in the concurrent medications, allergy to penicillin and adverse events both in first- and second-line treatment. Optimal effectiveness rates were mostly achieved by using bismuth and non-bismuth-based quadruple therapies. No clinically relevant differences in the effectiveness between the age groups were observed.

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Antibiotic Resistance: Moving From Individual Health Norms to Social Norms in One Health and Global Health

Antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients (individual health). Nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. It is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. In this regard, the health of humans, animals, and local antibiotic-resistance-polluted environments should influence the health of the whole interconnected local ecosystem (One Health). In addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. Consequently, antibiotic resistance is a pandemic that requires Global Health solutions. Social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. In this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human-natural ecosystem interactions.

Extended-spectrum β-lactamase-producing Enterobacteriaceae colonisation in long-term care facilities: a systematic review and meta-analysis

The objectives of this study were to estimate the colonisation rate by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) among residents of long-term care facilities (LTCFs) and to identify pertinent risk factors. A systematic search of PubMed and EMBASE databases for studies published up to May 2016 that provided raw data for gastrointestinal colonisation by ESBL-PE among LTCF residents was performed. Twenty-three studies reporting data on 9775 screened subjects met the inclusion criteria. The pooled prevalence of ESBL-PE among LTCF residents was 18% [95% confidence interval (CI) 12-24%]. Risk factors for colonisation included recent antibiotic use (within 6 months) [odds ratio (OR) = 2.06, 95% CI 1.78-2.38], previous hospitalisation (within 2.5 years) (OR = 1.50, 95% CI 1.04-2.15), history of invasive procedures (within 2 years) (OR = 2.79, 95% CI 1.66-4.70), previous ESBL-PE colonisation or infection (OR = 6.77, 95% CI 1.33-34.62), history of urinary tract infection (OR = 2.66, 95% CI 1.76-4.01) and urinary catheter use (OR = 2.55, 95% CI 1.29-5.04). In conclusion, almost one in five LTCF residents is colonised with ESBL-PE, and colonised residents are more likely to have a history of recent antibiotic use or healthcare facility utilisation. Strict adherence to antimicrobial stewardship in LTCFs is needed to address these high resistance rates.

Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities

BACKGROUND

Understanding the extent to which current antibiotic prescribing behaviour is influenced by clinicians' historical patterns of practice will help target interventions to optimize antibiotic use in long-term care. Our objective was to evaluate whether clinicians' historical prescribing behaviours influence the start, prolongation and class selection for treatment with antibiotics in residents of long-term care facilities.

METHODS

We conducted a retrospective cohort study of all physicians who prescribed to residents in long-term care facilities in Ontario between Jan. 1 and Dec. 31, 2014. We examined variability in antibiotic prescribing among physicians for 3 measures: start of treatment with antibiotics, use of prolonged durations exceeding 7 days and selection of fluoroquinolones. Funnel plots with control limits were used to determine the extent of variation and characterize physicians as extreme low, low, average, high and extreme high prescribers for each tendency. Multivariable logistic regression was used to assess whether a clinician's prescribing tendency in the previous year predicted current prescribing patterns, after accounting for residents' demographics, comorbidity, functional status and indwelling devices.

RESULTS

Among 1695 long-term care physicians, who prescribed for 93 132 residents, there was wide variability in the start of antibiotic treatment (median 45% of patients, interquartile range [IQR] 32%-55%), use of prolonged treatment durations (median 30% of antibiotic prescriptions, IQR 19%-46%) and selection of fluoroquinolones (median 27% of antibiotic prescriptions, IQR 18%-37%). Prescribing tendencies for antibiotics by physicians in 2014 correlated strongly with tendencies in the previous year. After controlling for individual resident characteristics, prior prescribing tendency was a significant predictor of current practice.

INTERPRETATION

Physicians prescribing antibiotics exhibited individual, measurable and historical tendencies toward start of antibiotic treatment, use of prolonged treatment duration and class selection. Prescriber audit and feedback may be a promising tool to optimize antibiotic use in long-term care facilities.

Infection Control in Alternative Health Care Settings: An Update

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Biofilm-based infections in long-term care facilities

The recent trend in the early admittance to long-term care facilities (LTCFs) of severely injured patients transferred from general hospitals has given a new dynamic to the incidence of healthcare-associated infections, including biofilm-based infections related to the implant of urinary and intravascular catheters, and the onset of pressure ulcers. Catheter-associated urinary tract infections lead in most of the surveys on LTCFs, approximately 80% of urinary tract infections in these settings being due to the short- or long-term insertion of a urinary catheter. Furthermore, the implantation of intravascular catheters is often responsible for catheter-related bloodstream infections caused by the development of an intraluminal biofilm. Pressure ulcers, frequently occurring in bedridden patients admitted to LTCFs, are also susceptible to infection by biofilm-growing aerobic and anaerobic bacteria, the biofilm formation on the wound being the main reason for its delayed healing.

In vitro antibacterial effect of wasp (Vespa orientalis) venom

Background

The emergence of antibacterial resistance against several classes of antibiotics is an inevitable consequence of drug overuse. As antimicrobial resistance spreads throughout the globe, new substances will always be necessary to fight against multidrug-resistant microorganisms. Venoms of many animals have recently gained attention in the search for new antimicrobials to treat infectious diseases. Thefore, the present study aimed to study the antibacterial effects of wasp (Vespa orientalis) crude venom.

Two gram-positive bacteria (Staphylococcus aureus and Bacillus subtilis) and two gram-negative ones (Escherichia coli and Klesiella pneumonia) were compared for their sensitivity to the venom by determining the inhibition zone (Kirby-Bauer method) and minimum inhibitory concentration (MIC). A microbroth kinetic system based on continuous monitoring of changes in the optical density of bacterial growth was also used for determination of antimicrobial activity.

Results

The venom exhibited a well-recognized antimicrobial property against the tested bacterial strains. The inhibition zones were determined to be 12.6, 22.7, 22.4 and 10.2 mm for S. aureus, B. subtilis, E. coli and K. pneumonia, respectively. The corresponding MIC values were determined to be 64, 8, 64 and 128 μg/mL, respectively. The MIC₅₀ and MIC₉₀ values of the venom were respectively determined to be 63.6 and 107 μg/mL for S. aureus, 4.3 and 7.0 μg/mL for B. subtilis, 45.3 and 65.7 μg/mL for E. coli and 74.4 and 119.2 μg/mL for K. pneumonia. Gram-positive bacteria were generally more sensitive to the venom than gram-negative ones.

Conclusions

Results revealed that the venom markedly inhibits the growth of both gram-positive and gram-negative bacteria and could be considered a potential source for developing new antibacterial drugs.

Patterns of antimicrobial use for respiratory tract infections in older residents of long-term care facilities

OBJECTIVES

To describe patterns of antimicrobial use for respiratory tract infections (RTIs) in older residents of long-term care facilities (LTCFs).

DESIGN

Data from a prospective, randomized, controlled study of the effect of vitamin E supplementation on RTIs conducted from April 1998 through August 2001 were analyzed.

SETTING

Thirty-three LTCFs in the greater Boston area.

PARTICIPANTS

Six hundred seventeen subjects aged 65 and older residing in LTCFs.

MEASUREMENTS

RTIs, categorized as acute bronchitis, pneumonia, common cold, influenza-like illness, pharyngitis, and sinusitis, were studied for appropriateness of antimicrobial use, type of antibiotics used, and factors associated with their use. For cases in which drug treatment was administered, antibiotic use was rated as appropriate (when an effective drug was used), inappropriate (when a more-effective drug was indicated), or unjustified (when use of any antimicrobial was not indicated).

RESULTS

Of 752 documented episodes of RTI, overall treatment was appropriate in 79% of episodes, inappropriate in 2%, and unjustified in 19%. For acute bronchitis, treatment was appropriate in 35% and unjustified in 65% of cases. For pneumonia, treatment was appropriate in 87% of episodes. Of the most commonly used antimicrobials, macrolide use was unjustified in 43% of cases. No statistically significant differences in the patterns of antibiotic use were observed when stratified according to age, sex, race, or comorbid conditions, including diabetes mellitus, dementia, and chronic kidney disease.

CONCLUSION

Antimicrobials were unjustifiably used for one-fifth of RTIs and more than two-thirds of cases of acute bronchitis, suggesting a need for programs to improve antibiotic prescribing at LTCFs.

Infection prevention in alternative health care settings

With the changing health care delivery, patients receive care at various settings, including acute care hospitals, skilled nursing facilities (SNFs), and ambulatory clinics, thus becoming exposed to pathogens. Various health care settings face unique challenges requiring individualized infection control programs. The programs in SNFs should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs. In ambulatory clinics, the program should address triage and standard transmission-based precautions; cleaning, disinfection, and sterilization principles; surveillance in surgical clinics; safe injection practices; and bioterrorism and disaster planning.

Effect of an educational intervention on optimizing antibiotic prescribing in long-term care facilities

OBJECTIVE

To assess the effect of an educational intervention aimed at optimizing antibiotic prescribing in long-term care (LTC) facilities.

DESIGN

Cluster randomized, controlled trial.

SETTING

Eight public LTC facilities in the Montreal area.

PARTICIPANTS

Thirty-six physicians.

INTERVENTION

The educational intervention consisted of mailing an antibiotic guide to physicians along with their antibiotic prescribing profile covering the previous 3 months. Targeted infections were urinary tract, lower respiratory tract, skin and soft tissues, and septicemia of unknown origin. In the prescribing profile, each antibiotic was classified as adherent or nonadherent to the guide. Physicians in the experimental group received the intervention twice, 4 months apart, whereas physicians in the control group provided usual care.

MEASUREMENTS

Data on antibiotic prescriptions were collected over four 3-month periods: preintervention, postintervention I, postintervention II, and follow-up. A generalized estimating equation (GEE) model was used to compare the proportion of nonadherent antibiotic prescriptions of the experimental and control groups.

RESULTS

By the end of the study, nonadherent antibiotic prescriptions decreased by 20.5% in the experimental group, compared with 5.1% in the control group. Based on the GEE model, during postintervention II, physicians in the experimental group were 64% less likely to prescribe nonadherent antibiotics than those in the control group (odds ratio=0.36, 95% confidence interval=0.18-0.73).

CONCLUSION

An educational intervention combining an antibiotic guide and a prescribing profile was effective in decreasing nonadherent antibiotic prescriptions. Repetition of the intervention at regular intervals may be necessary to maintain its effectiveness.

Snake Venom: Any Clue for Antibiotics and CAM?

Lately several naturally occurring peptides presenting antimicrobial activity have been described in the literature. However, snake venoms, which are an enormous source of peptides, have not been fully explored for searching such molecules. The aim of this work is to review the basis of antimicrobial mechanisms revealing snake venom as a feasible source for searching an antibiotic prototype. Therefore, it includes (i) a description of the constituents of the snake venoms involved in their main biological effects during the envenomation process; (ii) examples of snake venom molecules of commercial use; (iii) mechanisms of action of known antibiotics; and (iv) how the microorganisms can be resistant to antibiotics. This review also shows that snake venoms are not totally unexplored sources for antibiotics and complementary and alternative medicine (CAM).