Antibiotic overconsumption and resistance in Turkey

Pricing, Procurement and Reimbursement Policies for Incentivizing Market Entry of Novel Antibiotics and Diagnostics: Learnings from 10 Countries Globally

BACKGROUND

Fostering market entry of novel antibiotics and enhanced use of diagnostics to improve the quality of antibiotic prescribing are avenues to tackle antimicrobial resistance (AMR), which is a major public health threat. Pricing, procurement and reimbursement policies may work as AMR 'pull incentives' to support these objectives. This paper studies pull incentives in pricing, procurement and reimbursement policies (e.g., additions to, modifications of, and exemptions from standard policies) for novel antibiotics, diagnostics and health products with a similar profile in 10 study countries. It also explores whether incentives for non-AMR health products could be transferred to AMR health products.

METHODS

This research included a review of policies in 10 G20 countries based on literature and unpublished documents, and the production of country fact sheets that were validated by country experts. Initial research was conducted in 2020 and updated in 2023.

RESULTS

Identified pull incentives in pricing policies include free pricing, higher prices at launch and price increases over time, managed-entry agreements, and waiving or reducing mandatory discounts. Incentives in procurement comprise value-based procurement, pooled procurement and models that delink prices from volumes (subscription-based schemes), whereas incentives in reimbursement include lower evidence requirements for inclusion in the reimbursement scheme, accelerated reimbursement processes, separate budgets that offer add-on funding, and adapted prescribing conditions.

CONCLUSIONS

While a few pull incentives have been piloted or implemented for antibiotics in recent years, these mechanisms have been mainly used to incentivize launch of certain non-AMR health products, such as orphan medicines. Given similarities in their product characteristics, transferability of some of these pull incentives appears to be possible; however, it would be essential to conduct impact assessments of these incentives. Trade-offs between incentives to foster market entry and thus potentially improve access and the financial sustainability for payers need to be addressed.

Pharmacy practice and policy research in Türkiye: a systematic review of literature

Background

In recent decades, there has been an interest in clinical pharmacy practice in Türkiye with emerging studies in this area. Despite the recent emergence of diverse pharmacy practice studies in Türkiye, a comprehensive assessment of overall typology of studies and impact has not been conducted thus far.

Objectives

This systematic review aims to document and assess pharmaceutical policy and practice literature published within the last 5 years in Türkiye. The other aim is to summarise the expected impact of published studies on policy and practice research.

Methods

The systematic review was conducted according to the guidelines described in the PRISMA Statement. A comprehensive search approach, incorporating Medical Subject Headings (MeSH) queries and free-text terms was employed to locate pertinent literature related to pharmacy practice and policy in Türkiye. The search covered the period from January 1, 2019, to January 1, 2024, and involved electronic databases including PubMed, Medline Ovid, Scopus, ScienceDirect, Springer Link, PlosOne, and BMC.

Results

In the final grouping, 73 articles met the inclusion criteria and were selected for this review. Among the quantitative studies, majority studies were cross-sectional survey studies. Through the rigorous thematic content analysis seven research domains were developed from the selected literature: drug utilisation and rational drug use, the emerging role of pharmacist, access to medicines and generic medicines, community pharmacy practice, pharmacovigilance/adverse drug reactions, and pharmacoeconomic studies.

Conclusions

The pharmacist role is evolving; however, several challenges remain in fully realising the potential of pharmacists. These include regulatory barriers, limited public awareness of pharmacists' expanded roles, workforce capacity issues, and the need for ongoing professional development and training. Research studies are needed in the areas of generic prescribing, medicine adherence, intervention studies in community and hospital pharmacy practice, and on pharmacoeconomics and pharmacovigilance.

Bacterial Profile and Antimicrobial Resistance Patterns of Diabetic Foot Infections in a Major Research Hospital of Turkey

Background/Aim: Diabetic foot infection (DFI) occurs frequently in patients, followed up with diabetic foot ulcers (DFU). For this reason, antibiotic treatment is often used in patients followed with DFU. Inappropriate use of antibiotics and increasing antibiotic resistance threaten public health. We aimed to investigate the microbial spectrum and antimicrobial resistance patterns isolated from diabetic foot infections in Turkey and help clinicians to choose optimal antibiotics empirically. Materials and Methods: This study was planned as a retrospective, single-center, cross-sectional study. Two hundred sixty-two patients whose causative microorganism was isolated in culture of tissue between 1 January 2021 and 31 December 2022 were included in this study. Bacterial profile and antimicrobial resistance patterns were analyzed. Results: Four hundred thirty two isolates from 262 patients isolated in culture of tissue were evaluated. Of these microorganisms, 57.60% were Gram-negative, 41.20% were Gram-positive bacteria, and 1.2% were Candida spp. The most frequently detected Gram-positive microorganism was Staphylococcus spp. Gram-negative microorganisms were Escherichia coli (E. coli) and Pseudomonas aeruginosa (P. aeruginosa). Polymicrobial infections were observed in 40.5% of the patients. Methicillin-resistant Staphylococcus spp. rate was 51.3%, while extended-spectrum beta-lactamase (ESBL) resistance for E. coli was 66.7%. Conclusions: Due to increasing antibiotic resistance rates, treatment of common infections becomes more difficult. Knowledge of the microbiological profile and antibiotic resistance patterns of patients with DFIs is useful to guide empirical therapy.

Point prevalence of antibiotic usage in major referral hospital in Turkey

INTRODUCTION

The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center.

MATERIALS AND METHODS

A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated.

RESULTS

Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001).

CONCLUSION

Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.

The challenges in the monitoring of infectious diseases after the earthquake in Türkiye in 2023

After the devastating earthquake in Türkiye and Syria in February, 2023, the long-term failure to meet the need for shelter, unfavourable living conditions in tent settlements, poor access to clean drinking water, water suitable for personal hygiene, and sanitary facilities, as well as interruptions in provision of primary health-care services, have emerged as the most important risk factors contributing to the spread of infectious diseases. 3 months after the earthquake, most of these problems persist in Türkiye. Data on the control of infectious diseases are scarce according to the reports prepared by medical specialist associations based on observations of health-care providers working in the region and statements made by the local health authorities. According to these unsystematised data, and considering the conditions in the region, faecal-oral transmissible gastrointestinal infections, as well as respiratory and vector-borne infections, are the main challenges. Vaccine-preventable diseases, such as measles, varicella, meningitis, and polio can be spread in temporary shelters due to interrupted vaccine services and crowded living conditions. In addition to controlling risk factors for infectious diseases, sharing data on the status and control of infectious diseases in the region with the community, health-care providers, and relevant expert groups should be a priority to improve the understanding of the effects of interventions and prepare for possible infectious disease outbreaks.

Distribution of Clinical Staphylococccus aureus Isolates and Antibiotic Resistance Profile: Three-Year Data

Objective: Staphylococci cause community-acquired and hospital-acquired infections, and Staphylococcus aureus is one of leading agents. In the last decades methicillin-resistant S.aureus (MRSA), vancomycin-intermediate S.aureus (VISA) and vancomycin-resistant S.aureus (VRSA) became as major concerns. Resistance to other antibiotics is also another growing issue. The aim of this study was to investigate the prevalence of S.aureus species and to evaluate susceptibilities to antimicrobial agents in a state (tertiary) hospital. Methods: Clinical cultures from various samples (urinary tract, respiratory, wound, abscess, tissue, catheter and external auditory) obtained from January 2017 to December 2019 in XXX hospital were included in the study. Isolated S.aureus strains and their antibiotic susceptibilities were retrospectively evaluated. Results: A total of 765 S.aureus strains were isolated. 165 S.aureus strains were found as methicillin resistant (MRSA; 21.9%). There was not any statistically significant difference in MRSA rates among evaluated years (p=0.772). There was not any strain that was resistant to vancomycin, teicoplanin and/or linezolid. The highest rate was observed in penicillin resistance (n=646/728, 88.7%). There was not any statistically significant alteration in the resistance rates of all tested antibiotics during the three-year period. Conclusions: Despite dwindling MRSA rates in UAMDSS, CAESAR report indicates that Turkey seems to be in the beginning phase of this struggle. Local and/or national antimicrobial stewardship programs are in effect in Turkey, but further measures are required.

Country data on AMR in Türkiye in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

BACKGROUND

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

OBJECTIVES

To review AMR in Türkiye and initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Türkiye and to improve patient outcomes.

METHODS

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media, acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from both a local clinician and local clinical microbiologist were sought to contextualize this information.

CONCLUSIONS

Türkiye developed an antibiotic stewardship programme, The Rational Drug Use National Action Plan 2014-2017, prioritizing appropriate antibiotic prescription in the community. Public campaigns discouraging inappropriate antibiotic use were also initiated. Türkiye has a high level of antibiotic resistance and a high level of consumption, however, in 2015 over-the-counter antibiotic sales were prohibited, resulting in a declining trend in overall consumption. There is still a need for physician education on current developments in antibiotic use. Several ongoing global surveillance studies provide antibiotic susceptibility data in Türkiye. Clinicians in Türkiye use several country-specific guidelines for common CA-RTIs plus a range of international guidelines. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data on isolates from community-acquired infections in Türkiye, could make guideline use more relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcome.

Short-acting β2-agonist prescription patterns in patients with asthma in Turkey: results from SABINA III

Background

Over-reliance on short-acting β₂-agonists (SABAs) is associated with poor asthma outcomes. However, the extent of SABA use in Turkey is unclear owing to a lack of comprehensive healthcare databases. Here, we describe the demographics, disease characteristics and treatment patterns from the Turkish cohort of the SABA use IN Asthma (SABINA) III study.

Methods

This observational, cross-sectional study included patients aged ≥ 12 years with asthma from 24 centres across Turkey. Data on sociodemographics, disease characteristics and asthma treatments were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma [GINA]) and practice type (primary/specialist care). The primary objective was to describe SABA prescription patterns in the 12 months prior to the study visit.

Results

Overall, 579 patients were included (mean age [standard deviation; SD]: 47.4 [16.1] years; 74.3% female), all of whom were treated by specialists. Most patients had moderate-to-severe asthma (82.7%, GINA steps 3–5), were overweight or obese (70.5%), had high school or university/post-graduate education (51.8%) and reported fully reimbursed healthcare (97.1%). The mean (SD) asthma duration was 12.0 (9.9) years. Asthma was partly controlled/uncontrolled in 56.3% of patients, and 46.5% experienced ≥ 1 severe exacerbation in the preceding 12 months. Overall, 23.9% of patients were prescribed ≥ 3 SABA canisters in the previous 12 months (considered over-prescription); 42.9% received no SABA prescriptions. As few patients had mild asthma, only 5.7% were prescribed SABA monotherapy. Therefore, most patients (61.5%) were prescribed SABA in addition to maintenance therapy, with 42.8% receiving ≥ 3 SABA canisters in the previous 12 months. Inhaled corticosteroids (ICS), ICS + a long-acting β-agonist fixed-dose combination and oral corticosteroids were prescribed to 14.5%, 88.3% and 28.5% of all patients, respectively. Additionally, 10.2% of patients purchased SABA over the counter, of whom 27.1% purchased ≥ 3 canisters in the preceding 12 months.

Conclusions

Despite all patients being treated by specialists and most receiving fully reimbursed healthcare, nearly a quarter of patients received prescriptions for ≥ 3 SABA canisters in the previous 12 months. This highlights a public health concern and emphasizes the need to align clinical practices with the latest evidence-based recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02008-9.

Perspectives of physicians and pharmacists on rational use of antibiotics in Turkey and among Turkish migrants in Germany, Sweden and the Netherlands: a qualitative study

Background

Antimicrobial resistance may result from inappropriate use of antibiotics in health care. Turkey is one of the countries with the highest antibiotic consumption in the world. Considering the role of transnational ties between Turkish migrants and their social contacts in Turkey, the attitudes and behaviors relating to rational antibiotic use in Turkey can also affect the use of antibiotics by Turkish migrants residing abroad. This study explores physicians’ and pharmacists’ experiences and perspectives on rational antibiotic use among Turkish adults in Turkey and among Turkish migrants in Germany, Sweden, and the Netherlands, three European countries with large populations of Turkish migrants.

Methods

Following a qualitative study design using convenience and snowball sampling, in-depth interviews with 21 family physicians and 24 pharmacists were conducted in the aforementioned countries. We transcribed all interviews verbatim and performed content analysis separately in the countries, followed by translation, pooling and joint interpretation of the findings.

Results

Physicians and pharmacists encountered irrational use of antibiotics among their patients in Turkey. Physicians interviewed in the three European countries explained that Turkish migrants differ from non-migrants with respect to their attitudes towards antibiotics, for example by more often expecting to be prescribed antibiotics. All physicians and pharmacists in the selected countries reported to inform their patients on how to use antibiotics upon prescription; however, Turkish migrants’ poor language proficiency was considered as a substantial communication barrier by the physicians and pharmacists interviewed in the European countries.

Conclusions

The study illustrated some aspects of irrational antibiotic use among the population in Turkey and Turkish migrants in selected European countries. It emphasized the need for closer community participation, adequate information campaigns, as well as in-service training of health care providers in Turkey. The strategies and interventions on rational antibiotic use should also be supported and encouraged by health care providers, who need to reach out to people with various cultural backgrounds.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01636-8.

Evaluation of parental knowledge, attitudes and practices regarding antibiotic use in acute upper respiratory tract infections in children under 18 years of age: a cross-sectional study in Turkey

Background

Upper respiratory tract infections (URTIs) are common in children. Antibiotics still continue to be prescribed although most URTIs are of viral origin. This is inappropriate use and this unnecessary administration contributes or may cause antibiotic resistance. The problem of unnecessary antibiotic use among children is a concern for antibiotic resistance in low- and middle-income developing countries. This study aims to evaluate the knowledge and attitudes of parents of children with upper respiratory tract infections regarding antibiotic use and their antibiotic administration practices in a tertiary care hospital in Turkey.

Methods

Our study is a cross-sectional survey study. It was carried out between 14 December 2020 and 1 April 2021 for parents over 18 years of age with a child under 18 years’ old who applied to the general pediatrics outpatient clinics of Gazi University Faculty of Medicine Hospital Department of Pediatrics.

Results

Five hundred fifty-four parents responded to the questionnaire (93.2% rate of response). A total of 15.7% of parents stated to use antibiotics in any child with fever. 37% of parents believed that antibiotics could cure infections caused by viruses. 6.3% of parents declared that they put pressure on pediatricians to prescribe antibiotics. While 28% of the parents who thought that the use of inappropriate antibiotics would not change the effect and resistance of the treatment, 41% thought that new antibiotics could be developed continuously. 85.6% of the parents stated that they never gave their children non-prescription antibiotics when they had a high fever. 80.9% of them declared that they never used past antibiotics in the presence of a new infection.

Conclusion

According to the results of our study of parents’ lack of knowledge about antibiotics in Turkey, though generally it shows proper attitude and practices. It shows that some of the restrictions imposed by the National Action Plan are partially working. However, it is still necessary to continue to inform parents, pediatricians and pharmacists about the use of antibiotics, and to be more sensitive about the prescribing of antibiotics, and if necessary, sanctions should be imposed by the state in order to prevent unnecessary antibiotic prescriptions.

Community Use of Antibiotics in Turkey: The Role of Knowledge, Beliefs, Attitudes, and Health Anxiety

Turkey has been among the leading countries in antibiotic consumption. As a result of the 4-year National Action Plan for Rational Drug Use, antibiotic prescriptions had declined from 34.9% in 2011 to 24.6% in 2018. However, self-medication with antibiotics without prescription is common, which is not reflected in official statistics. The present study aims at investigating antibiotic use in the community and the factors related to it. A web-based survey was conducted among 945 Turkish-speaking respondents (61.3% female). The questionnaire included questions about antibiotic use for different illnesses, ways to obtain and handle leftover antibiotics, knowledge, beliefs of the antibiotic effectiveness, attitudes, health anxiety, and background factors. According to the results, 34.2% of the sample had self-medicated themselves with antibiotics without a valid prescription. The most common way to self-medicate was to use leftover antibiotics. While 80.4% knew that antibiotics are used to treat bacterial infections, 51.4% thought that antibiotics are effective for viral diseases. The most important predictor of antibiotic use frequency was the belief in their efficiency for various illnesses and symptoms, followed by negative attitudes to antibiotics, health anxiety, knowledge level, positive attitudes, and health status. The results underline the importance of targeting misbeliefs about antibiotics in future campaigns.

Assessment of quarter billion primary care prescriptions from a nationwide antimicrobial stewardship program

We described the significance of systematic monitoring nationwide antimicrobial stewardship programs (ASPs) in primary care. All the prescriptions given by family physicians were recorded in Prescription Information System established by the Turkish Medicines and Medical Devices Agency of Ministry of Health. We calculated, for each prescription, “antibiotics amount” as number of boxes times number of items per box for medicines that belong to antiinfectives for systemic use (i.e., J01 block in the Anatomical Therapeutic Chemical Classification System). We compared the antibiotics amount before (2015) and after (2016) the extensive training programs for the family physicians. We included 266,389,209 prescriptions from state-operated family healthcare units (FHUs) between January 1, 2015 and December 31, 2016. These prescriptions were given by 26,313 individual family physicians in 22,518 FHUs for 50,713,181 individual patients. At least one antimicrobial was given in 37,024,232 (28.31%) prescriptions in 2015 and 36,154,684 (26.66%) prescriptions in 2016. The most common diagnosis was “acute upper respiratory infections (AURI)” (i.e., J00-J06 block in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) with 28.05%. The average antibiotics amount over prescriptions with AURI decreased in 79 out of 81 provinces, and overall rate of decrease in average antibiotics amount was 8.33%, where 28 and 53 provinces experienced decreases (range is between 28.63% and −3.05%) above and below this value, respectively. In the most successful province, the highest decrease in average amount of “other beta-lactam antibacterials” per prescription for AURI was 49.63% in January. Computational analyses on a big data set collected from a nationwide healthcare system brought a significant contribution in improving ASPs.

Influenza A as a Common Viral Cause of Complex Febrile Seizures

Objective The most common childhood convulsive disorder happens to be febrile seizure (FS), which is an important health problem leading to economic burden and parental anxiety. Further investigation into the etiological causes of FS will guide us for appropriate measures during the follow-up period. The aim of study was to identify the percentage of viral and bacterial pathogens in the etiological causes of children with FS, and also if there is any difference between simple and complex FSs.

Methods This prospective study randomly enrolled 100 pediatric patients with FS between January 2017 and July 2017. Nasopharyngeal swabs were obtained from all children at presentation. The respiratory panel was performed with a multiplex real-time polymerase chain reaction method to detect the 21 most common viruses. A complete blood count, absolute neutrophil count, absolute lymphocyte count, C-reactive protein, erythrocyte sedimentation rate, procalcitonin, blood culture, throat culture, urine analyses, urinary culture, and stool tests analysis were performed in all the patients.

Results During the study period, at least one virus was detected in 87% of patients. Bacterial agents were detected in only 13% of patients. Coinfections of the viruses and bacterial pathogens were found in 24% of patients. The most frequently detected virus was influenza A (Inf A) (18%), followed by rhinovirus (12%). Coinfections of the viruses and bacterial pathogens, mixed viral infections, and Inf A were common in children who experienced complex FS. Inf A was detected in 16% of patients with simple FSs and 30% of patients with complex FSs and a significant difference between them (p < 0.01).

Conclusion The results of this study showed that respiratory viral and bacterial pathogens are important in the etiology of FS in children. It is considered that complex FSs may be triggered by Inf A. The fact is viral pathogens are very common; therefore, antibiotics must be carefully prescribed. These results also draw attention to the use of the quadrivalent influenza vaccine in the prevention of FS related to the flu.

Two Important Issues in Subacute Thyroiditis Management: Delayed Diagnosis and Inappropriate Use of Antibiotics

BACKGROUND

Subacute thyroiditis (SAT) is a rare inflammatory disease of the thyroid gland. It has been noticed that patients with a diagnosis of SAT visit more other clinics and receive antibiotics unnecessarily. Therefore, the aim of this study was to reveal the degree of delay in the diagnosis of SAT, prediagnosis antibiotic use rates, and the awareness of clinics for the diagnosis of SAT.

METHODS

A total of 121 patients with SAT were enrolled in the study. A retrospective analysis was made of the history of patient symptoms during the diagnosis, which physicians they visited, antibiotic use, laboratory test results, and ultrasonographic findings.

RESULTS

The median age of the patients was 41 years. Neck pain radiating to the jaw/ear was seen in most patients (71.1%). The median time from symptom onset to a diagnosis of SAT was 23 days (range, 6-70 days). Antibiotics were erroneously prescribed to 71 patients (58.7%) before the diagnosis. The median time to diagnosis was 28 days in patients using antibiotics and 20 days in the group not using antibiotics (p < 0.001). Two or more physicians had been visited before SAT diagnosis by 89 (73.6%) patients, and more antibiotics were prescribed to these patients than the group who visited fewer physicians (p < 0.05). The frequency of prescribing antibiotics by physicians was 73.7% by emergency physicians, 53.1% by family doctors, 51.1% by ENT specialists, and 35.4% by internal medicine specialists.

CONCLUSION

The diagnosis of SAT is often delayed, and misdiagnosis leads to erroneous antibiotic overuse. Physicians should increase their awareness of the diagnosis of SAT in patients with neck pain.

Pattern of systemic antibiotic use and potential drug interactions: Evaluations through a point prevalence study in Ankara University Hospitals

Background/aim

Most of the hospitalized patients are on a number of drugs for comorbidities and/or to prevent nosocomial infections. This necessitates a careful consideration of drug interactions not only to avoid possible toxicities but also to reach the highest efficiency with drug treatment. We aimed to investigate drug interactions related to systemic antibiotic use and compare three different databases to check for drug interactions while characterizing the main differences between medical and surgical departments.

Materials and methods

This point prevalence study covered data on 927 orders for patients hospitalized between June 3 and 10, 2018 in Ankara University Hospitals. Systemic antibiotic use and related drug interactions were documented using UptoDate, Drugs, and Medscape and comparisons between the departments of medical and surgical sciences were made.

Results

The number of orders, or the number of drugs or antibiotics per order were not different between the medical and surgical sciences departments. A total of 1335 antibiotic-related drug interactions of all levels were reported by one, two, or all three databases. UptoDate reported all common and major interactions. Pantoprazole was the most commonly prescribed drug and appeared in 63% of all orders. Among 75 different molecules, ceftriaxone and meropenem were the two most prescribed antibiotics by the surgical and medical departments, respectively.

Conclusion

A dramatic variance existed amongst antibiotics prescribed by different departments. This indicated the requirement for a centralized role of an infectious diseases specialist. Especially for the hospitalized patient, prophylactic coverage with at least one antibiotic brought about a number of drug interactions. A precise evaluation of orders in terms of drug interactions by a clinical pharmacist (currently none on duty) will reduce possible drug-related hazards.

The point prevalence and inappropriateness of antibiotic use at hospitals in Turkey: a systematic review and meta-analysis

Inappropriate antimicrobial use is a key problem causing antimicrobial resistance and increased health care costs. Although global point prevalence surveys on antimicrobial prescribing in hospitals were described, there is lack of data from Turkish hospitals. Here, we aimed to perform systematic review and meta-analysis for the point prevalence surveys on antimicrobial prescribing in Turkish hospitals. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline was used to identify studies for the review. Articles published between January 2004 and September 2020 by Turkish investigators were included if they used the point prevalence survey method. The Joanna Briggs Institute's critical appraisal tool and the World Health Organization's point prevalence survey tool were used to the evaluate studies. Results were combined using random effects meta-analysis. The pooled point prevalence of antimicrobial use in Turkish hospitals was 48% (95% confidence interval 43-54). There was considerable heterogeneity in prevalence among the studies (I²= 98.75 %, 95 % CI 98.49-98-97). The most commonly prescribed antimicrobial and indication for antimicrobial use were third generation cephalosporins (36%) and respiratory tract infections (88%), respectively. More than two thirds of the antimicrobials were prescribed empirically (median: 71% [interquartile range: 56-80]) in hospitals. The point prevalence and inappropriateness of antimicrobial use are high in Turkish hospitals. Turkey is one of the biggest consumers of antimicrobials. There is an urgent need for antimicrobial stewardship programmes at Turkish hospitals to improve antimicrobial prescribing. Our study findings can contribute to improving antimicrobial prescribing, and thereby control antimicrobial resistance.

Changes in antimicrobial resistance and outcomes of health care-associated infections

To describe the change in the epidemiology of health care-associated infections (HAI), resistance and predictors of fatality we conducted a nationwide study in 24 hospitals between 2015 and 2018. The 30-day fatality rate was 22% in 2015 and increased to 25% in 2018. In BSI, a significant increasing trend was observed for Candida and Enterococcus. The highest rate of 30-day fatality was detected among the patients with pneumonia (32%). In pneumonia, Pseudomonas infections increased in 2018. Colistin resistance increased and significantly associated with 30-day fatality in Pseudomonas infections. Among S. aureus methicillin, resistance increased from 31 to 41%.

Streptomycin and nalidixic acid elevate the spontaneous genome-wide mutation rate in Escherichia coli

Since antibiotic resistance is a growing public health problem worldwide, it is important to understand how antibiotics and spontaneous mutations cooperate and shape the genome-wide mutation rate and spectrum. Here, we quantitatively evaluate genome-wide mutational profiles of Escherichia coli after long-term subinhibitory exposure to a broad-spectrum (streptomycin) and a narrow-spectrum antibiotic (nalidixic acid), using a mutation accumulation design combined with whole-genome resequencing of replicate lines as a mutagenicity test. We determined that, while the genome-wide mutation rate is slightly higher in the streptomycin-treated lines compared to the control lines, there is a significant increase in the nalidixic acid-treated lines. Our findings suggest that both broad and narrow-spectrum antibiotics may elevate the mutation rates in E. coli, but mechanisms of action may affect the consequence, thus contribute to accelerating the rate of adaptation and conferring antibiotic resistance.

Surgical site infections after pancreaticoduodenectomy: Preoperative biliary system interventions and antimicrobial prophylaxis

BACKGROUND

The rate of surgical site infection (SSI) after pancreaticoduodenectomy (PD) is high and insertion of preoperative bile duct catheterization (PBDC) predispose a high risk of SSI with multidrug resistant (MDR) microorganisms.

AIM

To describe the effects of PBDC and the prophylaxis in development of SSI.

METHODS

We conducted a retrospective study between January 01, 2010 and December 2018 including the patients with PD and total pancreatectomy.

FINDINGS

In total 214 consecutive patients were included. The PBDC was inserted to 63 (29%) patients. The rate of intraoperative bile fluid culture positivity was higher among the patients with PBDC (84% vs. 17% respectively, p<0.001). The SSI was detected in 52 patients (24%). In multivariate analysis, the rate of SSI was found to be higher among the patients with PBDC (OR: 2.33, 95% Cl: 1.14-4.76, p=0.02). As the etiologic agents of SSI, Pseudomonas spp. and MDR pathogens were mainly detected in PBDC group. The resistance to ampicillin-sulbactam was significantly higher in the PBDC group (87.5% vs. 25%, p=0.012). The similar bacterial species both in bile fluid and the surgical site were detected in 11 (21%) patients with SSI. Among 8 patients (15%), antimicrobial susceptibility was the same. Only in five out of 52 (10%) patients, the SSI pathogens was susceptible to the agent that was used for surgical prophylaxis.

CONCLUSION

Unnecessary catheterizations should be avoided. By considering the increasing prevalence of resistant bacteria as the cause of SSI, the clinicians should closely follow-up their patients for choosing the proper antimicrobials.

Broad spectrum antibacterial photodynamic and photothermal therapy achieved with indocyanine green loaded SPIONs under near infrared irradiation

Antimicrobial photodynamic therapy (aPDT) and antimicrobial photothermal therapy (aPTT) are promising local and effective alternative therapies for antibiotic resistant bacterial infections and biofilms.

The effect of colistin resistance and other predictors on fatality among patients with bloodstream infections due to Klebsiella pneumoniae in an OXA-48 dominant region

BACKGROUND

The aim of this study was to determine the effect of colistin resistance and other predictors on fatality among patients with Klebsiella pneumoniae bloodstream infections (Kp-BSI) and to describe the effect of amikacin and tigecycline on the outcome in an OXA-48 dominant country.

METHOD

This was a retrospective study performed among patients >16 years of age in a tertiary hospital with 465 beds. All cases had ≥1 positive blood culture for K. pneumoniae 48 h after admission.

RESULTS

Among 210 patients with Kp-BSI, the 30-day mortality rate after isolation of the microorganism was 58%. The rate of carbapenem resistance was higher (64% vs. 38%, p < 0.001) and the colistin minimum inhibitory concentration (MIC) was elevated (7 vs. 4, p < 0.029) among the patients who died. Among the colistin-resistant K. pneumoniae, the rates of OXA-48, ST101, and NDM-1 were 78%, 67%, and 35%, respectively. Amikacin was added to the treatment of 13 patients with carbapenem and colistin-resistant Kp-BSI and 77% survived (p < 0.001). Tigecycline was added to the treatment of 24 patients with carbapenem and colistin-resistant Kp-BSI, and the 30-day mortality rate was 71% (p = 0.576). In the multivariate analysis, carbapenem resistance (odds ratio (OR) 5.2, 95% confidence interval (CI) 2.47-10.9, p < 0.001) and increasing APACHE II score (OR 1.19, 95% CI 1.12-1.26, p < 0.001) were significantly associated with 30-day mortality. The addition of amikacin to the treatment regimen (OR 0.05, 95% CI 0.01-0.23, p < 0.001) was significantly beneficial.

CONCLUSIONS

Carbapenem resistance, increasing MIC of colistin, and the lungs as the source of the infection were significantly associated with 30-day mortality. The empirical use of combined active aminoglycosides was found to be beneficial in the treatment of colistin-resistant K. pneumoniae infections.

Profiling infectious diseases in Turkey after the influx of 3.5 million Syrian refugees

Background

Since 2011, the conflict in Syria has led to over five million refugees. Turkey hosts the highest number of Syrian refugees in the world. By February 2019 over 3.6 million people had fled to Turkey to seek safety. Only 6.1% of Syrian refugees live in temporary shelters. Owing to the disrupted healthcare services, many children coming from the conflict zones are less likely to have received vaccination. In temporary shelters immunization coverage is >95% and the refugee population is receptive to vaccination.

Aims

The objective of this study was to review the infectious diseases situation among Syrian refugees in Turkey.

Sources

We have reviewed the reports and studies provided by the governmental and non-governmental organizations and obtained more detailed data from the Ministry of Health in Turkey.

Content

Between 2012 and 2016, 1 299 209 cases of respiratory tract infection and 158 058 episodes of diarrhoea with 59 bloody diarrhoeas were reported; 1354 hepatitis A cases and 108 active tuberculosis cases were detected and treated in the temporary shelters for Syrian refugees. Overall in Turkey, 7794 cutaneous leishmaniasis have been reported.

Implications

Since the influx of Syrian refugees, there has been an increase in cases of leishmaniasis and measles. No significant increase was detected for tuberculosis, other vector-borne infections, and healthcare associated or sexually transmitted infections. The Syrian refugees can be considered as a vulnerable group in Turkey due to their living and working conditions. Based on available data and our detailed analysis, the numbers show a stable situation regarding infectious diseases.

Effectiveness of clinical pathway for upper respiratory tract infections in emergency department

OBJECTIVE

We aimed to demonstrate the benefits of implementing a clinical pathway to decrease the inappropriate use of antibiotics in upper respiratory tract infections (URTI) in an emergency department (ED).

METHODS

The study was performed in a hospital with 300 beds. All patients who applied with URTI from 1st to 30th of April 2017 were included and the appropriateness of the antibiotics were compared with the patients in the same period in 2016. A checklist for the clinical pathway of URTI was completed by the ED physicians.

RESULTS

351 patients were included, 176 these patients were in pre-ASP period and 175 patients were in post-ASP period. The rate of prescriptions including antibiotics was 49% in pre-ASP period and has decreased to 29% in post-ASP period (p < 0.001). Adherence to clinical pathway has increased from 50% to 80% (p < 0.001). In the post-ASP period, clinical pathway was used in 133 out of 175 patients (76%) and the consequently rate of appropriate antibiotic use was 82%.

CONCLUSION

The implementation of clinical pathway for URTI has decreased inappropriate antibiotic use in ED. As the secondary effect, using clinical pathway in ED also has increased the awareness of ED physicians who did not adhere to clinical pathway.