The use and resistance to antibiotics in the community

Longitudinal Trends in In-Patient Antibiotic Consumption According to the WHO Access, Watch, Reserve (AWaRe) Antibiotic Groups and Cost: An Analysis of Data at a National Antimicrobial Consumption Network (NAC-NET) Site in North India over 7 Years (2017-2023)

(1) Background: Antibiotic surveillance data are crucial to map out strategies to promote their optimal use at hospital and community levels. We conducted a comprehensive analysis of longitudinal trends in antibiotic consumption over 7 years at a core "National Antimicrobial Consumption Network" site in North India. (2) Methods: In-patient antibiotic consumption data (2017-2023) were obtained from the hospital's central drug store and organised as follows: defined daily dose per 100 bed-days; antibiotic consumption as per the WHO access, watch and reserve classification; trends in overall and different antibiotic classes' consumption; paediatric formulations of antibiotics; and hospital's annual expenditure on antibiotics. (3) Results: During the 7-year study period, no significant trend could be observed in the overall antibiotic consumption (average annual percent change, AAPC: 9.22; 95% CI: -16.46, 34.9) and cost (AAPC: 13.55; -13.2, 40.3). There was a higher proportion of the consumption of antibiotics in the "reserve" group from 2021 onwards compared to previous years, but the overall trend over 7 years was not significant (AAPC: 319.75; -137.6, 777.1). Antibiotic combinations, classified under the WHO "not recommended" category, comprised a significant proportion of antibiotics consumed. A remarkably increased consumption of azithromycin and doxycycline was recorded during 2020 and 2021, coinciding with the COVID-19 pandemic. (4) Conclusions: Some recommendations to optimise antibiotic use are promoting the use of narrow spectrum "access" group agents; linking antimicrobial resistance and consumption data to formulate effective therapeutic and prophylactic antibiotic use guidelines; and the adoption of restrictive antibiotic policy.

Ultrasound-Mediated Antibiotic Delivery to In Vivo Biofilm Infections: A Review

Bacterial biofilms are a significant concern in various medical contexts due to their resilience to our immune system as well as antibiotic therapy. Biofilms often require surgical removal and frequently lead to recurrent or chronic infections. Therefore, there is an urgent need for improved strategies to treat biofilm infections. Ultrasound-mediated drug delivery is a technique that combines ultrasound application, often with the administration of acoustically-active agents, to enhance drug delivery to specific target tissues or cells within the body. This method involves using ultrasound waves to assist in the transportation or activation of medications, improving their penetration, distribution, and efficacy at the desired site. The advantages of ultrasound-mediated drug delivery include targeted and localized delivery, reduced systemic side effects, and improved efficacy of the drug at lower doses. This review scrutinizes recent advances in the application of ultrasound-mediated drug delivery for treating biofilm infections, focusing on in vivo studies. We examine the strengths and limitations of this technology in the context of wound infections, device-associated infections, lung infections and abscesses, and discuss current gaps in knowledge and clinical translation considerations.

Dynamics underlie the drug recognition mechanism by the efflux transporter EmrE

The multidrug efflux transporter EmrE from Escherichia coli requires anionic residues in the substrate binding pocket for coupling drug transport with the proton motive force. Here, we show how protonation of a single membrane embedded glutamate residue (Glu14) within the homodimer of EmrE modulates the structure and dynamics in an allosteric manner using NMR spectroscopy. The structure of EmrE in the Glu14 protonated state displays a partially occluded conformation that is inaccessible for drug binding by the presence of aromatic residues in the binding pocket. Deprotonation of a single Glu14 residue in one monomer induces an equilibrium shift toward the open state by altering its side chain position and that of a nearby tryptophan residue. This structural change promotes an open conformation that facilitates drug binding through a conformational selection mechanism and increases the binding affinity by approximately 2000-fold. The prevalence of proton-coupled exchange in efflux systems suggests a mechanism that may be shared in other antiporters where acid/base chemistry modulates access of drugs to the substrate binding pocket.

Effects of silybin supplementation on growth performance, serum indexes and liver transcriptome of Peking ducks

As an emerging feed additive extracted from the traditional herb milk thistle, silybin has few applications and studies in Peking ducks. The aim of this study was to explore the practical significance of silymarin application in Peking ducks and to provide more theoretical support for the application of silymarin in livestock and poultry production. A total of 156 1-day-old healthy Peking ducks were randomly divided into four groups and supplemented with 0 mg/kg (control group), 400 mg/kg (S400), 800 mg/kg (S800) and 1,600 mg/kg (S1600) of silybin in the diets at day 14, to investigate the effects of silymarin on the growth, serum indexes and liver transcriptome of Peking ducks. The whole experiment lasted until day 42, and the sample collection was scheduled to take place in the morning. A substantial inprovement in average daily gain (ADG) and a decrease in feed conversion ratio (FCR) occurred in the S1600 group on days 14-28 compared to the control group (p < 0.05). The FCRs of other additive groups in the same period showed the same results. Supplementation of diets with silybin significantly increased serum IgA levels and when 1,600 mg/kg of silybin was given, levels of TNF-α and IL-6 were also significantly decreased (p < 0.05). In addition, we observed that the S1600 group had a significantly lower (p < 0.05) glutamine transaminase and an increased (p < 0.05) T-SOD level in the S400 group (p < 0.05). Liver transcriptome sequencing showed that 71 and 258 differentially expressed genes (DEGs) were identified in the S400 and S1600 groups, respectively, compared with the control group. DEGs related to cell composition and function, antigen processing and presentation were up-regulated, while DEGs related to insulin resistance and JAK-STAT were down-regulated. Conclusively, silybin can be used as a feed additive to improve the growth performance and health status of Peking ducks.

How Combined Macrolide Nanomaterials are Effective Against Resistant Pathogens? A Comprehensive Review of the Literature

Macrolide drugs are among the broad-spectrum antibiotics that are considered as "miracle drugs" against infectious diseases that lead to higher morbidity and mortality rates. Nevertheless, their effectiveness is currently at risk owing to the presence of devastating, antimicrobial-resistant microbes. In view of this challenge, nanotechnology-driven innovations are currently being anticipated for promising approaches to overcome antimicrobial resistance. Nowadays, various nanostructures are being developed for the delivery of antimicrobials to counter drug-resistant microbial strains through different mechanisms. Metallic nanoparticle-based delivery of macrolides, particularly using silver and gold nanoparticles (AgNPs & AuNPs), demonstrated a promising outcome with worthy stability, oxidation resistance, and biocompatibility. Similarly, macrolide-conjugated magnetic NPs resulted in an augmented antimicrobial activity and reduced bacterial cell viability against resistant microbes. Liposomal delivery of macrolides also showed favorable synergistic antimicrobial activities in vitro against resistant strains. Loading macrolide drugs into various polymeric nanomaterials resulted in an enhanced zone of inhibition. Intercalated nanomaterials also conveyed an outstanding macrolide delivery characteristic with efficient targeting and controlled drug release against infectious microbes. This review abridges several nano-based delivery approaches for macrolide drugs along with their recent achievements, challenges, and future perspectives.

Impact of the COVID-19 Pandemic on Community Consumption of Antibiotics for Systemic Use and Resistance of Invasive Streptococcus pneumoniae in Slovenia

The present study aims to investigate the impact of the COVID-19 pandemic on community antibiotic consumption and the resistance of invasive Streptococcus pneumoniae (2015-2022) to penicillin in Slovenia. During the pandemic in 2020 and 2021, the total use of antibiotics for systemic use decreased by 23.5% and 24.3%, expressed in defined daily doses per 1000 inhabitants per day (DID), while the use of penicillins, macrolides and broad-spectrum penicillins decreased by 30%, 20% and by 17.5%, respectively, and that of broad-spectrum macrolides fell by 17.1%. The incidence of invasive pneumococcal diseases (IPD) in Slovenia had a large decline during the pandemic. Decreased resistance to macrolides was significantly associated with decreased use of macrolides, while for penicillins the correlation could not be statistically confirmed. The proportion of PCV13 serotypes in IPD in Slovenia decreased after the introduction of the vaccine in the national programme, falling from 81.6% in 2015 to 45.5% in 2022. We noticed a decrease in the serotypes 1, 14, 9V, 7F, 4, 6A and an increase in the serotypes 3, 8, 22F, 11A, 23A and 15A. National interventions during the COVID-19 pandemic substantially decreased outpatients' antibiotic consumption, as well as incidence and resistance of invasive S. pneumoniae.

Use of antibiotics and risk of type 2 diabetes, overweight and obesity: the Cardiovascular Risk in Young Finns Study and the national FINRISK study

PURPOSE

To investigate whether exposure to systemic antibiotics influences the risk of developing type 2 diabetes and overweight/obesity.

METHODS

The study sample comprised 2209 (110 with incident diabetes) participants from the population-based Cardiovascular Risk in Young Finns Study (YFS) aged 24-39 years in 2001. The exposure was national linked register data on purchased antibiotic courses between 1993 and 2001. Clinical examinations including BMI were conducted in 2001, 2007 and 2011. Participants with prevalent diabetes in 2001 were excluded. Data on type 2 diabetes was also obtained from two national registers until 2017. Data from four population-based National FINRISK studies were used for replication (N = 24,674, 1866 with incident diabetes).

RESULTS

Prior antibiotic exposure (> 5 versus 0-1 antibiotic courses) was associated with subsequent type 2 diabetes in both YFS (OR 2.29; 95%CI 1.33-3.96) and FINRISK (HR 1.73; 95%CI 1.51-1.99). An increased risk for type 2 diabetes was observed in YFS (OR 1.043; 95%CI 1.013-1.074) and FINRISK (HR 1.022; 95%CI 1.016-1.029) per course. Exposure to antibiotics increased the risk of overweight/obesity (BMI > 25 kg/m²) after a 10-year follow-up in YFS (OR 1.043; 95%CI 1.019-1.068) and in FINRISK (OR 1.023; 95%CI 1.018-1.029) at baseline per antibiotic course. Adjustments for confounders from early life in YFS and at baseline in FINRISK, including BMI, socioeconomic status, smoking, insulin, blood pressure, and physical activity, did not appreciably alter the findings.

CONCLUSION

Our results show that exposure to antibiotics was associated with increased risk for future type 2 diabetes and overweight/obesity and support judicious antibiotic prescribing.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Decentralized systems for the treatment of antimicrobial compounds released from hospital aquatic wastes

In many developing countries, untreated hospital effluents are discharged and treated simultaneously with municipal wastewater. However, if the hospital effluents are not treated separately, they pose concerning health risks due to the possible transport of the antimicrobial genes and microbes in the environment. Such effluent is considered as a point source for a number of potentially infectious microorganisms, waste antimicrobial compounds and other contaminants that could promote antimicrobial resistance development. The removal of these contaminants prior to discharge reduces the exposure of antimicrobials to the environment and this should lower the risk of superbug development. At an effluent discharge site, suitable pre-treatment of wastewater containing antimicrobials could maximise the ecological impact with potentially reduced risk to human health. In addressing these points, this paper reviews the applications of decentralized treatment systems toward reducing the concentration of antimicrobials in wastewater. The most commonly used techniques in decentralized wastewater treatment systems for onsite removal of antimicrobials were discussed and evidence suggests that hybrid techniques should be more useful for the efficient removal of antimicrobials. It is concluded that alongside the cooperation of administration departments, health industries, water treatment authorities and general public, decentralized treatment technology can efficiently enhance the removal of antimicrobial compounds, thereby decreasing the concentration of contaminants released to the environment that could pose risks to human and ecological health due to development of antimicrobial resistance in microbes.

High Prevalence of Asymptomatic Nasopharyngeal Carriage Rate and Multidrug Resistance Pattern of Streptococcus pneumoniae Among Pre-School Children in North Showa Ethiopia

Background

Streptococcus pneumoniae infection is still the world’s most serious public health problem among children under the age of five. Nasopharyngeal carriage rate of Streptococcus pneumoniae has been identified as an important risk factor for the acquisition of community acquired respiratory tract infection. To date, little is known about the nasopharyngeal infection and antimicrobial susceptibility pattern of Streptococcus pneumoniae among preschool children in Ethiopia.

Objective

The aim of this study was to assess the prevalence of nasopharyngeal carriage and antimicrobial susceptibility pattern of Streptococcus pneumoniae among preschool children.

Methods

A cross-sectional study was conducted from September 2021 to April 2022. A total of 418 preschool children were enrolled using a multistage sampling technique. Nasopharyngeal swab was collected and transported to Medical Microbiology Laboratory at Debre Berhan comprehensive specialized hospital using skim-milk tryptone glucose glycerol transport media. The swab was inoculated on blood agar plates supplemented with 5µg/mL gentamycin and incubated at 37°C for 24–48 hours under 5% CO2 using a candle jar. Identification of Streptococcus pneumoniae was performed using Gram stain, catalase test, optochin test and bile solubility test. Antimicrobial sensitivity tests were done using a modified Kirby-Bauer disk diffusion method. Data were entered into the statistical package Epi data 4.0.0.6 and transferred to and analyzed using SPSS software version-23. A P-value ≤0.05 with 95% CI was considered to be statistically significant.

Results

The prevalence of Streptococcus pneumoniae nasopharyngeal carriage was 29.9% (125/418). The overall rate of multidrug resistance was 86 (68.8%), with tetracycline (68.8%) and TMP-SMX (68%). Among risk factors, young age and passive smoking were associated with pneumococcal carriage.

Conclusion

The present study revealed a substantially lower prevalence of Streptococcus pneumoniae nasopharyngeal carriage. High antimicrobial resistance was observed for most antimicrobial drugs tested. Younger age groups and passive smokers were at risk of Streptococcus pneumoniae nasopharyngeal carriage.

The Effects of Agrimonia pilosa Ledeb, Anemone chinensis Bunge, and Smilax glabra Roxb on Broiler Performance, Nutrient Digestibility, and Gastrointestinal Tract Microorganisms

Poultry farming is growing globally, particularly in developing countries, to meet the demands of growing populations for poultry meat and eggs. This is likely to lead to an increase in the use of antibiotics in poultry feed, thus contributing to the development and spread of antibiotic resistance which, poses a serious threat to human and animal health worldwide. One way of reducing this threat is to reduce the use of antibiotics in poultry production by finding effective and sustainable antibiotic alternatives that can be used to support poultry health and productivity. Therefore, this study evaluates the incorporation of three medicinal plants, Anemone chinensis Bunge, Smilax glabra Roxb, and Agrimonia pilosa Ledeb, in poultry feed on production performance, nutrient digestibility, and bacteria in the chicken caecum in a 35-day performance trial with 420-day-old male Ross 308 broilers. Groups of randomly selected chicks received one of six dietary treatments. These included five experimental diets of reduced nutrient specifications as a negative control (NC); with amoxicillin as a positive antibiotic control (PC1); with A. pilosa Ledeb (NC1); with A. chinensis Bunge (NC2); and with S. glabra Roxb (NC3). One other positive control diet contained the recommended nutrient specification (PC2). Weight gain and feed intake were measured weekly and used to calculate the feed conversion ratio as performance parameters. Bacteria were enumerated from chicken caecum using a traditional plating method and selective agar. S. glabra Roxb and A. chinensis Bunge showed comparable effects to amoxicillin with significantly increased weight gain in birds offered these diets, compared to those offered the negative control from days 0 to 35 (p < 0.001). S. glabra Roxb exhibited effects similar to the amoxicillin control group with an improved feed conversion ratio (p < 0.001). In addition, S. glabra Roxb decreased numbers of E. coli and Campylobacter spp. on days 21 (p < 0.05) and 35 (p < 0.01) and increased numbers of lactic acid bacteria comparable to the antibiotic group on days 14 (p < 0.001) and 35 (p < 0.01). The findings of this in vivo trial highlight the potential of S. glabra Roxb and A. chinensis Bunge as beneficial feed material to promote poultry health and productivity in the absence of antibiotics.

The gut microbiome and antibiotic resistome of chronic diarrhea rhesus macaques (Macaca mulatta) and its similarity to the human gut microbiome

BACKGROUND

Chronic diarrhea is a common disease causing morbidity and mortality of captive rhesus macaques (RMs, Macaca mulatta). Chronic diarrhea in RMs is typically characterized by long-term diarrhea and a weak response to antibiotic treatment. Diarrhea is also a common disease in humans and can cause death. However, the etiology of about half of diarrheal cases of humans is still unclear. Therefore, we performed shotgun metagenomic sequencing to characterize the differences in the gut microbiome and resistome of chronic diarrhea RMs and asymptomatic individuals.

RESULTS

Our results showed Lactobacillus spp. (mainly L. johnsonii, L. reuteri and L. amylovorus) were significantly depleted in chronic diarrhea RM guts compared to asymptomatic individuals (5.2 vs 42.4%). Functional annotation of genes suggested these Lactobacillus spp. carried genes involved in the adhesion of intestinal epithelial cells and production of bacteriocin. Chronic diarrhea RM guts also had a significantly greater abundance of many other gut bacteria, including mucin-degrading bacteria and opportunistic pathogens. The metabolic pathways of chronic diarrhea RM gut microbiome were enriched in aerobactin biosynthesis, while the metabolic pathways of asymptomatic RM gut microbiome were enriched in the production of short-chain fatty acids (SCFAs). Chronic diarrhea RM guts had a significantly greater abundance of antibiotic resistance genes (ARGs), such as ermF, aph(3')-IIIa, ermB, and floR. The strains isolated from feces and tissue fluid of chronic diarrhea RMs had higher resistance rates to the majority of tested antibiotics, but not cephamycin and carbapenem antibiotics. Gut microbial composition comparisons showed that several captive nonhuman primate (NHP) guts were more similar to the guts of humans with a non-westernized diet than humans with a westernized diet. Chronic diarrhea RM gut microbiome was strikingly similar to rural-living humans with diarrhea and humans with a non-westernized diet than asymptomatic RMs.

CONCLUSIONS

Our results suggested chronic diarrhea significantly altered the composition and metabolic pathways of the RM gut microbiome. The frequent use of antibiotics caused antibiotic resistance in chronic diarrhea RM gut microbiome with serious consequences for individual treatment and survival. The findings of this study will help us to improve the effective prevention and treatment of diarrhea in RMs. Video Abstract.

Next-Generation Sequencing-Based Study of Helicobacter pylori Isolates from Myanmar and Their Susceptibility to Antibiotics

Evaluation of Helicobacter pylori resistance to antibiotics is crucial for treatment strategy in Myanmar. Moreover, the genetic mechanisms involved remain unknown. We aimed to investigate the prevalence of H. pylori infection, antibiotic resistance, and genetic mechanisms in Myanmar. One hundred fifty patients from two cities, Mawlamyine (n = 99) and Yangon (n = 51), were recruited. The prevalence of H. pylori infection was 43.3% (65/150). The successfully cultured H. pylori isolates (n = 65) were tested for antibiotic susceptibility to metronidazole, levofloxacin, clarithromycin, amoxicillin, and tetracycline by Etest, and the resistance rates were 80%, 33.8%, 7.7%, 4.6%, and 0%, respectively. In the multidrug resistance pattern, the metronidazole–levofloxacin resistance was highest for double-drug resistance (16/19; 84.2%), and all triple-drug resistance (3/3) was clarithromycin–metronidazole–levofloxacin resistance. Twenty-three strains were subjected to next-generation sequencing to study their genetic mechanisms. Interestingly, none of the strains resistant to clarithromycin had well-known mutations in 23S rRNA (e.g., A2142G, A2142C, and A2143G). New type mutation genotypes such as pbp1-A (e.g., V45I, S/R414R), 23S rRNA (e.g., T248C), gyrA (e.g., D210N, K230Q), gyrB (e.g., A584V, N679H), rdxA (e.g., V175I, S91P), and frxA (e.g., L33M) were also detected. In conclusion, the prevalence of H. pylori infection and its antibiotic resistance to metronidazole was high in Myanmar. The H. pylori eradication regimen with classical triple therapy, including amoxicillin and clarithromycin, can be used as the first-line therapy in Myanmar. In addition, next-generation sequencing is a powerful high-throughput method for identifying mutations within antibiotic resistance genes and monitoring the spread of H. pylori antibiotic-resistant strains.

Nutritional and ethnomedicinal scenario of koumiss: A concurrent review

Fermented foods are an essential source of nutrition for the communities living in developing areas of the world. Additionally, traditional fermented products are a rich source of various bioactive components. Experimental research regarding the functional exploration of these products is a way forward for better human health. Among fermented foods, Koumiss is rich in vitamins especially vitamin C and minerals, i.e., phosphorus and calcium. In addition, it is also rich in vitamins A, E, B2, B12, and pantothenic acid. High concentrations of lactose in milk favor bacterial fermentation, as the original cultures decompose it into lactic acid. Koumiss contains essential fatty acids such as linoleic and linolenic acid. Koumiss offers many health benefits including boosting the immune system and maintains blood pressure, good effect on the kidneys, endocrine glands, gut system, liver, and nervous and vascular system. The rich microflora from the fermented product has a pivotal role in maintaining gut health and treating various digestive diseases. The core focus of the current review paper is to highlight the nutritional and therapeutic potential, i.e., anticarcinogenic, hypocholesterolemia effect, antioxidative properties, antibacterial properties, antibacterial spectrum, intestinal enlargement, and β-galactosidase activity, of Koumiss as a traditional fermented product. Moreover, history and production technology of the Koumiss are also the main part of this review paper.

Exploring With Transcriptomic Approaches the Underlying Mechanisms of an Essential Oil-Based Phytogenic in the Small Intestine and Liver of Pigs

Phytogenics are plant-based feed additives utilized in animal nutrition to support animal growth and health. Worldwide restrictions and bans on the use of antibiotic growth promoters resulted in an increased demand for in-feed alternatives including phytogenics. However, several challenges remain for technology readiness in animal industry, especially regarding the standardization of the ingredients as well as our knowledge on the cellular mechanisms underlying their biological effects. In the present study, 32 weaned piglets were allocated for 28 days to four experimental diets, a control diet, a phytogenic feed additive (PFA) diet, or the same two diets but with the addition of oxidized oil (OO) at 10%. The last two diets aimed at evaluating the antioxidant properties of PFA. At the end of the trial, the ileum and the liver of the pigs were sampled, and RNA were isolated for profiling their transcriptome via RNA sequencing (RNA-Seq). In the ileum, the gene set enrichment analysis showed that the activity of several immune pathways (NF-kB, interferon α/β, antimicrobial peptide, and collagen pathways) was reduced in piglets fed PFA compared to the control piglets. As expected, the addition of OO induced strong effects on the liver transcriptome and most likely accounted for the significant growth impairment. The likelihood ratio test across the four diets revealed a global response driven by the oxidative stress challenge with hundreds of genes associated with fatty acid β-oxidation and peroxisome in the liver. The expression levels of those genes in the piglets fed OO+PFA were much less affected by the challenge. Collectively, the effects seen at day 28 suggest that substances in the PFA formulation provide anti-inflammatory and antioxidant properties. The use of RNA-Seq in animal nutrition allows exploring and deciphering novel mechanisms of natural growth promoters.

Trends in Antibiotic Self-Medication for Dental Pathologies among Patients in the Dominican Republic: A Cross-Sectional Study

The World Health Organisation has warned of the increase in antibiotic resistance, estimating that by 2050 it could become the leading cause of death worldwide. Several studies and literature reviews show a correlation between antibiotic use and bacterial resistance, with unnecessary broad-spectrum antibiotics, such as amoxicillin/clavulanic acid and azithromycin, being one of the main causative factors. An interview-based survey of 2160 participants was conducted to assess the prevalence in the practice of self-medication with antibiotics among dental patients in the Dominican Republic. A series of open-ended questions regarding self-medication and class of antibiotics were put to the patients. Over a third of the study population (39.7%) admitted to the practice of antibiotic self-medication. Most of the respondents (58.4%) who indulged in self-medication were females, and it was prevalent in the older adults between 32–42 years old (36%). There was a negative correlation between age and self-medication practice (p < 0.001) observed with point biserial correlation test. Binary logistic regression analysis found an odds ratio of 0.97 (p < 0.001). The most consumed antibiotics were amoxicillin/clavulanic acid (52%), amoxicillin (31.1%), and azithromycin (10.1%). It is imperative to educate patients about the harmful effects of self-medication and to stress the need for governments to implement stricter laws on non-prescription drug availability.

Antibiotic susceptibility of human-associated Staphylococcus aureus and its relation to agr typing, virulence genes, and biofilm formation

BACKGROUND AND OBJECTIVE

Carriage of virulence factors confers some evolutionary benefit to bacteria, which favors the resistant strains. We aimed to analyze whether antibiotic susceptibility of Staphylococcus aureus strains is affected by agr typing, biofilm formation ability, and virulence profiles.

METHODS

A total of 123 S. aureus clinical isolates were subjected to antimicrobial susceptibility testing by disk diffusion method, biofilm formation by microtiter plate method, as well as polymerase chain reaction screening to identify virulence genes and the accessory gene regulator (agr) types I-IV. A P value < 0.05 was considered significant.

RESULTS

The most prevalent virulence gene was staphyloxanthin crtN, followed by hemolysin genes, capsular cap8H, toxic shock toxin tst, and enterotoxin sea, respectively. Resistant isolates were more commonly found in the agr-negative group than in the agr-positive group. Isolates of agr type III were more virulent than agr I isolates. Strong biofilm producers showed more antibiotic susceptibility and carried more virulence genes than non-strong biofilm producers. Associations were found between the presence of virulence genes and susceptibility to antibiotics. Carriage of the virulence genes and agr was higher in the inpatients; while, resistance and strong biofilms were more prevalent in the outpatients.

CONCLUSION

These findings indicated the presence of several virulence factors, biofilm production capacity, agr types and resistance to antibiotics in clinical S. aureus isolates. Considering the importance of S. aureus for human medicine, an understanding of virulence and resistance relationships would help to reduce the impact of S. aureus infections.

Correlation between Antibiotic Consumption and Resistance of Invasive Streptococcus pneumoniae

There is a lack of long-term studies that correlate different metrics of antibiotic consumption and resistance of invasive S. pneumoniae. The present study aims to investigate the correlation between national outpatients total antibiotic, penicillin and broad spectrum penicillins consumption expressed in daily doses per 1000 inhabitants per day (DID) with the ATC/DDDs, WHO version of 2019 (new version) and 2018 (old version), number of prescriptions per 1000 inhabitants per year (RxIDs) and number of packages per 1000 inhabitant per day (PIDs) with the resistance of invasive S. pneumoniae in Slovenia in the period from 2000 to 2018. The prevalence of penicillin resistance of invasive S. pneumoniae decreased by 47.13%, from 19.1% to 10.1%. Decline of resistance showed the highest correlation (R = 0.86) between RxIDs followed by PID (R = 0.85) and resistance of S. pneumoniae. Higher correlation between total use of antibiotics expressed in DID WHO version 2019 (R = 0.80) than for WHO version 2018 (R = 0.78) was found. Very high (R = 0.84) correlation between use of β-lactams expressed in PID, and RxIDs (R = 0.82) and reasonable (R = 0.59) correlation expressed in DIDs version 2019 was shown as well. The consumption of broad -spectrum penicillins (J01CA and J01CR02) expressed in PID (R = 0.72) and RxIDs (0.57) correlated significantly with the resistance of S. pneumoniae as well. A new finding of this study is that RxIDs correlated better with the resistance of S. pneumoniae than total consumption of antibiotics expressed in DID and significant correlations exist between use of broad-spectrum penicillins expressed in PID and RxIDs.

Mapping the Role of AcrAB-TolC Efflux Pumps in the Evolution of Antibiotic Resistance Reveals Near-MIC Treatments Facilitate Resistance Acquisition

Antibiotic resistance has become a major public health concern as bacteria evolve to evade drugs, leading to recurring infections and a decrease in antibiotic efficacy. Systematic efforts have revealed mechanisms involved in resistance. Yet, in many cases, how these specific mechanisms accelerate or slow the evolution of resistance remains unclear. Here, we conducted a systematic study of the impact of the AcrAB-TolC efflux pump on the evolution of antibiotic resistance. We mapped how population growth rate and resistance change over time as a function of both the antibiotic concentration and the parent strain's genetic background. We compared the wild-type strain to a strain overexpressing AcrAB-TolC pumps and a strain lacking functional pumps. In all cases, resistance emerged when cultures were treated with chloramphenicol concentrations near the MIC of their respective parent strain. The genetic background of the parent strain also influenced resistance acquisition. The wild-type strain evolved resistance within 24 h through mutations in the acrAB operon and its associated regulators. Meanwhile, the strain overexpressing AcrAB-TolC evolved resistance more slowly than the wild-type strain; this strain achieved resistance in part through point mutations in acrB and the acrAB promoter. Surprisingly, the strain without functional AcrAB-TolC efflux pumps still gained resistance, which it achieved through upregulation of redundant efflux pumps. Overall, our results suggest that treatment conditions just above the MIC pose the largest risk for the evolution of resistance and that AcrAB-TolC efflux pumps impact the pathway by which chloramphenicol resistance is achieved.IMPORTANCE Combatting the rise of antibiotic resistance is a significant challenge. Efflux pumps are an important contributor to drug resistance; they exist across many cell types and can export numerous classes of antibiotics. Cells can regulate pump expression to maintain low intracellular drug concentrations. Here, we explored how resistance emerged depending on the antibiotic concentration, as well as the presence of efflux pumps and their regulators. We found that treatments near antibiotic concentrations that inhibit the parent strain's growth were most likely to promote resistance. While wild-type, pump overexpression, and pump knockout strains were all able to evolve resistance, they differed in the absolute level of resistance evolved, the speed at which they achieved resistance, and the genetic pathways involved. These results indicate that specific treatment regimens may be especially problematic for the evolution of resistance and that the strain background can influence how resistance is achieved.

Every medicine is medicine; exploring inappropriate antibiotic use at the community level in rural Ghana

Background

Inappropriate antibiotic use is an important driver of antibiotic resistance. This study sought to explore inappropriate antibiotic use and confusing antibiotics with other medicines in Ghana using ethnomethodology research approach.

Methods

This was an explorative study involving 15 in-depth interviews among health professionals and private dispensers and eight focus group discussions among 55 community members. Qualitative data were coded using Nvivo 12, thematically analysed and presented as narratives with quotes to support the findings.

Results

Self-medication was common and antibiotics were used to treat specific diseases but respondents were not aware these were ‘antibiotics’. Various antibiotics were used for indications that in principle do not require systemic antibiotics, like stomach ache and sores on the body. Antibiotics, in particular tetracycline and metronidazole, were poured into “akpeteshie” (local gin) to treat hernia and perceived stomach sores (stomach ulcer). These practices were copied/learnt from various sources like over-the-counter medicine sellers, family, friends, radio/television, drug peddlers, pharmacies and doctors. Medicines in capsules were referred to as ‘topaye’ or ‘abombelt’ in Twi (local dialect) and perceived to treat pain associated with diseases. Antibiotics in capsules were described with colours which appeared confusing as some capsules with different drugs in them have similar colours.

Conclusion

Inappropriate antibiotic use were influenced by general lack of knowledge on antibiotics and identification of antibiotics by colours of capsules which leads to confusion and could lead to inappropriate antibiotic use. There is the need for public health education on appropriate antibiotic use and standardization of appearance of antibiotics and other drugs to optimize use.

Privacy-preserving architecture for providing feedback to clinicians on their clinical performance

Background

Learning from routine healthcare data is important for the improvement of the quality of care. Providing feedback on clinicians’ performance in comparison to their peers has been shown to be more efficient for quality improvements. However, the current methods for providing feedback do not fully address the privacy concerns of stakeholders.

Methods

The paper proposes a distributed architecture for providing feedback to clinicians on their clinical performances while protecting their privacy. The indicators for the clinical performance of a clinician are computed within a healthcare institution based on pseudonymized data extracted from the electronic health record (EHR) system. Group-level indicators of clinicians across healthcare institutions are computed using privacy-preserving distributed data-mining techniques. A clinician receives feedback reports that compare his or her personal indicators with the aggregated indicators of the individual’s peers. Indicators aggregated across different geographical levels are the basis for monitoring changes in the quality of care.

The architecture feasibility was practically evaluated in three general practitioner (GP) offices in Norway that consist of about 20,245 patients. The architecture was applied for providing feedback reports to 21 GPs on their antibiotic prescriptions for selected respiratory tract infections (RTIs). Each GP received one feedback report that covered antibiotic prescriptions between 2015 and 2018, stratified yearly. We assessed the privacy protection and computation time of the architecture.

Results

Our evaluation indicates that the proposed architecture is feasible for practical use and protects the privacy of the patients, clinicians, and healthcare institutions. The architecture also maintains the physical access control of healthcare institutions over the patient data. We sent a single feedback report to each of the 21 GPs. A total of 14,396 cases were diagnosed with the selected RTIs during the study period across the institutions. Of these cases, 2924 (20.3%) were treated with antibiotics, where 40.8% (1194) of the antibiotic prescriptions were narrow-spectrum antibiotics.

Conclusions

It is feasible to provide feedback to clinicians on their clinical performance in comparison to peers across healthcare institutions while protecting privacy. The architecture also enables monitoring changes in the quality of care following interventions.

Age and gender-specific antibiotic resistance patterns among Bangladeshi patients with urinary tract infection caused by Escherichia coli

Background

In Bangladesh, treatment for urinary tract infection has become increasingly difficult due to antibiotic resistance. In addition, the prescription of age and gender-specific drugs is still far from being practiced in Bangladesh. We are examining trends of antibiotic resistance per age and gender in patients with urinary tract infection (UTI) caused by the most frequent agent, Escherichia coli.

Methods

We determined the resistance of 1663 E. coli isolates obtained from urine cultures. A sensitivity study using the Kirby-Bauer method was carried out to identify the antibiotic resistance trends.

Results

Imipenem with 1.9% resistance of all isolates found to be the lowest percentage of resistance. Meropenem (2.8%), amikacin (2.8%), colistin (2.9%), and nitrofurantoin (15.8%) showed low resistance percentages. The sensitivity analysis suggests that age and gender (area under curve = 0.67) should be taken into consideration to prescribe amikacin. The increasing odds ratios (OR) by age groups suggest that amikacin is a less effective agent for older patients with UTIs. Moreover, nitrofurantoin (OR = 1.45, 95% confidence interval (CI) = 1.07–1.95) and colistin (OR = 2.09, CI = 1.13–3.76) were less effective against isolates obtained from males compared to isolates obtained from females. Meropenem was effective against bacteria obtained from all age groups and genders. On the other hand, efficacy of imipenem was lower in isolates obtained from adults older than 40 years (OR: 0.44 for < = 18 years, OR = 0.47 for 19–40 years, OR = 0.86 for 41–60 years; reference: > = 61 years).

Conclusion

In Bangladesh, meropenem, imipenem, amikacin, colistin, and nitrofurantoin are suitable therapeutic alternatives against urinary tract pathogens. Among the oral agents, amikacin, colistin, and nitrofurantoin should be prescribed, taking consideration of age and gender. These results will assist physicians in prescribing effective primary care antibiotics for UTI patients and encouraging the implementation of health policies for a safe prescription of antibiotics.

Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years

Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.

Effects of antibacterial compound of Saccharomyces cerevisiae from koumiss on immune function and caecal microflora of mice challenged with pathogenic Escherichia coli O8

The yeastSaccharomyces cerevisiaefrom koumiss has been shown to have antibacterial effects onEscherichia coli, possibly by producing antibacterial compound in metabolism; however, there is limited knowledge about its application in animal production. We therefore investigated the effects of an antibacterial compound ofS. cerevisiaefrom koumiss on the immune function and caecal microflora of mice challenged with pathogenicEscherichia coliO8. Three groups were formed: negative control (NC), positive control (PC), and the antibacterial compound ofS. cerevisiaeat pH 2.0 (S2). Mice in the NC and PC groups were orally administered phosphate buffer solution (PBS) for 7 d. At 4 d,E. coliO8 was administered intraperitoneally in group PC. Mice in group S2 were first administered orally as mice in group NC, and subsequently intraperitoneally administeredE. coliO8 as mice in group PC. Compared with the NC group, mice in the PC group displayed clinical symptoms and pathological changes in the small intestine. Small intestine villi in the S2 group also developed some histologically pathological changes but not as severe as in the PC group. Moreover, there was less mortality in the S2 group than in the PC group. In PC group, thymus indexes, immunoglobulin A (IgA) in serum andBifidobacteriumin caecum were decreased andE. coliin the caecum was increased. In the S2 group, CD8+ of T lymphocyte subsets in blood andBifidobacteriumin caecum were decreased, while spleen indexes, IgG, IgM in serum, and CD3+ of T lymphocyte subsets in blood were increased. This suggests that S2 can relieve clinical symptoms of mice challenged with pathogenicE. coliO8, enhance their immune function, and influence their caecal microflora. The study will provide a theoretical foundation for utilizing antibacterial compound ofS. cerevisiaefrom koumiss for curative purposes.

Prevalence of Shigella species and its drug resistance pattern in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Shigella species are a major cause of dysentery and may attribute for death worldwide. Currently antibiotic resistance became the critical challenges for management of infectious disease. The aim was to conduct a systematic review and meta-analysis of Shigella species and its drug resistance pattern in Ethiopia.

METHODS

A comprehensive literature search was conducted through internet searches using database of MEDLINE, PubMed, Google scholar, EMBASE, HINARI, Cochrane Library and reference lists of previous prevalence studies from January 1999 to November 2018. Results were presented in forest plot, tables and figures with 95% CI. The Cochrane Q test and I2 test statistic were used to test heterogeneity across studies. The Pooled estimate of Shigella species and its drug resistance pattern was computed by a random effects model.

RESULTS

The pooled prevalence of Shigella species in Ethiopia was 6.6% (95% CI 4.7-8.8). In the subgroup analysis, the highest prevalence was observed among patients in Health facility (8.5%, 95% CI 6.2-11.5) whereas the lowest prevalence was observed in Community based studies (1.6%, 95% CI 0.8-3.4). In addition, Shigella species were highly resistant to ampicillin, amoxicillin, erythromycin and multi-drug resistant (MDR) with the pooled resistance proportions of 83.1% (95% CI 75.7-88.6), 84.1% (95% CI 75.6-90.1), 86.5% (95% CI 70.9-94.4) and 83.2% (95% CI 77.1-87.9), respectively. On the other hand, comparably low resistance pattern was reported for ciprofloxacin 8.9% (95% CI 6.0-12.8), ceftriaxone 9.3% (95% CI 3.9-20.5), and norfloxacin 8.2% (95% CI 3.8-16.6) and gentamycin 17.3% (95% CI 11.2-25.9). Subgroup analyses indicated that study years were associated with a decreasing Shigella prevalence over time (p = 0.002).

CONCLUSION

The pooled estimate showed high burden of Shigella infection and its high proportion of drug resistance pattern to ampicillin, amoxicillin and erythromycin in Ethiopia. Therefore, initiating and scale up of performing drug susceptibility test for each shigellosis case, educate the community and health care providers on appropriate use of antibiotics need to be considered and strengthened.

Knowledge, attitude, and practice of self-medication with antibiotics among community residents in Addis Ababa, Ethiopia

Background: Self-medication with antibiotics, which may cause significant antibiotic resistance, is predominant in developing countries. The aim of this study is to assess the knowledge, attitude, and practice of self-medication with antibiotics among community residents in Ethiopia. Methods: A cross-sectional study design was conducted from June to August 2017. Knowledge-Attitude-Practice questionnaire was developed and distributed to eligible household respondents in Addis Ababa and its surrounding area. Logistic regression analysis was used to identify factors associated with self-medication with antibiotics. Results: Among the 605 invited participants, 595 respondents were participated in this study (response rate = 98.3%) and 67.3% of the respondents had reported self-medication with antibiotics in the past 6 months. The median score of knowledge about antibiotics was 3 (Inter quarter range: 2-4) of a maximum possible score of 6 and the median score of attitude was 19 (Inter quarter range: 16-22) from a maximum of 29. Self-medication with antibiotics was significantly associated with age, educational status, and average monthly income of the communities. Conclusions: Respondents have inadequate knowledge and inappropriate practice toward rational use of antibiotics. Policies such as restricting the purchase of antibiotics without a medical prescription and educating appropriate use of antibiotics are urgently needed.

Multidrug-Resistant Bacteria from Raw Meat of Buffalo and Chicken, Nepal

Antimicrobial resistance is a major global issue for human and animals. Increased use of antimicrobials in livestock and poultry has become one of the causes of antimicrobial resistance development in microorganisms. The aim of the study was to characterize antimicrobial resistant bacteria from raw buffalo and chicken meat in standard in vitro condition. A total of 140 raw meat samples were collected from different retail shops of Bhaktapur Metropolitan City, Nepal. Among them, 70 were raw buffalo meat and 70 were raw chicken meat samples. Bacterial growth, identification, and antimicrobial susceptibility test were performed according to Clinical & Laboratory Standards Institute (CLSI) guidelines. Out of 140 samples, bacterial growth was seen in 67 raw buffalo meat and 59 raw chicken meat samples, i.e., bacterial growth was observed in 90.0% of the samples. A total of 161 bacterial isolates were detected. Escherichia coli (35.4%) and Klebsiella spp. (30.4%) were found to be the most prevalent bacteria followed by Citrobacter spp. (11.8%), Staphylococcus aureus (9.3%), Salmonella spp. (7.4%), and Proteus spp. (5.5%). Chicken meat isolates showed higher antimicrobial resistance rates in comparison to buffalo meat isolates, particularly against antimicrobials like Amoxicillin, Tetracycline, Cotrimoxazole and Nalidixic acid, p value<0.05 when compared between buffalo and chicken meat. Overall, 32.7% Multidrug-Resistant (MDR) isolates were found, in which 50.0% MDR isolates were found from chicken raw meat and 21.9% were found from buffalo raw meat. MDR isolates of Escherichia coli, Proteus spp. and Staphylococcus aureus constituted 52.5%, 77.7% and 40.0%, respectively, of both buffalo and chicken raw meat. This study indicates antimicrobials resistant bacteria existing at an alarming rate, higher in chicken meat than in buffalo meat.

Cross-sectional study of the use of antimicrobials following common infections by rural residents in Anhui, China

OBJECTIVE

To describe help seeking behaviour from a medical doctor and antimicrobial use for common infections among rural residents of Anhui province, China.

DESIGN

A cross-sectional retrospective household survey.

SETTING

12 administrative villages from rural Anhui, China.

PARTICIPANTS

2760 rural residents selected through cluster-randomised sampling using an interviewer administered questionnaire.

METHOD

Logistic regression models were used to estimate associations between exposures (health insurance and antimicrobial-related knowledge), adjusted for confounders (sex, age and education), and help-seeking behaviour from a medical doctor and antimicrobial use following common infections, including acute respiratory tract infections (ARTIs), gastrointestinal tract infections (GTIs) and urinary tract infections (UTIs).

RESULTS

In total 2611 (94.6%) rural residents completed the questionnaire. Help seeking from a medical doctor was highest for ARTIs (59.4%) followed by GTIs (42.1%), and UTIs (27.8%). Around two-thirds (82.3% for ARTIs, 87.0% for GTIs and 66.0% for UTIs) of respondents sought help within 3 days following symptom onset and over three quarters (88% for ARTIs, 98% for GTIs and 77% for UTIs) reported complete recovery within 7 days. Of the help-seeking respondents, 94.5% with ARTI symptoms recalled being prescribed either oral or intravenous antimicrobials (GTIs 81.7% and UTIs 70.4%). Use of antimicrobials bought from medicine shops without prescriptions ranged from 8.8% for GTIs to 17.2% for ARTIs; while use of antimicrobials leftover from previous illnesses or given by a relative ranged from 7.6% for UTIs to 13.4% for ARTIs. Multivariate logistic regression analysis revealed that respondents with a higher antimicrobial-related knowledge score and lack of insurance were associated with lower levels of help-seeking for ARTIs; while respondents with a higher antimicrobial-related knowledge score were less likely to be prescribed either oral or intravenous antimicrobials.

CONCLUSIONS

Excessive antimicrobial use in the studied primary care settings is still prevalent.

Lack of correlation between reduced outpatient consumption of macrolides and macrolide resistance of invasive Streptococcus pneumoniae isolates in Slovenia during 1997-2017

OBJECTIVES

The objective of this study was to investigate the correlation between decreased national consumption of macrolides and resistance of invasive Streptococcus pneumoniae isolates in Slovenia during 1997-2017.

METHODS

A total of 4241 invasive S. pneumoniae isolates were collected in Slovenia from 1997 to 2017. The presence of erm(B), mef(E), mef(A) and erm(TR) genes was determined by PCR in 612 erythromycin-resistant isolates. Selected isolates carrying the mef(A) gene were further examined by pulsed-field gel electrophoresis (PFGE). Multilocus sequence typing (MLST) was performed for 161 erythromycin-resistant isolates from 2004 to 2009.

RESULTS

Consumption of macrolides decreased by 42.5% between 1997 and 2017, and by 57.0% from the highest consumption during 1999 to 2017. Resistance of S. pneumoniae increased by 120.7% in the same period, from 5.8% in 1997 to 12.8% in 2017. The most prevalent serotypes among macrolide-resistant isolates were 14 (54.9%), 19A (9.0%), 19F (8.3%), 6B (7.2%), 6A (5.2%) and 9V (19; 3.0%). The most prevalent determinant of macrolide resistance in the observed period was erm(B) (43.0%; 263/612), followed by mef(A) (36.3%; 222/612) and mef(E) (14.9%; 91/612). During the study period, an increasing trend in serotype 14, mef(A)-carrying isolates was observed, with a peak in 2011 (P<0.001); 63/71 isolates (88.7%) with the mef(A) gene were clonally related and were related to the international England¹⁴-9 clonal cluster.

CONCLUSIONS

The reason for the observed increase in macrolide resistance among invasive S. pneumoniae in Slovenia despite decreased macrolide consumption was spread of the England¹⁴-9 clonal cluster.

Antimicrobial use by WHO methodology at primary health care centers: a cross sectional study in Punjab, Pakistan

BACKGROUND

To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan.

METHODS

A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS.

RESULTS

Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1-19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1-39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1-1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9-89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3-6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6-4.3). The PHCCs prescribed a median of 5 (range = 3-9) types of AMs, including 10 (range = 5-15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs.

CONCLUSIONS

In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Antibiotics Resistance Genes Screening and Comparative Genomics Analysis of Commensal Escherichia coli Isolated from Poultry Farms between China and Sudan

Escherichia coli (E. coli) strains, from the gut of animals and humans, harbor wide range of drug resistance genes. A comparative study is conducted on the intestinal E. coli from fecal samples of healthy chicken from China and Sudan in order to monitor the antimicrobial sensitivity pattern. A number of 250 E. coli isolates from chicken farms, including 120 from China and 130 from Sudan, were isolated and identified. All isolates were subjected to susceptibility tests against 10 antibiotics and the distribution of antibiotic resistant genes was confirmed by PCR amplification, involving genes such as ampC, tetA, pKD13, acrA, ermA, ermB, ermC, tetB, mphA, aadA14, aadA1, aac3-1, and aac3- III. Many isolates were found to exhibit resistance against more than one antibiotic. However, the Chinese isolates showed more antibiotics resistance and resistance genes compared to the Sudanese isolates. For better understanding of the multidrug resistance factors, we conducted whole genome analyses of E. coli D107 isolated from China, which revealed that the genome possesses multiple resistance genes including tetracycline, erythromycin, and kanamycin. Furthermore, E. coli D4 isolate from Sudan was more sensitive to antibiotics such as erythromycin, tetracycline, and gentamicin. After analysis by RAST and MAUVE, the two strains showed 89% average nucleotide identity. However, the genomes mostly differed at the number of antibiotics-related genes, as the genome of D107 revealed a considerable number of antibiotics resistance genes such as ermA and mphD which were found to be absent in D4 genome. These outcomes provided confirmation that the poultry farms environment in different countries (China and Sudan) may serve as a potential reservoir of antimicrobial resistance genes and also indicated the evolutionary differences of strains in terms of resistant genes expression.

Antibiotic consumption and resistance of gram-negative pathogens (collateral damage)

Antibiotics are commonly prescribed in community and hospital care. Overuse and misuse favors emergence and spread of resistant bacteria. The ATC/DDD methodology is commonly used for presenting the drug utilization data. In primary care, the consumption is usually expressed in DDD per 1,000 inhabitants per day, in hospital, preferably in DDD per 100 bed days and DDD per 100 admissions. The alternative metric is days of therapy (DOT), which needs IT support. Antibiotics have ecological adverse effects at individual and population level. Antibiotics select resistant bacteria among pathogens and normal flora. Broad-spectrum antibiotics, low dosage and prolonged antibiotic therapy favor the development of resistance. Although total use of antibiotics in hospital is much less than in the community, the intensity of use magnified by cross infection ensures a multitude of resistant bacteria in today's hospitals. Reversal of resistance is complex and might persist for many years despite the introduction of antimicrobial containment and stewardship programs.

Prescribing pattern and antibiotic use for hospitalized children in a Northern Nigerian Teaching Hospital

Background:

Assessment of patterns of drug to detect performance problems and compliance with standards facilitates objective comparisons and impact evaluation. Children are at higher risk of consequences of irrational prescribing and antibiotic misuse.

Objective:

The objective of the study was to evaluate the prescribing pattern and utilization of antibiotics for children using standard prescribing indicators and indices of rational drug prescribing.

Materials and Methods:

This was a retrospective study of prescriptions for pediatric inpatients at a teaching hospital in Northern Nigeria. Information was obtained from eligible prescriptions received over 24-month period using a modified WHO prescribing indicator form. The WHO prescribing indicators and the Index of Rational Drug Prescribing (IRDP) were used to evaluate prescriptions. Data were analyzed and presented as proportions, means, tables, and charts, comparing with WHO standards and with findings of similar studies.

Results:

There were 3908 eligible prescription orders, with a mean patient age of 3.1 (±2.7) years. With an average of 2.1 drugs per prescription, 66.8% were written with generic names, whereas a single antibiotic was included among 63% of prescriptions with antibiotics. Antibiotics and injections were contained in 49.5% and 67.7% of prescriptions, respectively. Medications were available in the Essential Medicines List in 95.5% of cases. The IRDP obtained is 2.99, against a standard of 5. Aminoglycosides, cephalosporins, and penicillins were the most common choices, whereas ampicillin/cloxacillin was the most common combination.

Conclusion:

Drug prescribing and antibiotic use were generally inappropriate compared with ideal standards. Continuous training/retraining on rational drug use, periodic monitoring, and use of treatment protocols in tertiary hospitals are recommended.

Knowledge, attitude and practice of antibiotic use and misuse among adults in Riyadh, Saudi Arabia

Objectives:

To assess the knowledge, attitude, and practice of antibiotics (ABs) use and misuse among adults living in Riyadh, Saudi Arabia.

Methods:

In this cross-sectional study, a self-administered questionnaire was distributed to participants from March 2016 to January 2017 in the outpatient department of King Khalid University Hospital and Dental Hospital, King Saud University, Riyadh, Saudi Arabia. The questionnaire was divided into 4 sections. The first and second section inquired regarding demographic details and knowledge of ABs. The third section assessed practice of ABs and the fourth section assessed attitude of participants towards ABs use. Questionnaires were hand delivered to respondents using convenience sampling. Statistical analysis using frequency distributions and knowledge responses of AB resistance for ‘yes’ and ‘no’ were associated with participant characteristics using Chi-square test.

Results:

A total of 1966 questionnaires were completed (response rate: 93.5%). Sixty-seven percent of the respondents were unaware of the meaning of ABs resistance. Sixty-seven percent of respondents were unaware of ABs being harmful for children’s teeth and 64.9% unaware of ABs that develop allergy and death. Twenty-four percent believed that ABs worked on viruses, 31% on cold and 21% can cure cough. Almost 51% used ABs without physician prescription while 37.5% obtained ABs directly from pharmacists without physician’s prescription. Almost 42% participants discontinued ABs on alleviation of symptoms. There was significant difference in knowledge response of AB resistance and source of AB use (p=0.026), reason of AB use (p=0.038) and discontinuation of ABs (p=0.041).

Conclusion:

Adults showed insufficient knowledge and understanding regarding the safe use of ABs consumption among the population.

Determinants of Antibiotic Consumption - Development of a Model using Partial Least Squares Regression based on Data from India

Antibiotic resistance, a consequence of antibiotic use, is a threat to health, with severe consequences for resource constrained settings. If determinants for human antibiotic use in India, a lower middle income country, with one of the highest antibiotic consumption in the world could be understood, interventions could be developed, having implications for similar settings. Year wise data for India, for potential determinants and antibiotic consumption, was sourced from publicly available databases for the years 2000–2010. Data was analyzed using Partial Least Squares regression and correlation between determinants and antibiotic consumption was evaluated, formulating ‘Predictors’ and ‘Prediction models’. The ‘prediction model’ with the statistically most significant predictors (root mean square errors of prediction for train set-377.0 and test set-297.0) formulated from a combination of Health infrastructure + Surface transport infrastructure (HISTI), predicted antibiotic consumption within 95% confidence interval and estimated an antibiotic consumption of 11.6 standard units/person (14.37 billion standard units totally; standard units = number of doses sold in the country; a dose being a pill, capsule, or ampoule) for India for 2014. The HISTI model may become useful in predicting antibiotic consumption for countries/regions having circumstances and data similar to India, but without resources to measure actual data of antibiotic consumption.

The Growing Genetic and Functional Diversity of Extended Spectrum Beta-Lactamases

The β-lactams-a large class of diverse compounds-due to their excellent safety profile and broad antimicrobial spectrum are considered to be the most widely used therapeutic class of antibacterials prescribed in human and veterinary clinical practices. This, unfortunately, has also given rise to a continuous increased resistance globally in health care settings as well as in the community due to their permanent selective force driving diversification of the resistance mechanism. Resistance against β-lactams is increasing rapidly as novel β-lactamases, enzymes that degrade β-lactams, are being discovered each day such as recent emergence of extended spectrum β-lactamases (ESBL) that have the ability to inactivate most of the cephalosporins. The complexity and diversity of ESBL are increasing so rapidly that more than 170 variants have thus far been described for only a single genotype, the blaCTX-M -encoding ESBL. This review is to organize all the current updated literature describing genomic features, organization, and mechanism of resistance and mode of dissemination of all known ESBLs.

Distribution of Virulence Factors According to Antibiotic Susceptibility among Escherichia coli Isolated from Urinary Tract Infection

Escherichia coli is the major causative pathogen of urinary tract infection (UTI) in humans. Virulence and drug resistance play important roles in the pathogenesis of E. coli infections. The aims were to investigate the presence of uropathogenic virulence genes and to evaluate a relationship between antibiotic resistance and virulence in E. coli from UTI. A total of 132 E. coli were collected between April and June 2015 in two hospitals of Sanandaj, Iran. Isolates were examined for susceptibility to 16 antibiotic disks using the disk diffusion method and for possession of virulence genes by polymerase chain reaction. Associations between antimicrobial resistance and virulence genes were investigated. A P < 0.05 was considered significant. Of the 132 isolates, the most prevalent virulence gene was pap (31.1%), followed by cnf (28.8%), hly (16.7%), and afa (10.6%). Different patterns of virulence genes were identified. A significant association was detected between the simultaneous presence of hly and pap. The most effective antibiotics were nitrofurantoin, cefoxitin, and imipenem and the least effective were ampicillin, trimethoprim-sulfamethoxazole, and cefotaxime. An association was seen between the presence of cnf and susceptibility to the certain antibiotics, whereas strains with a reduced susceptibility to the certain antibiotics were associated with a significantly increased prevalence of afa and hly (P < 0.05). These findings suggest a correlation between the presence of virulence gene and resistance in E. coli strains from UTI. The results indicate that there is a need for surveillance programs to monitor drug resistance in pathogenic E. coli.

Inappropriate use of antibiotics among communities of Gondar town, Ethiopia: a threat to the development of antimicrobial resistance

Background

The emergence of antimicrobial resistance, the main cause of morbidity and mortality from otherwise treatable infections, is largely attributed to the inappropriate use of antimicrobials. However, data on the extent of inappropriate use of antibiotics in the community is scarce in Ethiopia. The aim of present study is to document the extent of inappropriate use of antibiotics and its associated factors among the communities of Gondar, Northwest Ethiopia.

Methods

A community based cross-sectional survey was conducted on a total of 650 participants in Gondar town, northwest Ethiopia from December 1, 2016 to January 30, 2017. Descriptive statistics, univariate and multivariate logistic regression analysis were also performed to express different variables and to examine factors associated with inappropriate use of antibiotics.

Results

According to the finding of our study, 315 (48.5%) of the participants took antibiotics in the past 1 year, of which 115 (35.9%) of them used inappropriately. Amoxicillin (72%) was the most commonly utilized antibiotics and respiratory tract infection (40.9%) was the most common disease condition to which antibiotics had been sought. About 36.8% of the respondents got antibiotics from community drug retail outlets without a prescription and 67.9% of respondents had discontinued the use of antibiotics once their symptoms subside. Low educational status (AOR = 5.01, 95% CI = 2.62–9.34), being employed (AOR = 2.12, 95% CI = 1.81–7.29) and unsatisfied with health care services provided (AOR = 5.41, 95% CI = 2.71-14.21) were found to be strong predictors of inappropriate use of antibiotics use among the community.

Conclusion

Inappropriate use of antibiotics was found to be considerably high in the communities of Gondar, northwest Ethiopia. Taking into consideration the heightened importance of comprehensive knowledge in the rational use of antibiotics, different stakeholders working in the public health sectors should provide a comprehensive and customized education to the public so as to improve their knowledge about antibiotics. It is also essential to adopt a strong and explicit line of actions towards the accessibility of antibiotics without a valid prescription in community medicine retail outlets.

Antimicrobial resistance in clinical Escherichia coli isolates from poultry and livestock, China

Poultry and livestock are the most important reservoirs for pathogenic Escherichia coli and use of antimicrobials in animal farming is considered the most important factor promoting the emergence, selection and dissemination of antimicrobial-resistant microorganisms. The aim of our study was to investigate antimicrobial resistance in E. coli isolated from food animals in Jiangsu, China. The disc diffusion method was used to determine susceptibility to 18 antimicrobial agents in 862 clinical isolates collected from chickens, ducks, pigs, and cows between 2004 and 2012. Overall, 94% of the isolates showed resistance to at least one drug with 83% being resistance to at least three different classes of antimicrobials. The isolates from the different species were most commonly resistant to tetracycline, nalidixic acid, sulfamethoxazole, trimethoprim/sulfamethoxazole and ampicillin, and showed increasing resistance to amikacin, aztreonam, ceftazidime, cefotaxime, chloramphenicol, ciprofloxacin. They were least resistant to amoxicillin/clavulanic acid (3.4%) and ertapenem (0.2%). MDR was most common in isolates from ducks (44/44, 100%), followed by chickens (568/644, 88.2%), pigs (93/113, 82.3%) and cows (13/61, 21.3%). Our finding that clinical E. coli isolates from poultry and livestock are commonly resistant to multiple antibiotics should alert public health and veterinary authorities to limit and rationalize antimicrobial use in China.

Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape

AbstractDiagnosing the cause of acute febrile illness in resource-limited settings is important-to give the correct antimicrobials to patients who need them, to prevent unnecessary antimicrobial use, to detect emerging infectious diseases early, and to guide vaccine deployment. A variety of approaches are yielding more rapid and accurate tests that can detect more pathogens in a wider variety of settings. After decades of slow progress in diagnostics for acute febrile illness in resource-limited settings, a wave of converging advancements will enable clinicians in resource-limited settings to reduce uncertainty for the diagnosis of acute febrile illness.

Investigation of antimicrobial use at a tertiary care hospital in Southern Punjab, Pakistan using WHO methodology

Background

Globally, between 20 to 50% of antimicrobial consumption is inappropriate, causing significant impact on the quality of care, cost of therapy and incidence of adverse drug reactions. The purpose of this study was to investigate the prescribing patterns and utilization of antimicrobials in ten selected wards at Bahawal Victoria Hospital (BVH), Bahawalpur, Punjab, Pakistan.

Methods

A descriptive cross-sectional study was designed using the World Health Organization (WHO) indicators for antimicrobial use. Standard data collection forms were used in ten wards and the Pharmacy Department at BVH. Antimicrobial utilization patterns in terms of frequency and percentage were also determined. Systematic random sampling techniques were used to collect data from 1,000 prescription records out of 21,115 prescriptions written for the six months January to June 2016.

Results

For the hospital indicators, a formulary list or essential medicines list (FL/EML) was available, but standard treatment guidelines (STGs) for infectious diseases was not. The average number of days that key antimicrobials were out of stock was 3.3 days per month. The expenditure on antimicrobials as a percentage of the total medicines costs was 12.2%. For the prescribing indicators, the percentage of hospitalizations with antimicrobial(s) prescribed was 82.3%, and the average number of antimicrobials per hospitalization was 1.4 (SD = 0.6). The average duration of antimicrobial treatment per hospitalization was 5.4 days (SD = 3.2). The average cost of antimicrobials prescribed per hospitalization was USD 5.4 (SD = 6.7). None of the patients who were prescribed antimicrobials, received AM according to the STGs (pneumonia and cesarean section cases). Among the patient-care and supplemental indicators, the average duration of hospital stay of patients who received antimicrobials was 6.4 (SD = 4.3) days. The drug sensitivity testing was almost non-existent, with only 0.24% prescription records having drug sensitivity tests. Ceftriaxone (39.6%), metronidazole (23.4%) and cefotaxime (23.1%) were the top most frequently prescribed antimicrobials.

Conclusions

The results of the current study revealed less than optimal antimicrobial prescribing and utilization patterns of selected wards at BVH. Continuous education and training of physicians, and cost-effective policies could play an important role in promoting the rational use of antimicrobials in this setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-017-0199-7) contains supplementary material, which is available to authorized users.

In vitro antimicrobial activity of the organic extract of Cladonia substellata Vainio and usnic acid against Staphylococcus spp. obtained from cats and dogs

ABSTRACT: Cladonia substellata Vainio is a lichen found in different regions of the world, including the Northeast of Brazil. It contains several secondary metabolites with biological activity, including usnic acid, which has exhibited a wide range of biological activities. The aim of this study was to evaluate the in vitro antimicrobial activity of the organic extract of C. substellata and purified usnic acid. Initially, Staphylococcus spp., derived from samples of skin and ears of dogs and cats with suspected pyoderma and otitis, were isolated and analyzed. In antimicrobial susceptibility testing against Staphylococcus spp., 77% (105/136) of the isolates were resistant to the antimicrobials tested. In the assessment of biofilm production, 83% (113/136) were classified as producing biofilm. In genetic characterization, 32% (44/136) were positive for blaZ, no isolate (0/136) was positive for the mecA gene, and 2% (3/136) were positive for the icaD gene. The in vitro antimicrobial activity of the organic extract of C. substellata and purified usnic acid against Staphylococcus spp. ranged from 0.25mg/mL to 0.0019mg/mL, inhibiting bacterial growth at low concentrations. The substances were more effective against biofilm-producing bacteria (0.65mg/mL-0.42mg/mL) when compared to non-biofilm producing bacteria (2.52mg/mL-2.71mg/mL). Usnic acid and the organic extract of C. substellata can be effective in the treatment of pyoderma and otitis in dogs and cats caused by Staphylococcus spp.

The Food Production Environment and the Development of Antimicrobial Resistance in Human Pathogens of Animal Origin

Food-borne pathogens are a serious human health concern worldwide, and the emergence of antibiotic-resistant food pathogens has further confounded this problem. Once-highly-efficacious antibiotics are gradually becoming ineffective against many important pathogens, resulting in severe treatment crises. Among several reasons for the development and spread of antimicrobial resistance, their overuse in animal food production systems for purposes other than treatment of infections is prominent. Many pathogens of animals are zoonotic, and therefore any development of resistance in pathogens associated with food animals can spread to humans through the food chain. Human infections by antibiotic-resistant pathogens such as Campylobacter spp., Salmonella spp., Escherichia coli and Staphylococcus aureus are increasing. Considering the human health risk due to emerging antibiotic resistance in food animal-associated bacteria, many countries have banned the use of antibiotic growth promoters and the application in animals of antibiotics critically important in human medicine. Concerted global efforts are necessary to minimize the use of antimicrobials in food animals in order to control the development of antibiotic resistance in these systems and their spread to humans via food and water.

WHO/INRUD prescribing indicators and prescribing trends of antibiotics in the Accident and Emergency Department of Bahawal Victoria Hospital, Pakistan

A descriptive, retrospective and cross sectional study was conducted to assess the prescribing practices and antibiotic use patterns in the Accident and Emergency department of the Bahawal Victoria Hospital, Bahawalpur, Pakistan. A sample of 4320 prescriptions (systematic random sampling) was drawn out of a total of 1,080,000 prescriptions written during the period 1st January-31st December 2014. The standard World Health Organization/International Network for Rational Use of Drugs prescribing indicators were used to determine the prescribing practices of physicians. Published ideal standards for each of the indicators were used to identify irrational drug use. We also utilized an additional indicator to report the percentage share of antibiotics prescribed. The average number of drugs prescribed per encounter was 2.3 (SD = 1.3) (optimal value 1.6-1.8). Drugs prescribed by generic name occurred 83.1% of the time (optimal value 100%). Antibiotics and injections were prescribed 52.4% (optimal value 20.0-26.8%) and 98.0% (optimal value 13.4-24.1%) of the time respectively. Drugs prescribed from the Essential Drugs List equated to 81.5% (optimal value 100%). Out of 52.4% (n = 2262) prescriptions with antibiotics prescribed, 77.7% (n = 1758) had one antibiotic, 22.1% (n = 499) included two antibiotics, and 0.2% (n = 5) had three antibiotics. Cephalosporins were the most commonly prescribed class of antibiotics (81.5%) followed by penicillins (6.4%) and fluoroquinolones (6.2%). Among the individual antibiotics, ceftriaxone contributed the highest percentage share at 71.8% followed by cefotaxime (5.6%) and metronidazole (4.7%). The most frequently prescribed antibiotic combination was ciprofloxacin with metronidazole (52.1%). Irrational prescribing practices were common. Continuous education and training of physicians is required to ensure rational prescribing at Bahawal Victoria Hospital in the future.

Evaluation of Drug Treatment of Bronchopneumonia at the Pediatric Clinic in Sarajevo

INTRODUCTION

Bronchopneumonia is the most common clinical manifestation of pneumonia in pediatric population and leading infectious cause of mortality in children under 5 years. Evaluation of treatment involves diagnostic procedures, assessment of disease severity and treatment for disease with an emphasis on vulnerability of the population.

AIM

To determine the most commonly used antibiotics at the Pediatric Clinic in Sarajevo and concomitant therapy in the treatment of bronchopneumonia.

PATIENTS AND METHODS

The study was retrospective and included a total of 104 patients, hospitalized in pulmonary department of the Pediatric Clinic in the period from July to December 2014. The treatment of bronchopneumonia at the Pediatric Clinic was empirical and it conformed to the guidelines and recommendations of British Thoracic Society.

RESULTS AND DISCUSSION

First and third generation of cephalosporins and penicillin antibiotics were the most widely used antimicrobials, with parenteral route of administration and average duration of treatment of 4.3 days. Concomitant therapy included antipyretics, corticosteroids, leukotriene antagonists, agonists of β2 adrenergic receptor. In addition to pharmacotherapy, hospitalized patients were subjected to a diet with controlled intake of sodium, which included probiotic-rich foods and adequate hydration. Recommendations for further antimicrobial treatment include oral administration of first-generation cephalosporins and penicillin antibiotics.

CONCLUSION

Results of the drug treatment of bronchopneumonia at the Pediatric Clinic of the University Clinical Center of Sarajevo are comparable to the guidelines of the British Thoracic Society. It is necessary to establish a system for rational use of antimicrobial agents in order to reduce bacterial resistance.